Central nervous system examination

A neurological exam, also called a neuro exam, is an evaluation of a person’s nervous system that can be done in the healthcare provider’s office. It may be done with instruments, such as lights and reflex hammers. It usually does not cause any pain to the patient. The nervous system consists of the brain, the spinal cord, and the nerves from these areas. There are many aspects of this exam, including an assessment of motor and sensory skills, balance and coordination, mental status (the patient’s level of awareness and interaction with the environment), reflexes, and functioning of the nerves. 

Complete neurological exam may be done:

• During a routine physical
• Following any type of trauma
• To follow the progression of a disease
• If the person has any of the following complaints:

1. Headaches
2. Blurry vision
3. Change in behavior
4. Fatigue
5. Change in balance or coordination
6. Numbness or tingling in the arms or legs
7. Decrease in movement of the arms or legs
8. Injury to the head, neck, or back
9. Fever
10. Seizures
11. Slurred speech
12. Weakness
13. Tremor

The following is an overview of some of the areas that may be tested and evaluated during a neurological exam:

• Mental status :

Mental status (the patient’s level of awareness and interaction with the environment) may be assessed by conversing with the patient and establishing his or her awareness of person, place, and time. The person will also be observed for clear speech and making sense while talking. This is usually done by the patient’s healthcare provider just by observing the patient during normal interactions.

• Motor function and balance:

This may be tested by having the patient push and pull against the healthcare provider’s hands with his or her arms and legs. Balance may be checked by assessing how the person stands and walks or having the patient stand with his or her eyes closed while being gently pushed to one side or the other. The patient’s joints may also be checked simply by passive (performed by the healthcare provider) and active (performed by the patient) movement.

• Sensory exam:

The patient’s healthcare provider may also do a sensory test that checks his or her ability to feel. This may be done by using different instruments: dull needles, tuning forks, alcohol swabs, or other objects. The healthcare provider may touch the patient’s legs, arms, or other parts of the body and have him or her identify the sensation (for example, hot or cold, sharp or dull).

• Evaluation of the nerves of the brain.

There are 12 main nerves of the brain, called the cranial nerves. During a complete neurological exam, most of these nerves are evaluated to help determine the functioning of the brain .

Cranial nerve examination:

• Introduce yourself to patient
• Confirm patient details – name / DOB
• Explain the examination – “I’m going to be testing the nerves that supply your face”
• Gain consent
• Position patient on a chair at eye level – approximately one arm’s length away
• Ask if the patient currently has any pain.

• Gather equipment
• Pentorch
• Snellen eyechart
• Ishiharachart
• Ophthalmoscope
• Cottonwool
• Neuro-tip
• Tuning fork(512hz)
• Glass of water
• Mydriatic eye drops (if necessary)

• General inspection

– General appearance – comfortable at rest?

– Obvious facial asymmetries?

-Position of eyes – normal alignment/strabismus

-Ptosis – is this unilateral or bilateral? -Abnormality of speech or voice Signs

I – Olfactory nerve

• Any change in sense of smell? – “Have you noticed any recent change in your sense of smell?”
• Olfaction can be tested more formally using different odours, e.g. lemon.

II – Optic nerve

• CranialNerve2(Optic):This nerve carries visual impulses from the eye to the optical cortex of the brain by means of the optic tracts.

• Testing involves 3 phases (also covered in the section of this site dedicated to the Eye Exam).
• VISUALACUITY :

1. If the patient uses glasses to view distant objects, they should be permitted to wear them (referred to as best corrected vision).
2. A Snellen Chart is the standard, wall mounted device used for this assessment. Patients are asked to read the letters or numbers on successively lower lines (each with smaller images) until you identify the last line which can be read with 100% accuracy. Each line has a fraction written next to it. 20/20 indicates normal vision. 20/400 means that the patient’s vision 20 feet from an object is equivalent to that of a normal person viewing the same object from 400 feet. In other words, the larger the denominator, the worse the vision.

• PUPILLARYREFLEXES :

– To best see pupillary reflexes the room should be dimly lit.

– Direct pupillary reflex(afferent CNII, efferent CNIII):Shine a light into the pupil           and observe constriction of that pupil.

-Sluggish reaction or lack of constriction may suggest pathology–optic nerve/     brainstem/ drugs

Consensual pupillary reflex:

Againshinealightintothepupil,butthistimeobservethecontralateralpupil. Anormalconsensualresponseinvolvesthecontralateralpupilconstricting.

• COLOURVISION :

Assess color vision using Ishihara charts (unlikely to do this in an OSCE setting)

• VISUAL FIELDS

Sit directly facing the patient, approximately one meter away.

1. Ask the patient to cover their left eye with their left hand.
2. You should cover your right eye and be staring directly at the patient (mirroring the
patient).
3. Ask the patient to look into your eye and not move their head or eyes during the
assessment.
4. Ask the patient to tell you when they can see your fingertip wiggling.
5. Outstretch your arms, ensuring they are situated at an equal distance between
yourself and the patient.
6. Position your fingertip at the outer border of one of the quadrants of your visual field.
7. Slowly bring your fingertip inwards, towards the center of your visual field until the
patient sees it.
8. Repeat this process for each quadrant – at 10 o’clock /2 o’clock / 4 o’clock / 8 o’clock.
9. If you are able to see your fingertip but the patient cannot, this would suggest a visual
field defect.
10. Map out any visual field defects you detect.
11. Repeat the same assessment process on the other eye.

III,IV,VI–Oculomotor, Trochlear & Abducens nerves

• CN3(Oculomotor):Controlstheremaining4muscles
• CN 4 (Trochlear): Controls the Superior Oblique muscle.
• CN6(Abducens):Controls the Lateral Rectus muscle.
• EYE MOVEMENTS :

a. Hold your finger about 30cm directly in front of the patient’s eyes and ask them to look at it.
Look at the eyes in the primary position for any deviation or abnormal movements.
b. Ask the patient to keep their head still and follow your finger with their eyes.
c. Ask the patient to report any double vision.
d. Move your finger through the various axes of eye movement (“H” shape).
e. Observe for restriction of eye movement and note any nystagmus.

• Cover test :

This tests for a manifest strabismus/squint.

1. Ask patient to focus on a target (e.g. your pen top).
2. Cover one of the patient’s eyes.
3. Observe the uncovered eye for movement:

• No movement = normal response
• Eye moves temporally=convergent squint(esotropia)
• Eye moves nasally=divergent squint(exotropia)

V – Trigeminal nerve

• SENSORY EXAMINATION :

Assess light touch and pinprick sensation:

• Forehead – ophthalmic branch(V1)
• Cheek – maxillary branch(V2)
• Jaw – mandibular branch(V3)

• MOTOR EXAMINATION :

1. Ask the patient to clench their teeth whilst you feel the bulk of masseter and temporalis bilaterally.

2. Ask the patient to open their mouth whilst you apply resistance under the jaw – note any deviation (jaw will deviate to side of lesion)

• REFLEXES :

Jaw jerk (afferent CN V, efferent CN V):

• Ask patient to open mouth loosely
• Place your finger horizontally across the chin
• Tap your finger with a tendon hammer
• Normal=slight closure of the jaw
• Abnormal= brisk complete closure of the jaw – UMN lesion

Corneal reflex (afferent CN V, efferent CN VII):

• Explain procedure and gain consent
• Depress lower eyelid
• Ask patient to look upwards
• Touch edge of cornea using a wisp of cottonwool
• Normal response=Direct and consensual blinking

VII    – Facial nerve

INSPECT THE PATIENT’S FACE FOR SYMMETRY

Forehead wrinkles

• Nasolabial folds
• Angles of the mouth

Ask the patient to perform specific facial movements

• Raised eyebrows–“raise your eyebrows as if you’re surprised”–note asymmetry
• Closed eyes–“scrunch up your eyes and don’t let meopen them”–assess power
• Blown out cheeks–“blow out your cheeks and don’t let medeflate them”–assess power
• Smiling – “can you do a big smile for me?” – note asymmetry
• Pursed lips – “can you attempt to whistle for me?” – note asymmetry
• Closed lips – “close your lips tight and don’t let me open them” – check each side, assess power

VIII     – Vestibulo cochlear nerve Gross hearing testing

• GROSS HEARING TESTING :

1. Explaintothepatientthatyou’regoingtosayawordornumberandyou’dlikethemto repeat it back to you.

2. Withyourmouthapproximately15cmfromtheear,whisperanumberorword.
3. If the patient repeats the correct word or number, repeat the test at an arm’s length from the ear(normalhearingallowswhisperstobeperceivedat60cm)

• RINNE’S TEST :

1. Tap a 512 Hz tuning fork and place its base on the mastoid process
2. Ask the patient if they are able to hear it (bone conduction)Iftheyareabletohearit,askthemtoletyouknowwhentheycannolongerhearit

3. Oncethepatientisunabletohearthesoundviathemastoidprocessmovethetuningforkto approximately1inchfromtheexternalauditorymeatus
4. Ask the patient if they are able to hear the tuning fork (this is air conduction)

5. If the patient is able to hear the tuning fork via air conduction (after they were no longer able to hear via bone conduction) it suggests their air conduction is better than bone conduction (Rinne’s positive).

SUMMURY OF RINNE’S TEST RESULTS :

• Normal = Air conduction > Bone conduction (Confusingly termed “Rinne’s positive”, despiteitbeingthenormalresult.Itisprobablybesttoavoidthistermandjustdescribethe result)
• Neural deafness = Air conduction > Bone conduction (both air and bone conduction reduced equally)
• Conductive deafness = Bone conduction > Air conduction (“Rinne’s negative” – again best to avoid this term and describe the result)

• WEBER’S TEST :

1. Tapa512Hztuningforkandplaceinthemidlineoftheforehead
2. Ask the patient where they can hear the sound:

• Normal–sound is heard equally in both ears
• Neural deafness–sound is heard louder on the side of the intactear
• Conductive deafness–sound is heard louder on the side of the affected ear

IX   &X–Glossopharyngeal and Vagus nerves

ASSESE THE SOFT PALATE AND OVULA :

• Symmetry–note any obvious deviation of the uvula.
• Ask patient to say “ahhhh” – observe uvula moving upwards – any deviation? (deviation away from side of lesion)

• Gagre flex(afferent IX, efferent X)–you won’t be expected to do this in the OSCE, but make sure you mentionet

1. Ask patient to cough– damage to nerves IX and X can result in a bovine cough.
2. Swallow – ask patient to take a sip of water – note any coughing / delayed swallow.

XI   – Accessory nerve

1. Ask patient to shrug shoulders and resist you pushing down – trapezius
2. Ask patient to turn head to one side and resist you pushing it to the other– sternocleidomastoid.

XII    – Hypoglossal nerve

1. Inspect tongue for wasting and fasciculation satrest (minor fasciculations can be normal)
2. Ask patient to protrude tongue–any deviation?(deviates towards side of lesion)
3. Placeyourfingeronthepatient’scheekandasktopushtheirtongueagainstit–assess power.

REFLEXES :

Reflexdefinition:Areflex,orreflexaction,isaninvoluntaryandnearlyinstantaneous movement in response to a stimulus.

Types of reflexes :

• Deep reflexes (muscle stretch reflexes)
• Superficial reflexes
• Visceral or organic reflexes
• Miscellaneous reflexes

• Deepreflexes:Thesearethereflexeselicitedbyasuddenstretchofamuscleandhence they are better termed ‘muscle stretch reflexes’(MSR).

The terms such as tendon reflexes, deep tendon reflexes, periosteal reflexes and         myotactic reflexes are also used synonymously.

Allthesearemonosynapticreflexes,e.g.biceps,triceps,kneeandanklereflexes.

• Superficial reflexes: These are the reflexes elicited by stimulating the skin or mucous membrane. These are polysynaptic reflexes, e.g. abdominal and

• Visceral or organic reflexes: These are the reflexes which result in contraction of the viscera, e.g. micturition, defecation and deglutition reflexes.

• Miscellaneous reflexes: Postural reflexes, conditioned reflexes, cerebral reflexes, autonomic reflexes and others.

CLONUS

This term denotes a series of rhythmic, involuntary muscle contractions, induced by sudden passive stretch of a tendon. At times, it may occur spontaneously too. A true clonus persists as long as the stretch on the muscle is maintained. This occurs in extensive UMN lesions, and is always associated with exaggerated muscle stretch reflexes and spasticity.

Types of response :

Brisk reflexes refer to an above-average response during a reflex test.

DEEP REFLEXES :

Superficial reflexes

MUSCLE POWER EXAMINATION

An assessment of muscle strength is typically performed as part of a patient’s objective assessment and is an important component of the physical exam that can reveal information about neurologic deficits. It is used to evaluate weakness and can be effective in differentiating true weakness from imbalance or poor endurance. It may be referred to as motor testing, muscle strength grading, manual muscle testing, or any other synonyms. Muscle strength can be assessed by a number of methods-manually, functionally, or mechanically.¹Strength depends on the combination of morphological and neural factors including muscle cross-sectional area and architecture, musculotendinous stiffness, motor unit recruitment, rate coding, motor unit synchronization, and neuromuscular inhibition²

Importance :The function of muscle strength testing is to evaluate the complaint of weakness, often when there is a suspected neurologic disease or muscle imbalance/weakness. It is an important part of the assessment in many client groups including-

1. Patients with stroke, brain injury, spinal cord injury, neuropathy, amyotrophic lateral sclerosis, and a host of other neurologic problems.
2. Rehabilitation after sporting injuries e.g ACL repair
3. After fractures and joint replacements e.g TKR
4. Gaitand balance problems in the older adult
5. Falls risk assessment

• DYNAMOMETER

Distal strength can be semi quantitatively measured with a handgrip ergometer (or with an inflated BP cuff squeezed by the patient) to record grip strength. Requires specialized equipment, most commonly dynamometers. Dynamometry is a more precise measurement of the force that a muscle can exert and can allow for differences in strength to be recorded over time. 

• CLINICAL SIGNIFICANCE :
• The above mentioned Scale is commonly accepted and does not require special equipment, and demonstrates reasonable interrater reliability. More precise methods of measurement, such as hand-grip dynamometry, are less subjective and provide a quantifiable measurement that can be tracked over time.
• Functional assessment of strength focuses on how independently patients are able to perform their activities of daily living and whether strength is a limiting factor¹.
• Effect of Protein supplements on muscle-For untrained individuals, consuming supplemental protein likely has no impact on lean mass and muscle strength during the initial weeks of resistance training. Protein supplementation may accelerate gains in both aerobic and anaerobic power as the frequency, duration, volume of resistance training increase.

Tone

Resistance felt by the examiner when moving a joint passively through its R.O.M

• Hypotonia

Hypotonia is a state of low muscle tone (the amount of tension or resistance to stretch in a muscle), often involving reduced muscle strength. Hypotonia is not a specific medical disorder, but a potential manifestation of many different diseases and disorders that affect motor nerve control by the brain or muscle strength. Hypotonia is a lack of resistance to passive movement, whereas muscle weakness results in impaired active movement. 

Caused by LMN Lesion –Flaccidity

Eg: Cerebellar disease, Cerebral / spinal shock with muscle wasting, weakness and hyporeflexia.

• Hypertonia

            Hypertonia is a term sometimes used synonymously with spasticity and rigidity in the literature surrounding damage to the central nervous system, namely upper motor neuron lesions. Impaired ability of damaged motor neurons to regulate descending pathways gives rise to disordered spinal reflexes, increased excitability of muscle spindles, and decreased synaptic inhibition. These consequences result in abnormally increased muscle tone of symptomatic muscles.

Pyramidal tract Lesion (UMN)- spasticity- Arm – supinator

                                                                         -Leg-Clasp knife

Extrapyramidal Tract lesion – Rigidity

Method of procedure

1-Support the elbow with your left hand.

2-Hold pt hand like as it shaking hands.

3- Rapidly supinate and pronate the arm.

4- Use the same technique on each arm.

5-Always use the same hand to assess movement for the pt RT and left

6-If tone is normal there will be no resistance to these movements

Testing spasticity in the legs

1-pt the hand on the thigh and roll the whole leg

2-observe the movement of the foot

3-if tone normal: ROM=Rotation of the leg

Or 1-flex and extend the knee

2-if tone normal-No resistance to this movement.

Clonus

-Pt with the knee flexed and the hip externally rotate.

-Do sharply dorsiflex the foot.

-Normal tone -The foot will not move.

But 2-3 beats of clonus (plantar flexion f/b dorsiflexion of the foot) can be within normal limits

Sustained clonus is a sigh of an upper motor neuron problem.

TREMORS

• Most common form of involuntary movement
• Rhythmic occillatory, repetitive movement, produced by alternating or synchronous contraction of antagonist muscles.

TREMOR RATING

• – Non perceived
• – slight (barely noticeable)
• – moderate, noticeable, probably not disabling
• –marked, probably partially disabled
• – severe, coarse, disable

TYPES

Rest Tremor  

            Parkinson disease

            ET Variants

            Mid brain lesions

            Myorhythemic

Action Tremor

            Postural

• Physiologic
• Enhanced physiologic (stress, drug, endocrine)
• Orthostatic
• Cerebellar
• Neuropathic

Kinetic

• Cerebellar lesion (MS, stroke, Wilson disease,
• Midbrain

Miscellaneous

• Idiopathic
• Psychogenic
• Other involuntary movements like myoclonus, clonus, astrerixis

CO-ORDINATION

• Ability to execute smooth, accurate, controlled movement
• Kinematic + kinetic (force) parameters =  intended action

In-coordination

Awkward , Extraneous , Uneven , Inaccurate movements  =  Abnormal motor function

Coordination deficits due to dysfunction of  cereballam, basal ganglia, dorsal columns                      

Causes of coordination deficits 

• Multiple sclerosis
• Cerebral palsy
• Cerebellar tumor
• Parkinson disease
• Huntington’s disease
• Sydenham’s chorea

TEST

            Equilibrium Test

• Static and mobile components of movements – sitting position
• Involve both gross and fine motor activities

Non Equilibrium Test

• Consider both static and dynamic components – standing position

1. Finger nose test
2. Finger- to-therapist’s finger
3. Finger to finger
4. Alternate nose to finger
5. Finger opposition
6. Mass grasp
7. Alternate heal to knee ; heel to toe
8. Toe to examiner’s finger
9. Heel on shin
10. Drawing a circle

Difference between umn and lmn

• UMN -Upper Motor Neuron

An upper motor neuron exists in the brain and sends higher-level motor information to the medulla, located in the brain, or to the correct spinal cord level outside of the brain. From the medulla or the spinal cord, lower motor neurons carry motor information to muscle fibers, making them much more directly responsible for movement than upper motor neurons.

• LMN – Lower Motor Neuron

            The lower motor neuron is responsible for transmitting the signal from the upper motor neuron to the effector muscle to perform a movement. There are three broad types of lower motor neurons: somatic motor neurons, special visceral efferent (branchial) motor neurons, and general visceral motor neurons.

DIFFERENCE BETWEEN UMN AND LMN LESION

CLINICAL EXAMINATION OF MUSCULOSKELETAL SYSTEM

SYMPTOMS AND DEFINITIONS

• PAIN :

1. Site

Determine whether the pain originates from a joint (arthralgia) , muscle (myalgia) or other soft tissue.

The site may be well localised and suggest the diagnosis, e.g. the first metatarsophalangeal joint in gout, or in several joints suggesting an inflammatory arthritis.

– How many joints are involved?

– One joint is a monoarthritis;

– 2–4 jointsoligoarthritis;

– >4 is polyarthritis.

-Are the small or large joints of the arms or legs affected? Different patterns of joint involvement help the differential diagnosis.

-Surrounding structures can be painful and include ligaments, tendons, tendon sheaths, bursae, muscleand bone

-It may be difficult to determine the source of referred pain. Almost all adults with arthritis (inflamed and swollen joints) have arthralgia (joint pain), but only a minority of patients with arthralgia have arthritis.

2. Onset

-Pain from traumatic injury is usually immediate and is exacerbated by movement or haemarthrosis (bleeding into the affected joint).

-Pain from inflammatory arthritis can develop over 24 hours, or more insidiously.

-Crystal arthritis (gout and pseudogout) causes acute, sometimes extreme pain which develops quickly, often overnight. Joint sepsis causes pain that develops over a day or two.

3. Character

-Bone pain is penetrating, deep or boring, and is characteristically worse at night.

-Localised pain suggests tumour, osteomyelitis (infection), osteonecrosis or osteoid osteoma (benign bone tumour)

-Generalised bony conditions, such as osteomalacia, usually cause diffuse pain.

-Muscle pain is often described as ‘stiffness’ and is poorly localised, deep and aggravated by use of the affected muscle(s). It is associated with muscle weakness in some conditions, e.g., polymyositis, but not in polymyalgia rheumatica.

-Partial muscle tears are painful; complete rupture may be less so.

-Fracture pain is sharp and stabbing, aggravated by attempted movement or use, and relieved by rest and splintage.

-Shooting’ pain is often caused by mechanical impingement of a peripheral nerve or nerve root: e.g., buttock pain which ‘shoots down the back of the leg’, caused by lumbar intervertebral disc protrusion.

-Chronic joint pain in patients >40 years with progression over years is commonly caused by osteoarthritis.

-Neurological involvement in diabetes mellitus, leprosy, syringomyelia and syphilis (tabes dorsalis) may cause loss of joint sensation, so pain is less than expected from examination. In these conditions, even grossly abnormal joints may be pain-free (Charcot joint).

-Chronic pain syndrome (fibromyalgia) causes widespread, unremitting pain with little diurnal variation that is poorly controlled by conventional analgesic/ anti-inflammatory drugs. Chronic pain syndrome is defined as pain present for more than 3 months. It is due to pain pathway sensitisation and is commonly associated with sleep disorders, psychological stress and depression. Examination is normal except for the presence of typical tender points .

4. Radiation

-Pain from nerve compression radiates to the distribution of that nerve, e.g., lower leg pain in prolapsed intervertebral disc or hand pain in carpal tunnel syndrome.

-Neck pain radiates to the shoulder or over the top of the head.

-Hip pain is usually felt in the groin but may radiate to the thigh or knee.

5. Alleviating factors/associated symptoms

-Pain caused by a mechanical problem is worse on movement and eases with rest.

-Pain due to inflammation is worse first thing in the morning and eases with movement.     

-Pain from a septic joint is present both at rest and with movement.

6. Timing (frequency, duration and periodicity of symptoms)

-A history of several years of pain with a normal examination suggests chronic pain syndrome.

-A history of several weeks of pain, early-morning stiffness and loss of function is likely to be an inflammatory arthritis. ‘Flitting’ pain starting in one joint and moving to others over a period of days is a feature of rheumatic fever and gonococcal arthritis.

-If intermittent with resolution between episodes it is likely to be palindromic rheumatism.

7. Exacerbating factors

-Pain from joints damaged by intra-articular derangement or osteoarthritic degeneration will worsen with exercise.

8. Severity

-Apart from trauma, the most severe joint pain occurs in septic and crystal arthritis.

9. Stiffness

Establish what the patient means by stiffness. Is it:

• restricted range of movement?
• difficulty moving, but with a normal range?
• painful movement?
• localized to a particular joint or more generalized?

Stiffness may relate to the soft tissues rather than the joint itself. In polymyalgia rheumatica stiffness commonly affects the shoulder and pelvic areas.         

There are characteristic differences between inflammatory and non-inflammatory presentations of joint stiffness:

-Inflammatory arthritis presents with early-morning stiffness that takes at least 30 minutes to wear off with activity.

– Non-inflammatory, mechanical arthritis has stiffness after rest which lasts only a few minutes on movement.

10. Swelling

Establish the site, extent and time course of any swelling.

-Active inflammatory arthritis from any cause results in swelling.

-When vascular structures, e.g., bone and ligament, are injured, bleeding into the joint or soft tissues produces tense swelling within minutes. This is even more rapid and severe if the patient takes anticoagulants or has an underlying bleeding disorder, e.g., haemophilia.

-If avascular structures, e.g., the menisci, are torn or articular cartilage is abraded, it can take hours or days to produce a significant effusion.

11. Erythema (redness) and warmth

-Erythema is common in infective, traumatic and crystal-induced conditions and may be mildly present in inflammatory arthritis. All joints with an inflammatory or infective component will be warm.

-Erythema associated with distal interphalangeal (DIP) joint swelling helps to distinguish DIP joint psoriatic arthritis from the Heberden’s nodes of osteoarthritis.

12. Weakness

Weakness suggests joint, neurological or muscle disease. The problem may be focal or generalised.

-Weakness due to joint disorders is either from pain inhibiting function or to disruption of the joint or its supporting structures.

-For neurological disorders producing weakness. Always consider nerve entrapment as a cause, e.g., carpal tunnel syndrome at the wrist and leg weakness due to spinal root compression caused by a prolapsed intervertebral disc or spinal stenosis.

-Muscle disorders can produce widespread weakness associated with pain and fatigue, e.g., in polymyositis and with a rash in dermatomyositis. Proximal muscle weakness can occur in endocrine disorders, e.g., hypothyroidism.

13. Locking and triggering

‘Locking’ is an incomplete range of movement at a joint because of an anatomical block. It may be associated with pain. Patients use ‘locking’ to describe a variety of problems, so clarify exactly what they mean. True locking is a block to the normal range of movement caused by mechanical obstruction, e.g., a loose body or torn meniscus, within the joint. This prevents the joint from reaching the extremes of normal range. The patient is characteristically able to ‘unlock’ the joint by trick manoeuvres.

-Pseudo-locking is a loss of range of movement due to pain.

Triggering is a block to extension, which then ‘gives’ suddenly when extending a finger from a flexed position. In adults it usually affects the ring or middle fingers and results from nodular tendon thickening or fibrous thickening of the flexor sheath due to chronic low-grade trauma, e.g., occupational or associated with inflammatory arthritis. Triggering can be congenital, usually affecting the thumb.

14. Extra-articular features

Patients may present with features of extra-articular disease which they may not connect with musculoskeletal problems. The pattern of the joint condition (a/symmetric, flitting) and extent (mono-, oligo- or polyarthritis) suggests the diagnosis and directs the history.

-Ask about rashes (psoriasis, vasculitis, erythema nodosum) and whether they are photosensitive (systemic lupus erythematosus: SLE).

-Weight loss, low-grade fever and malaise are associated with rheumatoid arthritis and SLE.

-High-spiking fevers in the evening with a rash occur in adult-onset Still’s disease. Headache, jaw pain on chewing (claudication) and scalp tenderness are features of temporal arteritis.

-Connective tissue disease may present with Raynaud’s phenomenon, sicca symptoms (dryness of mouth and eyes), rash, mouth ulcers, dysphagia and gastrointestinal problems.

-Dyspnoea may be related to lung disease associated with rheumatoid arthritis or connective tissue disease.

-Abdominal pain, diarrhoea, bloody stool and mouth ulcers may suggest an arthritis associated with inflammatory bowel disease.

15. Gait

Ask the patient to walk ahead in a straight line for several steps, then turn and walk back towards you. Look for smoothness and symmetry of the gait.

16. Arms

Stand in front of the patient.

-Ask him to clench his fists, and then open his hands flat. This tests both wrists and hands.

-Inspect the dorsum of the hands and check for full finger extension at the MCP, PIP and DIP joints.

-Ask him to squeeze your index and middle fingers. This tests the strength of the power grip.

-Have him touch each fingertip with his thumb. This tests precision grip and problems in co-ordination or concentration.

-Gently squeeze the metacarpal heads. Tenderness suggests inflammation, e.g., rheumatoid arthritis, involving the MCP joints.

-Show him how to make a ‘prayer sign’, bending the wrist back as far as possible. Put the backs of the hands together in a similar fashion. This tests wrist flexion and extension.

-Ask him to put his arms straight out in front of the body. This tests elbow extension.

-Ask the patient to bend the arms up to touch the shoulders. This tests elbow flexion.

-Have him place the elbows by the side of the body and bend them 90°. Turn the palms up and down. This tests pronation and supination at the wrist and elbow.

-Ask him to put his hands behind the head, with the elbows going back. This tests abduction and external rotation of the glenohumeral joint.

-Firmly press the midpoint of each supraspinatus to detect hyperalgesia.

17. Legs

-Ask the patient to lie supine (face up) on the couch.

-If there is no contraindication, perform Thomas’s test for fixed flexion deformity on both hips.

-Palpate each knee for warmth and swelling. Check for patellar tap. These detect inflammation and effusions.

-Flex each hip and knee with your hand on the patient’s knee. Feel for crepitus in the patellofemoral joint and knee .

-Flex the patient’s knee and hip to 90°, and passively rotate each hip internally and externally, noting pain or limited movement.

-Look at the feet for any abnormality. Examine the soles, looking for calluses and ulcers, indicative of abnormal load bearing.

-Gently squeeze the metatarsal heads for tenderness.

18.Spine

• Stand behind the patient. Assess the straightness of the spine, muscle bulk and symmetry in the legs and trunk. Look for asymmetry at the level of the iliac crests (unilateral leg shortening) and swelling or other abnormality of the gluteal, hamstring, popliteal and calf muscles. Look at the Achilles tendons and hindfoot regions for swelling or deformity.
• Stand beside the patient. Ask him to bend down and try to touch his toes. This highlights any abnormal spinal curvature or limited hip extension. If he can put his hands flat to the floor, he may have hypermobility.
• Stand behind the patient, hold the pelvis, and ask him to turn from side to side without moving his feet. This tests thoracolumbar rotation.
• Ask him to slide the hand down the lateral aspect of the leg towards the knee. This tests lateral lumbar flexion.
• Stand in front of the patient. Ask him to put his ear on his shoulder to test lateral cervical flexion.
• Ask him to look up at the ceiling and then down at the floor to test cervical flexion and extension.
• Ask him to let the jaw drop open and move it from side to side. This tests both temporomandibular joints.

Abnormal findings :

Hypermobility Some patients have a greater than normal range of joint movement. They may present with recurrent dislocations or sensations of instability if this is severe, but frequently only complain of arthralgia.

Mild hypermobility is normal but two inherited conditions affecting connective tissues – Marfan’s syndrome and Ehlers–Danlos syndrome – cause hypermobility.

Further examination

The GALS screen provides a rapid, but limited, assessment. This section describes the detailed examination required for better evaluation.

1. GAIT

Gait is the cyclical pattern of musculoskeletal motion that carries the body forwards. Normal gait is smooth, symmetrical and ergonomically economical, with each leg 50% out of phase with the other.

For each leg, gait has two phases: stance and swing. The stance phase is from foot-strike to toe-off, when the foot is on the ground and load bearing. The swing phase is from toe-off to foot-strike, when the foot clears the ground. When both feet are on the ground this is double stance.

A limp is an abnormal gait due to pain or structural change, e.g. lower limb length discrepancy, tone abnormality (including spasticity and co-contraction, in both of which there is inappropriate muscle contraction) or weakness.

1. PAIN

An antalgic gait is one altered to reduce pain. Pain in a lower limb is usually aggravated by weight-bearing, so minimal time is spent in the stance phase on that side. This results in a ‘dot–dash’ mode of walking. If the source of pain is in the spine, axial rotatory movements are minimised, resulting in a slow gait with small paces. Patients with hip pain may lean towards the affected side as this decreases the compression force on the hip joint.

1. STRUCTURAL CHANGE

Patients with limb-length discrepancy may walk on tiptoe on the shorter side, with compensatory hip and knee flexion on the longer side. Assess for limb-length discrepancy with block testing. Other structural changes producing an abnormal gait include joint fusion, bone malunion and contracture.

1. WEAKNESS

This may be due to nerve or muscle pathology or alteration in muscle tone. In a normal gait the hip abductors of the stance leg raise the contralateral hemipelvis. In Trendelenburg gait, abductor function is poor when weight bearing on the affected side, so the contralateral hemipelvis falls.

Common causes of a Trendelenburg gait are:

• weakness of the hip abductors, e.g., in polio or paresis of the superior gluteal nerve after total hip replacement
• structural hip joint problems, e.g., congenital dislocation of the hip
• painful hip joint problems, e.g., osteoarthritis.

Foot drop occurs in common peroneal nerve palsy. The gait is high-stepping to allow clearance of the weak foot.

1. INCREASED TONE

This occurs following an upper motor neurone lesion, e.g., cerebrovascular accident (stroke) or cerebral palsy. The gait depends on the specific lesion, contractures and compensatory mechanisms. A common pattern in cerebral palsy is the crouch gait, in which the hips and knees are always flexed.

EXAMINATION SEQUENCE

1. Examination of gait

• Gait :

Ask the patient to walk barefoot in a straight line; then repeat in shoes.

• Observe the patient from behind, in front and from the side.
• Evaluate what happens at each level (foot, ankle, knee, hip and pelvis, trunk and spine) during both stance and swing phases.
• Assess each joint

• Spine :

The spine is divided into the cervical, thoracic, lumbar and sacral segments. Most spinal diseases affect multiple segments, causing alteration in the posture or function of the whole spine. Spinal disease may occur without local symptoms and present with pain, neurological symptoms or signs in the trunk or limbs. Accurate diagnosis depends on knowing the underlying bony and neurological anatomy , a careful history, and eliciting signs and symptoms to differentiate between mechanical (non-inflammatory) and inflammatory causes

.

Definitions :

• Spinal deformities :

-Scoliosis is lateral curvature of the spine .

-Kyphosis is curvature of the spine in the sagittal (anterior–posterior)               plane, with the apex posterior. The thoracic spine normally has a mild kyphosis.

-Lordosis is curvature of the spine in the sagittal (anterior–posterior) plane, with the apex anterior.

-Gibbus is a spinal deformity caused by an anterior wedge deformity localised to a single vertebra, producing an increase in forward flexion.

-Spondylosis is degenerative change in the spine. Spondylolysis is a defect in the pars interarticularis of a vertebral arch.

-Spondylolisthesis is one vertebra slipping anteriorly on an inferior vertebra.

-Retrolisthesis is one vertebra slipping posteriorly on an inferior vertebra.

• Cervical spine :

The most common symptoms are pain and difficulty turning the head and neck. Patients find difficulty driving, especially when attempting to reverse. Neck pain is usually felt posteriorly but may be referred to the head, shoulder, arm or interscapular region. Cervical disc lesions cause radicular pain in one or other arm, roughly following the dermatomes of the affected nerve roots. If the spinal cord is compromised (cervical myelopathy), then lower limb weakness, difficulty walking, loss of sensation and sphincter disturbance may occur.

Be particularly careful when examining patients with rheumatoid arthritis, as atlantoaxial instability can lead to spinal cord damage when the neck is flexed.

In patients with neck injury, never move the neck. Splint it and check for abnormal posture. Check neurological function in the limbs and X-ray to assess bony injury.

Examination of the cervical spine :

Ask the patient to remove enough clothing for you to see the neck and upper thorax, then to sit on a chair.

1. Look :

Face the patient. Observe the posture of the head and neck. Note any abnormality or deformity, e.g. loss of lordosis (usually due to muscle spasm).

1. Feel :

-Feel the midline spinous processes from the occiput to T1 (the T1 process is usually the most prominent).

-Feel the paraspinal soft tissues.

-Feel the supraclavicular fossae for cervical ribs or enlarged lymph nodes.

-Feel the anterior neck structures, including the thyroid.

Note  : any tenderness in the spine, trapezius, interscapular and paraspinal muscles.

1. Move :

-Assess active movements.

-Ask the patient to put his chin on to the chest to assess forward flexion.     -The normal range is 0 (neutral) to 80°. Record a decreased range as the chin–chest distance.

-Ask him to look upwards at the ceiling as far back as possible, to assess extension. The normal range is 0 (neutral) to 50°. Thus, the total flexion–extension arc is normally ∼130°.

-Ask him to put his ear on to the shoulder, to assess lateral flexion. The normal range is 0 (neutral) to 45°.

-Ask the patient to look over his right/left shoulder. The normal range of lateral rotation is 0 (neutral) to 80°.

-If active movements are reduced, gently perform passive movements. -Establish if the end of the range has a sudden or a gradual resistance and whether it is pain or stiffness that restricts movement. Pain or paraesthesia in the arm on passive neck movement suggests nerve root involvement.

-Perform a neurological assessment of the upper and lower limbs.

• Thoracic spine :

– Examination of the thoracic and lumbar spine

Ask the patient to undress to expose the neck, chest and back.

1. Look

With the patient standing, inspect the posture from behind, the side and the front, noting any deformity, e.g., rib hump or abnormal curvature.

1. Feel

Feel the midline spinous processes from T1 to T12. Feel for increased prominence of one or more posterior spinal processes, implying anterior wedge-shaped collapse of the vertebral body – often related to osteoporosis.

Feel the paraspinal soft tissues for tenderness.

1. Move

Ask the patient to sit with his arms crossed. Ask him to twist round both ways and look at you.

• Lumbar spine :

The surface markings are the spinous processes of L4/5, which are level with the pelvic brim, and the ‘dimples of Venus’, which overlie the sacroiliac joints. The normal lordosis may be lost in disorders such as ankylosing spondylitis and lumbar disc protrusion.

The principal movements are flexion, extension, lateral flexion and rotation. Most patients can bring the tips of their fingers at least to the level of the knees in forward and lateral flexion. Extension should be approximately 10–20°. In flexion, the upper segments move first, followed by the lower segments, to produce a smooth lumbar curve. However, even with a rigid lumbar spine, patients may be able to touch their toes if their hips are mobile.

In the adult, the spinal cord ends at L2. Below this, the spinal nerve roots may be injured or compressed by disc protrusion. Above this level the spinal cord itself may be involved.

The history :

Low back pain is extremely common. Most is ‘mechanical’, and due to degenerative disease. Radicular back pain due to nerve root compression radiates down the posterior aspect of the leg to the lower leg or ankle. Pain due to inflammation of the sacroiliac joints is commonly felt in the buttocks, but may be referred down both legs to the knees. Groin and thigh pain in the absence of hip abnormality suggests referred pain from L1–2.

Red flag features suggest significant spinal pathology. Consider abdominal and retroperitoneal pathology too, e.g., abdominal aortic aneurysm, pancreatitis, peptic ulcer and renal disorders.

Important spinal conditions :

          Are acute disc protrusion, spinal stenosis, ankylosing spondylitis, osteoporotic fracture, infection and tumours. Infection and tumours are associated with fever or weight loss. In many patients, however, backache reflects age- related degenerative change in discs and facet joints (spondylosis).

Mechanical low back pain is common after standing for too long or sitting in a poor position. Symptoms worsen as the day progresses and improve after resting or on rising in the morning.

Insidious onset of backache and stiffness in an adolescent or young adult suggests inflammatory disease of the sacroiliac joints and lumbar spine, e.g. ankylosing spondylitis . Symptoms are worse in the morning or after inactivity, and ease with movement. Morning stiffness is more marked than in osteoarthritis, lasting at least 30 minutes. Other clues to the diagnosis are peripheral joint involvement, extra-articular features or a positive family history.

Acute onset of low back pain in a young adult, often associated with bending or lifting, is typical of acute disc protrusion (slipped disc). The acute episode may be superimposed on a background of preceding episodic backache due to disc degeneration. Activities such as coughing or straining to open the bowels exacerbate the pain. There may be symptoms of lumbar or sacral nerve root compression. Cauda equina syndrome involves a central disc prolapse, or similar space-occupying lesion, impinging on the cauda equina. There are features of sensory and motor disturbances, including diminished perianal sensation and bladder function disturbance. The motor disturbance may be profound, e.g. paraplegia.

Acute back pain in the middle-aged, elderly or those with risk factors, e.g., steroid therapy, may be due to osteoporotic fracture. This is eased by lying, exacerbated by spinal flexion and not usually associated with neurological symptoms.

Acute onset of severe progressive pain, especially associated with malaise, weight loss or night sweats, may indicate pyogenic or tuberculous infection of the lumbar spine or sacroiliac joint. The patient may have a past history of diabetes mellitus or immunosuppression, e.g., steroid therapy or HIV infection, and complain of pain and great difficulty in moving. The infection may involve the intervertebral discs and adjacent vertebrae and may track into the psoas muscle sheath, presenting as a painful flexed hip or a groin swelling.

Consider malignant disease involving a vertebral body in patients with unremitting spinal pain of recent onset, disturbing sleep. Other clues are a previous history of cancer, and systemic symptoms or weight loss. Tumours rarely affect intervertebral discs.

Cauda equina syndrome and spinal cord compression are neurosurgical emergencies. If suspected, refer the patient immediately for assessment and possible surgical decompression.

Intermittent discomfort or pain in the lumbar spine occurring over a long period of time is typical of degenerative disc disease. There is stiffness in the morning or after immobility. Pain and stiffness are relieved by gentle activity but recur with, or after, excessive activity. Over years there is gradual loss of lumbar spine mobility, sometimes with spontaneous improvement in pain as the facet joints increasingly stiffen.

Diffuse pain in the buttocks or thighs brought on by standing too long or walking is the presenting symptom of lumbosacral spinal stenosis. This can be difficult to distinguish from intermittent claudication. The pain may be accompanied by tingling and numbness and difficult for the patient to describe. Typically, it is relieved by rest or spinal flexion. Stooping or holding on to a supermarket trolley may increase exercise tolerance. Narrowing of the spinal canal or neural exit foramina is caused by degenerative changes in the intervertebral discs and facet joints, and there is a long preceding history of discomfort typical of degenerative joint disease.

• Examination of the thoracic and lumbar spine

Ask the patient to stand with the back fully exposed.

1. Look

Look for obvious deformity, such as decreased/increased lordosis, obvious scoliosis, soft-tissue abnormalities like a hairy patch or lipoma that might overlie a congenital abnormality, e.g., spina bifida.

1. Feel

Palpate the spinous processes and paraspinal tissues. Note the overall alignment and focal tenderness (the L4/5 interspinous space is palpable at the level of the iliac crests).

After warning the patient, lightly percuss the spine with your closed fist and note any tenderness.

1. Move

Flexion: ask the patient to try to touch his toes with his legs straight. Record how far down his legs he can reach. Some of this movement depends on hip flexion. Usually, the upper segments flex before the lower ones, and this progression should be smooth.

Extension: ask the patient to straighten up and lean back as far as possible (normal 10–20° from neutral erect posture).

Lateral flexion: ask him to reach down to each side, touching the outside of the leg as far down as possible while keeping the legs straight.

• Special tests :

1. Schober’s test :

Schober’s test for forward flexion

-Mark the skin in the midline at the level of the posterior iliac spines (L5), which overlie the sacroiliac joints (mark A).

-Use a tape measure to draw two more marks: one 10 cm above (mark B) and one 5 cm below this (mark C).

-Place the end of the tape measure on the upper mark (B). Ask the patient to touch his toes. The distance from mark B to mark C should increase from 15 to more than 20 cm.

-Root compression tests Intervertebral disc prolapse causing nerve root pressure occurs most often in the lower lumbar region, leading to compression of the corresponding nerve roots.

-The femoral nerve (L2–4) lies anterior to the pubic ramus, so straight-leg raising or other forms of hip flexion do not increase its root tension. Problems with the femoral nerve roots may cause quadriceps weakness and/or diminished knee jerk on that side.

The sciatic nerve (L4–5; S1–3) runs behind the pelvis, so manoeuvres to put tension on the lower nerve roots (L4 exiting the L4/5 foramen, L5 exiting the L5/S1 foramen) differ from those for the upper lumbar nerve roots (L2, L3).

Straight-leg raise tests L4, L5, S1 nerve root tension (L3/4, L4/5 and L5/S1 disc prolapse respectively).

1. Straight leg raise

With the patient lying supine, lift the foot to flex the hip passively, keeping the knee straight.

Measure the angle between the couch and the flexed leg to determine any limitation (normal 80–90° hip flexion) caused by thigh or leg pain.

If a limit is reached, raise the leg to just less than this level, and dorsiflex the foot to test for nerve root tension.

1. Tibial nerve stretch tests L4–5, S1–3

Tibial nerve stretch test

With the patient supine, flex the hip to 90°.

Extend the knee. In this position the tibial nerve ‘bowstrings’ across the popliteal fossa.

Press over either of the hamstring tendons, and then over the nerve in the middle of the fossa. The test is positive if pain occurs when the nerve is pressed, but not the hamstring tendons.

1. Femoral nerve stretch tests L2–4

With the patient lying on his front (prone), flex the knee and extend the hip. This stretches the femoral nerve. A positive result is pain felt in the back, or the front of the thigh. This test can, if necessary, be performed with the patient lying on his side (with the test side uppermost).

1. Flip test for functional overlay

Ask the patient to sit on the end of the couch with the hips and knees flexed to 90° .

-Examine the knee reflexes.

Extend the knee, as if to examine the ankle jerk. A patient with nerve root impingement will lie back (‘flip’).

THE UPPER LIMB

The prime function of the upper limb is to position the hand appropriately in space. This requires shoulder, elbow and wrist movements. The hand may function in both precision and power modes. The intrinsic muscles of the hand allow grip and fine manipulative movements, and the forearm muscles provide power and stability.

Distinguish between systemic and local conditions. Systemic conditions, e.g. rheumatoid arthritis, usually cause pathology at several sites. Differentiate local conditions from referred or radicular pain. Establish whether the condition is inflammatory or not on the pattern of diurnal stiffness and pain.

The hand and wrist

The wrist joint has metacarpocarpal, intercarpal, ulnocarpal and radiocarpal components. There is a wide range of possible movements, including flexion, extension, adduction (deviation towards the ulnar side), abduction (deviation towards the radial side) and the composite movement of circumduction (the hand moves in a conical fashion on the wrist). When examining and documenting the fingers, use their names to avoid confusion. The PIP and DIP joints are hinge joints and allow only flexion and extension. The metacarpophalangeal (MCP) joints allow flexion and extension, and some abduction/adduction that is greatest when the MCP joints are extended.

History :

The patient will often localise complaints of pain, stiffness, loss of function, contractures, disfigurement and trauma. If symptoms are vague or diffuse, consider referred pain or a compressive neuropathy, e.g. median nerve compression as it traverses the carpal tunnel in the wrist, which leads to symptoms and signs of carpal tunnel syndrome. If PIP or MCP joint swelling is prominent consider inflammatory arthritis.

• Examination sequence

Examination of the hand

Seat the patient, facing you, with arms and shoulders exposed. Start examining the hand and fingers first, and move proximally.

1. Look

• Colour changes including palmar erythema.
• Hand and wrist swelling.(A) Ask the patient to make a fist. Look at it straight on to detect any loss of ‘hill…

Swelling of MCP joints produces loss of interknuckle indentation on the dorsum of the hand, especially when the MCP and IP joints are fully flexed (loss of normal ‘hill–valley–hill–valley’ aspect; . Swelling at the PIP joints produces ‘spindling’ .

Deformity of phalangeal fractures may produce rotation. Ask the patient to flex the fingers together and then in turn. Normally, with the MCP and IP joints flexed, the fingers should not cross, and should point to the scaphoid tubercle in the wrist.

Extra-articular signs :

• Small muscle wasting, especially of the interossei in inflammatory arthritis (T1 nerve root lesion or ulnar nerve palsy).
• Vasculitis of the fingers, most commonly detected in the nail folds.
• Nail changes, e.g. pitting (psoriasis) and onycholysis (loosening of the nail from its bed) in psoriatic arthritis.

1. Feel

• Hard swellings are bony; soft swelling suggests synovitis.
• Palpate above and below the IP joints with your thumb and index finger to detect sponginess.
• Test the MCP joints by examining for sponginess and squeeze gently across them for pain.
• Palpate the flexor tendon sheaths in the hand and fingers to detect local swellings or tenderness. If you detect any swelling (usually just proximal to the MCP joints), ask the patient to flex and then extend the finger and see if there is triggering or ‘locking’.
• Feel for crepitus. Place your index finger across the fully extended fingers and ask the patient to open and close the fingers.

1. Move

Active movements

• Ask the patient to make a fist, and then extend his fingers fully.
• Insert your index and middle finger from the thumb side into the patient’s palm and ask him to squeeze them as hard as possible to test grip.

Passive movements

• Move each finger through flexion and extension and notice any triggering.
• Reduced range of movement at right wrist.

Ask the patient to put the palms of his hands together and extend the wrists fully – the ‘prayer sign’ (normal is 90° of extension) .

• Ask the patient to put the backs of his hands together and flex the wrists fully – the ‘reverse prayer sign’ (normal 90° of flexion) .
•  

Abnormal findings

Look Erythema suggests acute inflammation caused by soft-tissue infection, septic arthritis, tendon sheath infection or crystalopathy (gout and pseudogout). Swelling at the MCP and/or IP joints suggests synovitis. Spindling is typically seen in rheumatoid arthritis and collateral ligament injuries.

At the DIP joints , a ‘mallet’ finger is a flexion deformity which is passively correctable. This is usually caused by minor trauma disrupting the terminal extensor expansion at the base of the distal phalanx, with or without bony avulsion.

Boutonnière (or buttonhook) deformity is a flexion deformity at the PIP joint with hyperextension at the DIP joint and fixed flexion at the PIP joint . ‘Swan neck’ deformity is hyperextension at the PIP joint with flexion at the DIP joint.

 There may be subluxation and ulnar deviation of the MCP joints in rheumatoid arthritis . Dupuytren’s contracture affects the palmar fascia, resulting in the MCP and PIP joints of the little and ring fingers becoming fixed in flexion . Anterior (or volar) displacement (partial dislocation) of the wrist may be seen in rheumatoid arthritis.

Feel Hard swellings may be due to osteophytes (characteristic of osteoarthritis), mucous cysts or, rarely, tumours. Heberden’s and Bouchard’s nodes occur at the DIP and PIP joints respectively.

Sponginess suggests synovitis. Swelling, tenderness and crepitus are found over the tendon sheaths of abductor pollicis longus and extensor pollicis brevis in De Quervain’s tenosynovitis. Symptoms are aggravated by movements at the wrist and thumb. Crepitus at this site is often felt as a creaking sensation and may even be audible. Crepitus may also occur with movement of the radiocarpal joints in osteoarthritis, most commonly secondary to old scaphoid or distal radial fractures.

Move Lack of full extension of one or more fingers may indicate tendon rupture.

Examination sequence

• Muscles and tendons

Flexor digitorum profundus: ask the patient to flex the DIP joint while you hold the PIP joint in extension .

• Flexor digitorum superficialis: hold the other fingers fully extended (to eliminate the action of flexor digitorum profundus, as it can also flex the PIP joint) and ask the patient to flex the PIP joint in question.
• Extensor digitorum: ask the patient to extend the fingers with the wrist in the neutral position .
• Flexor and extensor pollicis longus: hold the proximal phalanx of the patient’s thumb firmly and ask him to flex and extend the IP joint.
• Extensor pollicis longus: ask the patient to place his palm on a flat surface and to extend his thumb like a hitch-hiker . If the tendon is intact, the patient will be able to do this. Pain occurs in De Quervain’s disease.
•  
• Nerves (radial, ulnar and median motor function only)

Use ‘Paper – scissors – stone – OK’ as an aide-mémoire.

Ask the patient to:

Fully extend the wrist and fingers (‘paper sign’). The radial nerve supplies the wrist and finger extensors.

• Make the ‘scissors sign’ .

The ulnar nerve supplies the hypothenar muscles, interossei, two medial lumbricals, adductor pollicis, flexor carpi ulnaris and the ulnar half of flexor digitorum profundus.

• Clench the fist fully (‘stone sign’).

The median nerve supplies the thenar muscles that abduct and oppose the thumb, the lateral two lumbricals, the medial half of flexor digitorum profundus, flexor digitorum superficialis, flexor carpi radialis, palmaris longus and pronator teres. Because of inconstant cross-over in the nerve supply to the thenar eminence muscles other than abductor pollicis brevis, the best test of median nerve motor function is the ability to abduct the thumb away from the palm. However, clenching a fist fully (‘rock’ sign) also depends on median function because of its flexor supply.

• Make the ‘OK’ sign .

The anterior interosseous nerve (commonly injured in supracondylar fractures) is a purely motor terminal branch of the median nerve. It supplies flexor pollicis longus, the index finger flexor digitorum profundus and pronator quadratus. Making the OK sign depends on both flexor pollicis longus and index finger flexor digitorum profundus functioning.

The elbow

The elbow joint has humero-ulnar, radio-capitellar and superior radio-ulnar articulations. The medial and lateral epicondyles are the flexor and extensor origins respectively for the forearm muscles. These two prominences and the tip of the olecranon are easily palpated. They normally form an equilateral triangle when the elbow is flexed to 90°, and lie in a straight line when the elbow is fully extended. A subcutaneous bursa overlies the olecranon and may become inflamed or infected (bursitis). Elbow pain may be localised or referred from the neck. Rheumatoid arthritis and epicondylitis commonly cause elbow pain.

Examination sequence

1. Look

• At the overall alignment of the extended elbow. There is normally a valgus angle of 11–13° when the elbow is fully extended (the ‘carrying angle’).
• For:
  • swelling, bruising and scars
  • swelling of synovitis between the lateral epicondyle and olecranon
  • rash, olecranon bursitis, tophi or nodules
  • rheumatoid nodules on the proximal extensor surface of the forearm.

1. Feel

• The bony contours of the lateral and medial epicondyles and olecranon tip, defining an equilateral triangle with the elbow flexed at 90°.
• For sponginess on either side of the olecranon and ask about tenderness. Synovitis feels spongy or boggy when the elbow is fully extended.
• Focal tenderness, over the lateral or medial epicondyle. When isolated to one site, this may indicate ‘tennis’ (lateral) or ‘golfer’s’ (medial) elbow.
• For bursae, fluid-filled sacs which are usually soft, but if acutely inflamed or infected may be firm.
• For rheumatoid nodules on the proximal extensor surface of the forearm.

1. Move

• Assess the extension–flexion arc: ask the patient to touch his shoulder on the same side and then straighten the elbow as far as possible. The normal range of movement is 0–145°; a range less than 30–110° will cause functional problems.
• Assess supination and pronation: ask the patient to put his elbows by the side of the body and flex them to 90°. Now ask him to turn the hands upwards to face the ceiling (supination: normal range 0–90°) and then downwards to face the floor (pronation: normal range 0–85°).

• Special tests

Examination sequence

1. Tennis elbow (lateral epicondylitis)

• Ask the patient to flex the elbow to 90° and pronate and flex the hand/wrist fully.
• Support the patient’s elbow. Ask him to extend the wrist against your resistance.
• Pain is produced at the lateral epicondyle and may be referred down the extensor aspect of the arm.

1. Golfer’s elbow (medial epicondylitis)

• Ask the patient to flex the elbow to 90° and supinate the hand/wrist fully.
• Support the patient’s elbow. Ask him to flex the wrist against your resistance.
• Pain is produced at the medial epicondyle and may be referred down the flexor aspect of the arm.

The shoulder

The shoulder joint consists of the glenohumeral joint and the acromioclavicular joint, but movement also occurs between the scapula and the posterior chest wall. Movements of the shoulder girdle, especially abduction and rotation, also produce movement at the sternoclavicular joint. The rotator cuff muscles are supraspinatus, subscapularis, teres minor and infraspinatus. They and their tendinous insertions help stability and movement (especially abduction;  at the glenohumeral joint.

• Symptoms and definitions :

Pain is common and frequently referred to the upper arm. Glenohumeral pain may occur over the anterolateral aspect of the upper arm. Pain felt at the shoulder may be referred from the cervical spine, radicular pain caused by central nerve root compression, or diaphragm and subdiaphragmatic peritoneum via the phrenic nerve. The most common cause of referred pain is cervical spondylosis, where disc space narrowing and osteophytes cause nerve root impingement and inflammation.

Stiffness and limitation of movement around the shoulder, caused by adhesive capsulitis of the glenohumeral joint, are common after immobilisation or disuse following injury or stroke. This is a ‘frozen shoulder’. However, movement can still occur between the scapula and chest wall.

Some rotator cuff disorders, especially impingement syndromes and tears, present with a painful arc where abduction of the arm between 60 and 120° causes discomfort .

• Examination sequence

Ask the patient to sit or stand and expose the shoulder completely.

1. Look

Examine from the front and the back and in the axilla for deformity the deformities of anterior glenohumeral and complete acromioclavicular joint dislocation are obvious ,but the shoulder contour in posterior glenohumeral dislocation may only appear abnormal when you stand above the seated patient and look down on the shoulder

• swelling
• muscle wasting: especially of the deltoid, supraspinatus and infraspinatus. Wasting of supraspinatus or infraspinatus indicates a chronic tear of their tendons

1. Feel

• Feel from the sternoclavicular joint along the clavicle to the acromioclavicular joint.
• Palpate the acromion and coracoid (2 cm inferior and medial to the clavicle tip) processes, the scapula spine and the biceps tendon in the bicipital groove.
• Extend the shoulder to bring supraspinatus anterior to the acromion process. Palpate the supraspinatus tendon.

1. Move

To screen for shoulder dysfunction:

• Stand behind the patient.
• Ask the patient to put both hands behind the head.
• Then put the arms down and reach behind his back to touch the shoulder blades.

If there is pain, swelling or limitation of movement, proceed to examine the shoulder fully.

Range of movement :

• First assess active movement, then passive.
• Ask the patient to flex and extend the shoulder as far as possible.
• Abduction: ask the patient to lift his arm away from his side.

Palpate the inferior pole of the scapula between your thumb and index finger to detect scapular rotation and determine how much movement occurs at the glenohumeral joint. In all, 50–70% of abduction occurs at the glenohumeral joint (the rest with movement of the scapula on the chest wall). This increases if the arm is externally rotated. Note the degree and smoothness of scapular movement. If the glenohumeral joint is excessively stiff, movement of the scapula over the chest wall will predominate. If there is any limitation or pain (painful arc) associated with abduction, test the rotator cuff .

• Internal rotation: with the patient’s arm by his side and the elbow flexed at 90°, ask him to put his hand behind his back and feel as high up the spine as possible. Document the highest spinous process that he can reach with the thumb.
• External rotation: in the same position with the elbow tucked against his side, ask him to rotate the hand out.
• Deltoid: ask the patient to abduct the arm out from his side, parallel to the floor, and resist while you push down on the humerus. Compare each side.

Rotator cuff :

• Ask the patient to start abducting the arm from his side against your resistance. If abduction cannot be initiated or is painful, this suggests a rotator cuff problem.

Impingement (painful arc) :

• Passively abduct the patient’s arm fully
• Ask him to lower (adduct) it slowly .

Pain occurring between 60 and 120° of abduction occurs in painful arc.

• If the patient cannot initiate abduction, place your hand over the scapula to confirm there is no scapular movement.
• Passively abduct the internally rotated arm to 30–45°
• Ask him to continue to abduct the arm.

Pain on active movement, especially against resistance, suggests impingement.

Ligamentous tears and injuries :

Discrepancy between active and passive ranges suggests a tendinous tear  in particular subscapularis, where there may be an excessive range of passive internal rotation. To test the component muscles of the rotator cuff, it is necessary to neutralise the effect of other muscles crossing the shoulder.

• Subscapularis and pectoralis major (internal rotation of the shoulder):
  • To isolate subscapularis, test internal rotation with the patient’s hand behind his back. Loss of power suggests a tear. Pain on forced internal rotation suggests tendonitis.
• With the arm by his side, test abduction. Loss of power suggests a tear. Pain on forced abduction at 60° suggests tendonitis.
• Infraspinatus and teres minor. Test external rotation with the arm in the neutral position, and 30° flexion to reduce the contribution of deltoid. Loss of power suggests a tear. Pain on forced external rotation suggests tendonitis.

Bicipital tendonitis :

• Palpate the bicipital tendon in its groove, noting any tenderness.
• Ask the patient to supinate the forearm, and then flex the arm against resistance. Pain occurs in bicipital tendonitis.

Gṛdhrasī

• It is a musculoskeletal disorder with cardinal features like Ruk, Toda, Muhurspandana, Stambha in the Sphik, Kaṭī, Ūru, Jānu, Jaṅghāand Pāda and Sakthyutkṣepanigraha.
• It is of two types Vātaja and Vātakaphaja. KaphajaGṛdhrasī associated with Tandra, Aruci, Gaurava. In GṛdhrasīVāta afflicting the Kaṇḍarā/ Snāyuof lower limbs.
• Gṛdhrais a bird called as vulture in English. This bird is fond of meat and it eats flesh of an animal in such a fashion that deeply pierce its beak in the flesh then draws it out forcefully. Exactly such type of pain occurs in Gṛdhrasī because of which the name was given.
• Another meaning is in this disease the patient walks like bird Gṛdhra and his legs becomes tense and slightly curved having the resemblance with the gait of Gṛdhra, hence the name might have given to this disease as Gṛdhrasī.
• Stambha, Ruk, Grahaṇaand Spandana are the distinctive features of Gṛdhrasī. It originates from the SphikPradeśaand radiates down wards through the Pṛṣṭabhāgaof Kaṭī, Ūru, Jānu, Jaṅghā and Pāda.
• Acharya Suśrutaexplained that the vitiated VātaDoṣaafflicts the Kaṇḍarā producing Gṛdhrasī, where in the patient finds difficulty in extending the leg.

EXAMINATION

• History
• General Examination
• Inspection
• Palpation
• Range of Movement
• Special Test

Patient history:

• Information is gathered regarding current signs and symptoms
• Location of pain – localized, radiating
• Onset of pain – acute, chronic
• Consistency of pain – Pain from inflammation (strain, sprain, contusion), Pain of mechanical nature (nerve root compression)
• Mechanism of injury (etiology)
• Prior history of accidentsor spine injury
• Family history and lifestyle
• Medication etc.

This medical background can help give a better picture of what might need further investigation.

Inspection

• To gain idea regarding the degree of disability.
• Observe the patient from the moment he or she enters the consulting room.
• How does the patient enter the room?

A posture deformity in flexion or a deformity with a lateral pelvic tilt, possibly a slight limp, may be seen.

• How does the patient sit down and how comfortably/ uncomfortably does he or she sit?
• How does the patient get up from the chair?

A patient with low back pain may splint the spine in order to avoid painful movements.

• What is the facial expression? Is it in accordance with the pain the patient seems to suffer?
• Look for discoloration of skin, presence of tuft oh hair, muscle wasting, scoliosis etc
• Observe posteriorly and laterally

Posteriorly

• Iliac crests should line up with the fourth lumbar vertebra.
• Lower extremities should share the body load and be in good alignment
• Hip joints not adducted or abducted, knees not bowed, feet parallel or toeing out slightly, and the calcaneal bones neither pronated nor supinated.

Laterally

• Pelvis should be in the neutral position, i.e. the anterior superior iliac spines lie in the same vertical plane as the symphysis pubis.
• Hip, knee and ankle joints should be neither flexed nor hyperextended.

Palpation

• Detect irregularities of the lumbar spinous processes:
  • The index and middle fingers run quickly down the spine feeling for any abnormal projections .

• • Wedging of a vertebral body
  • Complete loss of two adjacent disc spaces
  • Bone erosion of a vertebral body (osteoporosis, tuberculous caries, secondary deposit or an old fracture)
• Pain in the center of the back or the spinal region suggests pain from the from the vertebra.
• Pain just lateral to the center or para-spinal regions suggests pain from a muscle strain of the paraspinal muscles.

Range of movements

• Four active movements are examined while the examiner watches the patient from behind:
  • Extension – Backward bending
  • Lateral Bending – Bending to each side
    • Run hand – down the thigh – as far as possible
  • Flexion – Forward bending – completed at full range by neck flexion
    • Touching toes without bending at the knees
    • In flexion normal lumbar lordosis must be abolished
  • Painful restriction of spinal movement is an important sign of lumbar spondylosis and disc pathologies.

Sacroiliac joint:

• Pain in the buttock most often results from disorders of the lumbar spine. However, pain from hip and sacroiliac disorders is referred to the same area.
• Test to exclude sacroiliac disorders:
  • The examiner places the hands on the anterior superior spines of the ilium with the arms crossed. Pressure is exerted in a downward and outward direction and should be evenly distributed to prevent moving the lumbar region.
  • In a positive test, a deepseated unilateral ache is evoked at the gluteal area.
  • Unilateral pain strongly indicates sacroiliitis or strain of the anterior sacroiliac ligaments.
  • Central pain suggests lumbar disorder

Hip joint:

• • Flexion
  •  Medial rotation
  •  Lateral rotation

Special tests

Root compression tests 

• Inter vertebral disc prolapse causing nerve root pressure occurs most often in the lower lumbar region, leading to compression of the corresponding nerve roots.
• The femoral nerve (L2–4) lies anterior to the pubic ramus, so straight-leg raising or other forms of hip flexion do not increase its root tension. Problems with the femoral nerve roots may cause quadriceps weakness and/or diminished knee jerk on that side.
• The sciatic nerve (L4–5; S1–3) runs behind the pelvis, so manoeuvres to put tension on the lower nerve roots (L4 exiting the L4/5 foramen, L5 exiting the L5/S1 foramen) differ from those for the upper lumbar nerve roots (L2, L3).

Straight Leg Raise Test (SLR Test)

Straight leg raise tests for L4, L5, S1 nerve root tension (L3/4, L4/5 and L5/S1 disc prolapse).

Procedure :

• With the patient lying supine, lift the foot to flex the hip passively, keeping the knee straight.
• Measure the angle between the couch and the flexed leg to determine any limitation (normal 80–90° hip flexion) caused by thigh or leg pain.
• If a limit is reached, raise the leg to just less than this level, and dorsiflex the foot to test for nerve root tension.

Cross leg SLR

• The examiner will passively flex the patient’s uninvolved hip while maintaining the knee in full extension.
• A positive test is considered when the patient reports reproduction of pain in the involved limb at 40 degrees of hip flexion of the uninvolved limb.

Bragard’s test

• The patient was positioned supine on the examination table with both legs straight.
• Raise the leg to the point of pain.
• Lower the leg by 5 degree.
• Dorsiflex the foot.
• Positive test- Pain due to traction of the sciatic nerve.

Schober’s test

• To measure the ability of a patient to flex the lower back
• While the patient is in a standing position the examiner makes a mark approximately at the level of L5 .
• Two points are marked: 5 cm below and 10 cm above this point (for a total of 15 cm distance).
• Then the patient is asked to touch his/her toes while keeping the knees straight.
• If the distance of the two points do not increase by at least 5 cm (with the total distance greater than 20 cm), then this is a sign of restriction in the lumbar flexion.
• This can be useful in examining a patient suspected of ankylosing spondylitis.

Tibial Nerve Stretch Test

Tibial nerve stretch tests for L4–5, S1–3 nerve root tension

Procedure :

• With the patient supine, flex the hip to 90° and extend the knee.
• In this position the tibial nerve ‘bowstrings’ across the popliteal fossa.
• Press over either of the hamstring tendons, and then over the nerve in the middle of the fossa.
• The test is positive if pain occurs when the nerve is pressed, but not the hamstring tendons.

Femoral Nerve Stretch Tests

Femoral nerve stretch tests for L2–4 nerve root tension

• With the patient lying on his front (prone), flex the knee and extend the hip. This stretches the femoral nerve.
• A positive result is pain felt in the back, or the front of the thigh. This test can, if necessary, be performed with the patient lying on his side with the test side uppermost.

Flip Test

• For functional overlay
• Ask the patient to sit on the end of the couch with the hips and knees flexed to 90° .
• Extend the knee, as if to examine the ankle jerk. A patient with nerve root impingement will lie back (‘flip’).

Examine the reflexes

Knee reflex

• This may be diminished in lesions of the third lumbar root
• Each knee is raised in turn with one hand and the ligamentum patellae struck with the reflex hammer

Babinski’s sign

• The reverse end of the reflex hammer is run firmly over the plantar surface of the foot from the calcaneus along the lateral border to the forefoot, ending at the ball of the great toe.
• In a positive reaction the great toe extends, while the other toes plantarflex and splay (positive Babinski’s sign).
• In a negative reaction the toes either do not move at all or flex uniformly (negative Babinski’s sign).

Ankle Reflex Test

• The foot is raised with one hand. Then all the slack of the plantar-flexors is taken up by the little finger pushing the foot into dorsiflexion, before striking the Achilles tendon.

• This reflex is diminished or absent unilaterally in fifth lumbar and first or second sacral root palsy.
• Once lost, this reflex does not return in about half the cases. Hence, in a new attack of lumbago, the absence of the ankle jerk does not confirm recently impaired root conduction.
• Absence of the reflex on both sides is found in Tabes Dorsalis, Malignant Disease And Spondylolisthesis, when the emerging nerve roots are involved bilaterally.

viśvācī

• In Ayurveda, the symptoms of Viśvācī, a Vāta imbalance disorder can be compared with the symptoms of Brachial neuralgia. It is also called as Brachial neuritis.
• Brachial neuritis is a neck pain condition. It is characterized with shoulder pain and neck pain extending to arms. There can also be numbness and some may end up with paralysis.
• Severe pain more localised in shoulder and neck but extending towards the tip of the finger or till the elbow joint is the characteristic feature of this disease.
• The word Viśvācīhas been derived from the root word ‘Viśvā’ which means ‘dhatu (tissues)’ and ‘Anc’ refers to paralysis of the arm and the back.
• The texts define Viśvācīas a disease which is caused due to vitiated Vāta on affliction towards the Kaṇḍarā (muscles, tendons and ligaments) that run to the tip of the fingers from behind the root of upper arm, causing restriction of the movements and depriving them of their ability of flexion or extension causing severe pain.

Examination of the shoulder joint

Ask the patient to sit or stand and expose the shoulder completely.

Inspection:

• Examine from the front and the back and in the axilla for deformity.
• The deformities of anterior glenohumeral and complete acromioclavicular joint dislocation are obvious ,but the shoulder contour in posterior glenohumeral dislocation may only appear abnormal when you stand above the seated patient and look down on the shoulder.

Swelling :

-Muscle wasting especially of the deltoid, supraspinatus and infraspinatus.

-Wasting of supraspinatus or infraspinatus indicates a chronic tear of their tendons

Palpation:

• Feel from the sternoclavicular joint along the clavicle to the acromioclavicular joint.
• Palpate the acromion and coracoid (2 cm inferior and medial to the clavicle tip) processes, the scapula spine and the biceps tendon in the bicipital groove.
• Extend the shoulder to bring supraspinatus anterior to the acromion process. Palpate the supraspinatus tendon.

Movement :

• To screen for shoulder dysfunction:
• Stand behind the patient.
• Ask the patient to put both hands behind the head.
• Then put the arms down and reach behind his back to touch the shoulder blades.
• If there is pain, swelling or limitation of movement, proceed to examine the shoulder fully.
• Range of movement
• First assess active movement, then passive.
• Ask the patient to flex and extend the shoulder as far as possible.

Abduction:

• Ask the patient to lift his arm away from his side.
• Palpate the inferior pole of the scapula between your thumb and index finger to detect scapular rotation and determine how much movement occurs at the glenohumeral joint.
• In all, 50–70% of abduction occurs at the glenohumeral joint (the rest with movement of the scapula on the chest wall). This increases if the arm is externally rotated.
• Note the degree and smoothness of scapular movement. If the glenohumeral joint is excessively stiff, movement of the scapula over the chest wall will predominate. If there is any limitation or pain (painful arc) associated with abduction, test the rotator cuff .

Internal rotation:

• With the patient’s arm by his side and the elbow flexed at 90°, ask him to put his hand behind his back and feel as high up the spine as possible.
• Document the highest spinous process that he can reach with the thumb.

External rotation:

• In the same position with the elbow tucked against his side, ask him to rotate the hand out.

Deltoid: Ask the patient to abduct the arm out from his side, parallel to the floor, and resist while you push down on the humerus. Compare each side.

Rotator cuff :Ask the patient to start abducting the arm from his side against your resistance. If abduction cannot be initiated or is painful, this suggests a rotator cuff problem.

Impingement (painful arc) :

• Passively abduct the patient’s arm fully
• Ask him to lower (adduct) it slowly.
• Pain occurring between 60 and 120° of abduction occurs in painful arc.
• If the patient cannot initiate abduction, place your hand over the scapula to confirm there is no scapular movement.
• Passively abduct the internally rotated arm to 30–45°
• Ask him to continue to abduct the arm.
• Pain on active movement, especially against resistance, suggests impingement.

Ligamentous tears and injuries

Discrepancy between active and passive ranges suggests a tendinous tear – in particular subscapularis, where there may be an excessive range of passive internal rotation. To test the component muscles of the rotator cuff, it is necessary to neutralise the effect of other muscles crossing the shoulder.

Subscapularis and pectoralis major (internal rotation of the shoulder):

To isolate subscapularis, test internal rotation with the patient’s hand behind his back. Loss of power suggests a tear. Pain on forced internal rotation suggests tendonitis.

Supraspinatus:

With the arm by his side, test abduction. Loss of power suggests a tear. Pain on forced abduction at 60° suggests tendonitis.

Infraspinatus and teres minor:

Test external rotation with the arm in the neutral position, and 30° flexion to reduce the contribution of deltoid. Loss of power suggests a tear. Pain on forced external rotation suggests tendonitis.

Bicipital tendonitis :

• Palpate the bicipital tendon in its groove, noting any tenderness.
• Ask the patient to supinate the forearm, and then flex the arm against resistance. Pain occurs in bicipital tendonitis.

common conditions affecting the cervical spine

• Cervical spondylosis
•  Cervical radiculopathy 
•  Cervical myelopathy 
•  Cervical Strain / spasm 
•  Cervical Sprain
•  Cervical Stenosis
•  HNP(Herniated Nucleus pulposus)   
•  Fractures/subluxation etc.

CERVICAL SPONDYLOSIS

Cervical spondylosis is a term that encompasses a wide range of progressive degenerative changes that affect all the components of the cervical spine (i.e., intervertebral discs, facet joints, ligamentum flava, and laminae). It is a natural process of aging and presents in the majority of people after the fifth decade of life.

In the cervical spine this chronic degenerative process affects the intervertebral discs and facet joints, and may progress to disk herniation, osteophyte formation, vertebral body degeneration, compression of the spinal cord, or cervical spondylotic myelopathy.

Symptomsof cervical spondylosis manifest as neck pain and neck stiffness and can be accompanied by radicular symptoms when there is compression of neural structures.

Clinical Presentation

Cervical spondylosis presents in three symptomatic forms as:

• Non-specific neck pain – pain localised to the spinal column.
• Cervical radiculopathy– complaints in a dermatomal or myotomal distribution often occurring in the arms.
• May be numbness, pain or loss of function.

Diagnostic Procedures

Cervical spondylosis is often diagnosed on clinical signs and symptoms alone.

Signs:

• Poorly localised tenderness
• Limited range of motion
• Minor neurological changes (unless complicated by myelopathy or radiculopathy)

Symptoms:

• Cervical pain aggravated by movement
• Referred pain (occiput, between the shoulder blades, upper limbs)
• Retro-orbital or temporal pain
• Cervical stiffness
• Vague numbness, tingling or weakness in upper limbs
• Dizziness or vertigo
• Poor balance
• Rarely, syncope, triggers migraine

Most patients do not need further investigation and the diagnosis is made on clinical grounds alone however, diagnostic imaging such as X-ray, CT, MRI, and EMG can be used to confirm a diagnosis 

Plain radiographs of the cervical spine may show a loss of normal cervical lordosis, suggesting muscle spasm, but most other features of degenerative disease are found in asymptomatic people and correlate poorly with clinical symptoms

MRI of the cervical spine is the investigation of choice if more serious pathology is suspected, as it gives detailed information about the spinal cord, bones, discs, and soft tissue structures.

Pain provocation tests such as Spurling’s test can be used to differentiate between shoulder disorders and cervical spondylosis.

Axial neck pain

Commonly complain of stiffness and pain in the cervical spine that is most severe in the upright position and relieved with bed rest when removing the load from the neck

Neck motion, especially in hyperextension and side-bending, typically increases the pain

In upper and lower cervical spine disease, patients may report radiating pain into the back of the ear or occiput versus radiating pain into the superior trapezius or periscapular musculature, respectively.

Occasionally, patients can present with atypical symptoms cervical angina such as jaw pain or chest pain.

Cervical radiculopathy

Radicular symptoms usually follow a myotomal distribution depending on the nerve root(s) involved and can present as unilateral or bilateral neck pain, arm pain, scapular pain, paraesthesia, and arm or hand weakness

Pain is exacerbated by head tilt toward the affected side or by hyperextension and side-bending toward the affected side

Cervical myelopathy

Cervical myelopathy is a  cluster of complaints and findings due to intrinsic damage to the spinal cord itself.Numbness, coordination and gait issues, grip weakness and bowel and bladder complaints with associated physical findings may be reported.

Typically has an insidious onset with or without neck pain (frequently absent). It can initially present with hand weakness and clumsiness, resulting in the inability to complete tasks requiring fine motor coordination (e.g., buttoning a shirt, tying shoelaces, picking up small objects). Frequent reports of gait instability and unexplained falls.

examination of cervical spine

• History
• General Examination
• Inspection
• Palpation
• Range of Movement
• Special Test

Patient history:

• Information is gathered regarding current signs and symptoms
• Location of pain – localized, radiating
• Onset of pain – acute, chronic
• Consistency of pain – Pain from inflammation (strain, sprain, contusion), Pain of mechanical nature (nerve root compression)
• Mechanism of injury (etiology)
• Prior history of accidentsor cervical and spine injury
• Family history and lifestyle
• Medication etc.

This medical background can help give a better picture of what might need further investigation.

Inspection:

• FRONT
• Posture of head and neck – symmetry / abnormal position
• Symmetry of shoulders – note any misalignment
• SIDE
• Cervical lordosis – assess for hyper-lordosis – spondylolisthesis / osteoporosis / discitis
• Thoracic kyphosis – normal is 20-45º – hyper kyphosis (>45º) – vertebral fracture
• Lumbar lordosis – assess for hyper lordosis – obesity / tight lower back muscles
• BEHIND
• Scars – can provide clues as to previous surgery/trauma
• Wasting – paraspinal muscles/other muscles of the back – may suggest chronic immobility
• Scoliosis – lateral curvature of the spine – resembles an “S” shape
• Abnormal hair growth – spina bifida

Palpation:

• Local rise in temperature
• Palpate all spinous process 
• Prominent spinous process
• Feel
• The midline spinous processes
• The paraspinal soft tissues
• The supraclavicular fossae – for cervical ribs or enlarged lymph nodes
• The anterior neck structures including the thyroid

Range of movements:

Flexion– Ask the patient to bend the head forwards – chin should be able to touch the chest – Normal : 80°

Extension– Ask the patient to look up and back – Normal : 50°

Lateral flexion – ask the patient to touch his shoulder with the ear – involve atlanto-axial and atlanto-occipital joints  – Normal : 45°

Rotation – ask the patient to look over his shoulder – Normal : 80° – restricted and painful in cervical spondylitis

Special Tests

1. Compression test

• Testing for compression of cervical nerve root or facet joint irritation in the lower cervical spine
• The patient is seated on a plinth with the examiner resting the palmar surface of his or her hands on top of the patient’s head.
• The tester applies a downward pressure.
• Positive sign
• Radiating pain or other neurological sign in the same side arm (nerve root) and pain local to the neck or shoulder
• A narrowing of neural foramen, pressure on the facet joints or muscle spasm can cause increase pain upon compression

2. Spurling Test

• Same positioning as cervical compression test
• Compression of a cervical nerve root or facet joint irritation in the lower cervical spine
• The patient will then laterally flex the head while the tester applies a downward pressure. This is to be done with lateral flexion bilaterally
• Positive sign:- Radiating pain or other neurological sign in the same side arm(nerve root) and pain local to the neck or shoulder (facet joint irritation)

3. Distraction Test

• To relive the pressure on the cervical roots (may be used after Spurling or compression test)
• Place the open palm of one hand under the pt.’s chin, and the other hand is upon occiput & temporalis
• Then, gradually lift (distract) the head to remove its weight from the neck
• To demonstrate the effect that neck traction might have help in relieving the pain by decreasing pressure on the joint capsules around the facet joints.

4. Valsalva Test

• Ask patient to hold his breath and bear down as if he were moving his bowels
• Then, ask whether he feels any increase in pain and describe the location
• This test increase intrathecal pressure
• If a space occupying lesion, such as a herniated disc or a tumor present in cervical canal, pt. may develop pain in cervical spine secondary to increase pressure
• The pain also may radiate to the dermatome distribution of cervical spine pathology

5. Swallowing Test

• Difficulty or pain upon swallowing can sometimes caused by cervical spine pathology such as :
• Bony protuberance
• Bony osteophytes
• Soft tissue swelling due to hematomas, infection or tumor in ant portion of cervical spine

6. Lhermitte’s Sign

• This sign detects protrusion of cervical intervertebral disc or an extradural spinal tumour irritating the spinal duramater.
• The patient sits on an examining table,
• Now the head of the patient is bent down passively(flexion of cervical spine ) and simultaneously the lower limbs are lifted(flexing the hip joints) keeping the knees straight.
• This will causes sharp pain radiating down the spine and to both the extremities.

7. Adson Test

• Pull the arm downwards
• Palpate the radial pulse
• Turn the pt.’s head to the same side and extend the neck
• Abduct, extend, and laterally rotate the shoulder.
• From this position, have the patient take a deep breath and hold
• Feel the radial pulse
• Fading of the radial pulse indicates positive thoracic outlet obstruction

8. Hoffman sign test :

• The Hoffman sign is an involuntary flexion movement of the thumb and or index finger when the examiner flicks the fingernail of the middle finger down.
• The reflexive pathway causes the thumb to flex and adduct quickly.
• A positive Hoffman sign indicates an upper motor neuron lesion and corticospinal pathway dysfunction likely due to cervical cord compression. 

Respiratory systemic examination

GENERAL EXAMINATION

Examination of hands :

• Clubbing – caused due to diseases associated with heart and lungs.
• Peripheral cyanosis – caused due to heart failure, COPD, vascular disorders .
• Yellow nail syndrome- About half of all people with yellow nail syndrome have either recurrent chest infections or a chronic lung condition known as bronchiectasis .
• Warm hands – due to carbon dioxide retention , irregular flapping tremor may also occurs when the hands are outstretched .
• Jugular venous pressure – due to heart and pulmonary disorders.
• Peripheral edema –due to severe pulmonary diseases .

Lymph nodes- palpate and palpation of spleen

Swelling

• Lymph nodes may become enlarged due to an infection, tumor, autoimmune disease, drug reactions, or to leukemia. Swollen lymph nodes (or the disease causing them) are referred to as lymphadenopathy

Cancer

• Lymph nodes can be affected by both primary cancers of lymph tissue, and secondary cancers affecting other parts of the body.

Cancer of lymph nodes can cause a wide range of symptoms from painless long-term slowly growing swelling to sudden, rapid enlargement over days or weeks

Lymph node involvement is often a key part in the diagnosis and treatment of cancer,

Respiratory examination

 Divided in to 2 parts

1.Upper respiratory examination

2.Lower respiratory examination

1.Upper respiratory examination

1. Examination of two nostrils by torch light

-See the nasal septum

-Look mucous membrane                  

-Discharge

1. Oral cavity and pharynx

Examine- Tongue, Teeth , Gum, Cheek , Pharyngeal wall , tonsillar fossa, position of uvula pharyngeal arches

look for – Redness, Secretions, any patch present

1. Examination of larynx by 2 ways

(a)Direct laryngoscopy

(b)Indirect laryngoscopy

LOWER RESPIRATORY EXAMINATION

Inspection of the chest

• Size and shape of the chest
• Symmetrical or Asymmetrical
• Convexity on both side
• Shape of the chest
• Pigeon chest

Marked forward protrusion of the sternum and adjacent costal cartilages.

Causes: congenital anomalies, chronic nasal or nasopharyngeal obstruction,             respiratory disease, rickets in childhood.

• Barrel chest

In order to accommodate the increased bulk of the lungs in hypertrophic emphysema, the thoracic cage becomes cylindrical or barrel like other causes include old age,      severe kyphotic deformity of spine, chronic asthma with bronchitis.

• Funnel chest

Structural deformity of the anterior thoracic wall in which the sternum and rib cage are shaped abnormally Causes: familial or hereditary, an occupational deformity as in cobblers, rickets in childhood.

• Rachitic changes

In child hood rickets, the bones are unduly soft and liable to yield to various pressure and pulls. Which predisposes the rickety deformities.

• Unilateral flattening of chest

May results from unilateral tuberculosis, fibrosis of lung, collapse of lung, long standing pleurisy, wasting of muscles, acute anterior poliomyelitis.

Types or Act of respiration:

1. Abdominal -In men – Abdominal movements are prominent
2. Thoracic -In women- Thoracic movements are prominent.

Respiratory rate :

Average resting respiratory rates by age are:

-Birth to 6 weeks: 30–40 breaths per minute

-6 months: 25–40 breaths per minute

-3 years: 20–30 breaths per minute

-6 years: 18–25 breaths per minute

-10 years: 17–23 breaths per minute

-Adults: 12-18 breaths per minute

-Elderly ≥ 65 years old: 12-28 breaths per minute.

-Elderly ≥ 80 years old: 10-30 breaths per minute.

• The reparation pulse ratio is normally about 1 to 4 ( 18 respirations to about 72 pulse beats per minute)
• Tachypnea – increased in respiratory rate (greater than 20 breaths per minute)

Causes: sepsis, diabetic ketoacidosis or other metabolic acidosis, pneumonia, pleural effusion, carbon monoxide poisoning, pulmonary embolism, asthma, COPD, laryngospasm, allergic reaction, foreign body aspiration, congestive heart failure, anxiety states.

• Bradypnea– decreased in respiratory rate (breathing rate of below 12 breaths per minute for more than 2 minutes)

Causes: Exposure to drugs or toxins, Surgery, Hormonal imbalances, Problems with the brain stem, Problems with the heart, electrolyte imbalance.

• Chest expansion:

Ask the patient to do deep inspiration and expansion, there should be equal expansion on both sides. -This means equal quantity of air is going in both the lungs.

observe the movement from back, observe the movements of scapular on both sides.

• Position of trachea– observe the head of sternomastoid muscles

– It should be equally prominent on both sides .

-Which indicates the trachea is in central .

-In different diseases trachea can be pulled on one side or push on the side.

• Look for apeax beat

It should be in 5th intercostal space in mid clavicular line

• Note accessory muscles

–If any are dominant or vigorously acting like

-ali nasi in pneumonia in children

-sternocleidomastoid in severe attack of bronchial asthma

-normally accessory muscles are not prominent

Palpation of the chest

Palpation – touch the dorsal surface of the hand for the temperature to find out the local rise of Temperature.

-Local rise of temperature indicates suspicious cancers and tumours.

-Palpation for tenderness – palpation with the palm of the hand Measurement of the chest

-Measurement of the chest- with tape and cord board boards for posterior and anteroposterior diameter.

-Expansion is measured in the form of circumference of the chest with tape at nipple level during expansion and then after deep inspiration Chest expansion is expected about 5cm after deep inspiration.

-Palpation of respiratory movements of chest expansion

1. From front
2. From back
3. Also apices of lungs

1.From front

-Ask the patient to take a deep breath and comparison is made between the displacement of the tip of each thumb.

-Hands are transversely placed, the tips of the fingers in the axillary region and tip of the thumbs over mid sternum.

-Ulnar border of the hand over the costal borders while thumbs placed in xiphoid process.

2.From back

Now ask the patient to turn on back side, keep hands at mid scapular region, here also thumb should move equal distance on both sides.

3.From apex

Examination at apices is also important because T.B. mainly occurs at apex of lungs

– for examination of apex keep 4 fingers on shoulder and thumb in mid portion of scapulae

-ask the patient to do deep inspiration and expiration

-upward movement of four fingers or shoulder will equal on both sides.

• Palpate for the apex beat

It should be in 5th left intercostal space, in mid clavicular line The apex beat, also called the apical impulse, is the pulse felt at the point of maximum impulse (PMI)

• TVF- TACTILE VOCAL FREMITUS

Sound waves travel faster and louder in solid medium as compared to fluid or air medium So subject asked to Say 1-1-1 or 9-9-9.

With ulnar border of the palm, we palpate the chest for vibration.

• In solid medium – TVF is increased
• In air or liquid medium – TVF is decreased
• In consolidation – TVF is increases
• In pleurisy and pneumothorax – TVF decreases

PERCUSSION OF THE CHEST

❖ From front, back, infra and axillary area

❖ Position of the patient – sitting, standing, or recumbent position

❖ Sitting up position is the choice of position

❖ For percussion back of the patient bends slightly forwards and head flexed on the chest

❖ Should starts from apices of the lungs

Technique:-

– The middle phalanx of the third finger of the examiner left hand must be placed firmly on the chest wall.

– Third finger of the examiner’s right hand is kept flexed at a right angle and must hit in the middle phalanx of the pleximeter finger

-Percussion should proceed from more resonant to less resonant Findings:- hyper resonance – emphysema , pneumothorax Impaired resonance or dullness

– consolidation, fibrosis and collapse of lungs Shifted dullness

– if dullness shifts when the pt changes position, it is called shifting dullness. To detect the air and fluid in the pleural cavity. Eg Hydropneumothorax

AUSCULTATION OF CHEST

Auscultation of the lungs yields more information than any of the other three classical methods of physical examination.

Position of the patient:- same as percussion of the chest

1. Pt should take forced and deep breathing
2. Should breathe through the mouth
3. Identical intercostal space is auscultated on left and right side and findings are compared
4. Air entry (quantity check)
5. Type of breathing (quality check)
6. Should absorb adventitious sounds
7. And vocal resonance

TYPES OF NORMAL BREATH SOUND

1. Vesicular breathing

Vesicular breath sounds are soft and low pitched with a rustling quality during inspiration and are even softer during expiration. These are the most commonly auscultated breath sounds, normally heard over most of the lung surface. They have an inspiratory/expiratory ratio of 3 to 1 or I:E of 3:1.

2. Bronchial breath sounds

bronchial breath sounds over the trachea has a higher pitch, louder. It is like blowing of air through pipe

ABNORMAL BREATH SOUNDS

1. RONCHI:- Prolonged uninterrupted musical sounds due to partial obstruction to the air flow.
2. WHEEZE:- High pitched musical sounds results from partial airway obstruction.
3. STRIDOR:- Jerky high pitched coarse sounds during inspiration.
4. CRACKLING:- This is a series of short, explosive sounds. They can also sound like bubbling, rattling, or clicking.
5. PLEURAL RUB:- The membranes that cover the walls of the chest cavity and the outer surface of the lungs are called pleura. If they get inflamed and rub together, they can make this rough, scratchy sound.

VOCAL RESONANCE

Principle is similar to as TVF

• Sound waves travel faster and louder in solid medium as compared to fluid or air medium
• Ask the patient to say 9-9-9 and auscultate chest intercostal space on both Sides.

Applied anatomy and physiology of Respiratory system

1. Chronic obstructive pulmonary disease (COPD): Damage to the lungs results in difficulty blowing air out, causing shortness of breath. Smoking is by far the most common cause of COPD.

Tubes called airways carry air into and out of your lungs. If you have COPD, these airways may become partly blocked from swelling or mucus. This makes it hard to breathe.

Causes : cigarette smoking, dust, air pollution, or certain chemicals for long periods of time. In rare cases, your genes may put you at risk for COPD.

1. Emphysema: A form of COPD usually caused by smoking. The fragile walls between the lungs’ air sacs (alveoli) are damaged, trapping air in the lungs and making breathing difficult.

when the linings of the tiny air sacs in your lungs become damaged beyond repair. Over time, your lung damage gets worse. Here’s what happens:

-The fragile tissues between air sacs are destroyed and air pockets form in the lungs.

– Air gets trapped in these pouches of damaged tissue.

-The lungs slowly get larger, and you find it harder to breathe.

1. Chronic bronchitis: Repeated, frequent episodes of productive cough, usually caused by smoking. Breathing also becomes difficult in this form of COPD.
2. Pneumonia: Infection in one or both lungs. Bacteria, especially Streptococcus pneumoniae, are the most common cause.
3. Asthma: The lungs’ airways (bronchi) become inflamed and can spasm, causing shortness of breath and wheezing. Allergies, viral infections, or air pollution often trigger asthma symptoms.
4. Acute bronchitis: An infection of the lungs’ large airways (bronchi), usually caused by a virus. Cough is the main symptom of acute bronchitis.
5. Pulmonary fibrosis: A form of interstitial lung disease. The interstitium (walls between air sacs) become scarred, making the lungs stiff and causing shortness of breath. Pulmonary fibrosis is a lung disease that occurs when lung tissue becomes damaged and scarred. This thickened, stiff tissue makes it more difficult for your lungs to work properly. As pulmonary fibrosis worsens, you become progressively more short of breath.
6. Sarcoidosis: Tiny areas of inflammation can affect all organs in the body, with the lungs involved most of the time. The symptoms are usually mild; sarcoidosis is usually found when X-rays are done for other reasons.

– cause of sarcoidosis is unknown, but experts think it results from the body’s immune system responding to an unknown substance. Some research suggests that infectious agents, chemicals, dust and a potential abnormal reaction to the body’s own proteins (self-proteins) could be responsible for the formation of granulomas in people who are genetically predisposed.

1. Obesity hypoventilation syndrome: Extra weight makes it difficult to expand the chest when breathing. This can lead to long-term breathing problems.
2. Pleural effusion: Fluid builds up in the normally tiny space between the lung and the inside of the chest wall (the pleural space). If large, pleural effusions can cause problems with breathing.
3. Pleurisy: Inflammation of the lining of the lung (pleura), which often causes pain when breathing in. Autoimmune conditions, infections, or a pulmonary embolism may cause pleurisy.
4. Bronchiectasis: The airways (bronchi) become inflamed and expand abnormally, usually after repeated infections. Coughing, with large amounts of mucus, is the main symptom of bronchiectasis. ● Lymphangioleiomyomatosis (LAM): A rare condition in which cysts form throughout the lungs, causing breathing problems similar to emphysema. LAM occurs almost exclusively in women of childbearing age
5. Cystic fibrosis: A genetic condition in which mucus does not clear easily from the airways. The excess mucus causes repeated episodes of bronchitis and pneumonia throughout life.
6. Lung cancer: Cancer may affect almost any part of the lung. Most lung cancer is caused by smoking.
7. Tuberculosis: A slowly progressive pneumonia caused by the bacteria Mycobacterium tuberculosis. Chronic cough, fever, weight loss, and night sweats are common symptoms of tuberculosis.
8. Acute respiratory distress syndrome (ARDS): Severe, sudden injury to the lungs caused by a serious illness. Life support with mechanical ventilation is usually needed to survive until the lungs recover.
9. Coccidioidomycosis: A pneumonia caused by Coccidioides, a fungus found in the soil. Most people experience no symptoms, or a flu-like illness with complete recovery.
10. Histoplasmosis: An infection caused by inhaling Histoplasma capsulatum, a fungus found in the soil. Most Histoplasma pneumonias are mild, causing only a short-lived cough and flu-like symptoms.
11. Hypersensitivity pneumonitis (allergic alveolitis): Inhaled dust causes an allergic reaction in the lungs. Usually this occurs in farmers or others who work with dried, dusty plant material.
12. Influenza (flu): An infection by one or more flu viruses causes fever, body aches, and coughing lasting a week or more. Influenza can progress to life-threatening pneumonia, especially in older people with medical problems.
13. Mesothelioma: A rare form of cancer that forms from the cells lining various organs of the body with the lungs being the most common. Mesothelioma tends to emerge several decades after asbestos exposure.
14. Pertussis (whooping cough): A highly contagious infection of the airways (bronchi) by Bordetella pertussis, causing persistent cough. A booster vaccine (Tdap) is recommended for adolescents and adults to prevent pertussis.
15. Pulmonary hypertension: Many conditions can lead to high blood pressure in the arteries leading from the heart to the lungs. If no cause can be identified, the condition is called idiopathic pulmonary arterial hypertension.
16. Pulmonary embolism: A blood clot (usually from a vein in the leg) may break off and travel to the heart, which pumps the clot (embolus) into the lungs. Sudden shortness of breath is the most common symptom of a pulmonary embolism.
17. Severe acute respiratory syndrome (SARS): A severe pneumonia caused by a specific virus first discovered in Asia in 2002.
18. Pneumothorax: Air in the chest; it occurs when air enters the area around the lung (the pleural space) abnormally. Pneumothorax can be caused by an injury or may happen spontaneously.

EXAMINATION OF CVS

The cardiovascular (CVS) examination is essentially an examination of the patient’s heart; however it is a complex examination which also includes examination of other parts of the body including the hands, face and neck. The CVS examination aims to pick up on any cardiovascular pathology that may be causing a patient’s symptoms, such as chest pain, breathlessness, or heart failure. This examination is performed on every patient that is admitted to hospital and regularly in clinics and general practice.

Like most major examination stations this follows the usual procedure of:

• Inspect
• Palpate
• Auscultate

GENERAL INSPECTION

CLINICAL SIGNS

Inspect the patient from the end of the bed whilst at rest, looking for clinical signs suggestive of underlying pathology:

• Cyanosis:a bluish discolouration of the skin due to poor circulation (e.g. peripheral vasoconstriction secondary to hypovolaemia) or inadequate oxygenation of the blood (e.g. right-to-left cardiac shunting).
• Shortness of breath:may indicate underlying cardiovascular (e.g. congestive heart failure, pericarditis) or respiratory disease (e.g. pneumonia, pulmonary embolism).
• Pallor:a pale colour of the skin that can suggest underlying anaemia (e.g. haemorrhage, chronic disease) or poor perfusion (e.g. congestive cardiac failure). It should be noted that a healthy individual may have a pale complexion that mimics pallor, however, pathological causes should be ruled out.
• Malar flush:plum-red discolouration of the cheeks associated with mitral stenosis.
• Oedema:typically presents with swelling of the limbs (e.g. pedal oedema) or abdomen (i.e. ascites). There are many causes of oedema, but in the context of a cardiovascular examination OSCE station, congestive heart failure is the most likely culprit.

Objects Or Equipment 

Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current clinical status:

• Medical equipment:note any oxygen delivery devices, ECG leads, medications (e.g. glyceryl trinitrate spray), catheters (note volume/colour of urine) and intravenous access.
• Mobility aids:items such as wheelchairs and walking aids give an indication of the patient’s current mobility status.
• Pillows:patients with congestive heart failure typically suffer from orthopnoea, preventing them from being able to lie flat. As a result, they often use multiple pillows to prop themselves up.
• Vital signs:charts on which vital signs are recorded will give an indication of the patient’s current clinical status and how their physiological parameters have changed over time.
• Fluid balance:fluid balance charts will give an indication of the patient’s current fluid status which may be relevant if a patient appears fluid overloaded or dehydrated.
• Prescriptions:prescribing charts or personal prescriptions can provide useful information about the patient’s recent medications.

HANDS

The hands can provide lots of clinically relevant information and therefore a focused, structured assessment is essential.

INSPECTION:

GENERAL OBSERVATION

Inspect the hands for clinical signs relevant to the cardiovascular system:

• Colour:pallor suggests poor peripheral perfusion (e.g. congestive heart failure) and cyanosis may indicate underlying hypoxaemia.
• Tar staining:caused by smoking, a significant risk factor for cardiovascular disease (e.g. coronary artery disease, hypertension).
• Xanthomata:raised yellow cholesterol-rich deposits that are often noted on the palm, tendons of the wrist and elbow. Xanthomata are associated with hyperlipidaemia (typically familial hypercholesterolaemia), another important risk factor for cardiovascular disease (e.g. coronary artery disease, hypertension).
• Arachnodactyly (‘spider fingers’):fingers and toes are abnormally long and slender, in comparison to the palm of the hand and arch of the foot. Arachnodactyly is a feature of Marfan’s syndrome, which is associated with mitral/aortic valve prolapse and aortic dissection.

FINGER CLUBBING :

Finger clubbing involves uniform soft tissue swelling of the terminal phalanx of a digit with subsequent loss of the normal angle between the nail and the nail bed. Finger clubbing is associated with several underlying disease processes, but those most likely to appear in a cardiovascular OSCE station include congenital cyanotic heart disease, infective endocarditis and atrial myxoma (very rare).

To assess for finger clubbing:

• Ask the patient to place the nailsof theirindex fingers back to back.
• In a healthy individual, you should be able to observe a small diamond-shapedbwindow(known as Schamroth’s window)
• When finger clubbing develops, this window is lost.

SIGNS IN THE HANDS ASSOCIATED WITH ENDOCARDITIS

There are several other signs in the hands that are associated with endocarditis including:

• Splinter haemorrhages: a longitudinal, red-brown haemorrhage under a nail that looks like a wood splinter. Causes include local trauma, infective endocarditis, sepsis, vasculitis and psoriatic nail disease.
• Janeway lesions: non-tender, haemorrhagic lesions that occur on the thenar and hypothenar eminences of the palms (and soles). Janeway lesions are typically associated with infective endocarditis.
• Osler’s nodes: red-purple, slightly raised, tender lumps, often with a pale centre, typically found on the fingers or toes. They are typically associated with infective endocarditis.
• TEMPERATURE :

Place the dorsal aspect of your hand onto the patient’s to assess temperature:

• In healthy individuals, the hands should be symmetrically warm, suggesting adequate perfusion.
• Cool handsmay suggest poor peripheral perfusion(e.g. congestive cardiac failure, acute coronary syndrome).
• Cooland sweaty/clammyhands are typically associated with acute coronary syndrome.
• CAPILLARY REFILL TIME (CRT)

Measuring capillary refill time (CRT) in the hands is a useful way of assessing peripheral perfusion:

• Apply five seconds of pressureto the distal phalanxof one of a patient’s fingers and then release.
• In healthy individuals, the initial pallor of the area you compressed should return to its normal colourin less than two seconds.
• A CRT that is greater than two secondssuggests poor peripheral perfusion(e.g. hypovolaemia, congestive heart failure) and the need to assess central capillary refill time.

Pulses and blood pressure

RADIAL PULSE :

Palpate the patient’s radial pulse, located at the radial side of the wrist, with the tips of your index and middle fingers aligned longitudinally over the course of the artery.

Once you have located the radial pulse, assess the rate and rhythm.

HEART RATE

Assessing heart rate:

• You can calculate the heart rate in a number of ways, including measuring for 60 seconds, measuring for 30 seconds and multiplying by 2 or measuring for 15 seconds and multiplying by 4.
• For irregular rhythms, you should measure the pulse for a full 60 secondsto improve accuracy.

Normal and abnormal heart rates

In healthy adults, the pulse should be between 60-100 bpm.

A pulse <60 bpm is known as bradycardia and has a wide range of aetiologies (e.g. healthy athletic individuals, atrioventricular block, medications, sick sinus syndrome).

A pulse of >100 bpm is known as tachycardia and has a wide range of aetiologies (e.g. anxiety, supraventricular tachycardia, hypovolaemia, hyperthyroidism).

An irregular rhythm is most commonly caused by atrial fibrillation, but other causes include ectopic beats in healthy individuals and atrioventricular blocks.

Radio-radial delay

Radio-radial delay describes a loss of synchronicity between the radial pulse on each arm, resulting in the pulses occurring at different times.

To assess for radio-radial delay:

• Palpate both radial pulses simultaneously.
• In healthy individuals, the pulses should occur at the same time.
• If the radial pulses are out of sync, this would be described as radio-radial delay.

Causes of radio-radial delay include:

• Subclavian artery stenosis (e.g. compression by a cervical rib)
• Aortic dissection
• Aortic coarctation

COLLAPSING PULSE

A collapsing pulse is a forceful pulse that rapidly increases and subsequently collapses. It is also sometimes referred to as a ‘water hammer pulse’.

To assess for a collapsing pulse:

1. Ask the patient if they have any painin their right shoulder, as you will need to move it briskly as part of the assessment for a collapsing pulse (if they do, this assessment should be avoided).
2. Palpate the radial pulsewith your right hand wrapped around the patient’s wrist.
3. Palpate the brachial pulse(medial to the biceps brachii tendon) with your left hand, whilst also supporting the patient’s elbow.
4. Raise the patient’s arm above their head briskly.
5. Palpate for a collapsing pulse:As blood rapidly empties from the arm in diastole, you should be able to feel a tapping impulse through the muscle bulk of the arm. This is caused by the sudden retraction of the column of blood within the arm during diastole.

Causes of a collapsing pulse

• Normal physiological states (e.g. fever, pregnancy)
• Cardiac lesions (e.g. aortic regurgitation, patent ductus arteriosus)
• High output states (e.g. anaemia, arteriovenous fistula, thyrotoxicosis)

BRACHIAL PULSE :

PALPATION OF BRACHIAL PULSE

Palpate the brachial pulse in their right arm, assessing volume and character:

1. Support the patient’s right forearm with your left hand.
2. Position the patient so that their upper arm is abducted, their elbow is partially flexed and their forearm is externally rotated.
3. With your right hand, palpate medial to the biceps brachii tendon and lateral to the medial epicondyle of the humerus. Deeper palpation is required (compared to radial pulse palpation) due to the location of the brachial artery.

Types of pulse character

1. Normal
2. Slow-rising (associated with aortic stenosis)
3. Bounding (associated with aortic regurgitation as well as CO₂retention)
4. Thready (associated with intravascular hypovolaemia in conditions such as sepsis)

BLOOD PRESSURE

MEASURE THE BLOOOD PRESSURE

Measure the patient’s blood pressure in both arms (see our blood pressure guide for more details).

A comprehensive blood pressure assessment should also include lying and standing blood pressure.

In a cardiovascular examination OSCE station,  are unlikely to have to carry out a thorough blood pressure assessment due to time restraints, however, one should demonstrate that you have an awareness of what this would involve.

Blood pressure abnormalities include:

• Hypertension:blood pressure of greater than or equal to 140/90 mmHg if under 80 years old or greater than or equal to 150/90 mmHg if you’re over 80 years old.
• Hypotension:blood pressure of less than 90/60 mmHg.
• Narrow pulse pressure: less than 25 mmHg of difference between the systolic and diastolic blood pressure. Causes include aortic stenosis, congestive heart failure and cardiac tamponade.
• Wide pulse pressure: more than 100 mmHg of difference between systolic and diastolic blood pressure. Causes include aortic regurgitation and aortic dissection.
• Difference between arms:more than 20 mmHg difference in blood pressure between each arm is abnormal and may suggest aortic dissection.

CAROTID PULSE :

The carotid pulse can be located between the larynx and the anterior border of the sternocleIdomastoid muscle.

AUSCULTATION

Prior to palpating the carotid artery, you need to auscultate the vessel to rule out the presence of a bruit. The presence of a bruit suggests underlying carotid stenosis, making palpation of the vessel potentially dangerous due to the risk of dislodging a carotid plaque and causing an ischaemic stroke.

Place the diaphragm of your stethoscope between the larynx and the anterior border of the sternocleidomastoid muscle over the carotid pulse and ask the patient to take a deep breath and then hold it whilst you listen.

Be aware that at this point in the examination, the presence of a ‘carotid bruit’ may, in fact, be a radiating cardiac murmur (e.g. aortic stenosis).

PALPATION

If no bruits were identified, proceed to carotid pulse palpation:

1. Ensure the patient is positioned safely on the bed, as there is a risk of inducing reflex bradycardia when palpating the carotid artery (potentially causing a syncopal episode).
2. Gently place your fingers between the larynxand the anterior border of the sternocleidomastoid muscle to locate the carotid pulse.
3. Assess the character(e.g. slow-rising, thready) and volume of the pulse.

JUGULAR VENOUS PRESSURE (JVP)

Provides an indirect measure of central venous pressure. This is possible because the internal jugular vein (IJV) connects to the right atrium without any intervening valves, resulting in a continuous column of blood. The presence of this continuous column of blood means that changes in right atrial pressure are reflected in the IJV (e.g. raised right atrial pressure results in distension of the IJV).

The IJV runs between the medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid, making it difficult to visualise (its double waveform pulsation is, however, sometimes visible due to transmission through the sternocleidomastoid muscle).

Because of the inability to easily visualise the IJV, it’s tempting to use the external jugular vein (EJV) as a proxy for assessment of central venous pressure during clinical assessment. However, because the EJV typically branches at a right angle from the subclavian vein (unlike the IJV which sits in a straight line above the right atrium) it is a less reliable indicator of central venous pressure.

MEASURE THE JVP

1. Position the patient in a semi-recumbent position (at 45°).
2. Ask the patient to turn their headslightly to the left.
3. Inspect for evidence of the IJV, running between the medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid (it may be visible between just above the clavicle between the sternal and clavicular heads of the sternocleidomastoid. The IJV has a double waveform pulsation, which helps to differentiate it from the pulsation of the external carotid artery.
4. Measure the JVP by assessing the vertical distance between thesternal angle and the top of the pulsation point of the IJV (in healthy individuals, this should be no greater than 3 cm).

Causes of a raised JVP

• Cardiac causes of a raised JVP include:

Right-sided heart failure: commonly caused by left-sided heart failure. Pulmonary hypertension is another cause of right-sided heart failure, often occurring due to chronic obstructive pulmonary disease or interstitial lung disease.

Tricuspid regurgitation: causes include infective endocarditis and rheumatic heart disease.

Constrictive pericarditis: often idiopathic, but rheumatoid arthritis and tuberculosis are also possible underlying causes.

• Presence of venoushypertension.

HEPATOJUGULAR REFLUX TEST :

The hepatojugular reflux test involves the application of pressure to the liver whilst observing for a sustained rise in JVP.

ELICITATION :

To be able to perform the test, there should be at least a 3cm distance from the upper margin of the baseline JVP to the angle of the mandible:

• Position the patient in a semi-recumbent position(45º).
• Apply direct pressure to the liver.
• Closely observe the IJVfor a rise.
• In healthy individuals, this rise should last no longer than 1-2 cardiac cycles(it should then fall).
• If the rise in JVP is sustainedand equal to or greater than 4cmthis is deemed a positive result.
• This assessment can be uncomfortable for the patient and therefore it should only be performed when felt necessary (an examiner will often prevent you from performing it in an OSCE but you should mention it).

Conditions associated with hepatojugular reflux :

• A positive hepatojugular reflux resultsuggests the right ventricle is unable to accommodate an increased venous return, but it is not diagnostic of any specific condition. The following conditions frequently produce a positive hepatojugular reflux test.
• Constrictive pericarditis.
• Right ventricular failure.
• Left ventricular failure.
• Restrictive cardiomyopathy

Face

EYES :

INSPECT EYES FOR SIGNS RELEVANT TO CVS

• Conjunctival pallor: suggestive of underlying anaemia.Ask the patient to gently pull down their lower eyelid to allow you to inspect the conjunctiva.
• Corneal arcus:a hazy white, grey or blue opaque ring located in the peripheral cornea, typically occurring in patients over the age of 60. In older patients, the condition is considered benign, however, its presence in patients under the age of 50 suggests underlying hypercholesterolaemia.
• Xanthelasma: yellow, raised cholesterol-rich deposits around the eyes associated with hypercholesterolaemia.
• Kayser-Fleischer rings: dark rings that encircle the iris associated with Wilson’s disease. The disease involves abnormal copper processing by the liver, resulting in accumulation and deposition in various tissues (including the heart where it can cause cardiomyopathy).

MOUTH :

INSPECT MOUTH FOR SIGNS RELEVANT TO CVS

• Central cyanosis:bluish discolouration of the lips and/or the tongue associated with hypoxaemia (e.g. a right to left cardiac shunt)
• Angular stomatitis:a common inflammatory condition affecting the corners of the mouth. It has a wide range of causes including iron deficiency.
• High arched palate: a feature of Marfan syndrome which is associated with mitral/aortic valve prolapse and aortic dissection.
• Dental hygiene: poor dental hygiene is a risk factor for infective endocarditis.

CHEST

INSPECTION :

Look for clinical signs that may provide clues as to the patient’s past medical/surgical history:

• Scars suggestive of previous thoracic surgery:see the thoracic scars section below.
• Pectus excavatum:a caved-in or sunken appearance of the chest.
• Pectus carinatum:protrusion of the sternum and ribs.
• Visible pulsations:a forceful apex beat may be visible secondary to underlying ventricular hypertrophy.
• Thoracic scars:
• Median sternotomy scar:located in the midline of the thorax. This surgical approach is used for cardiac valve replacement and coronary artery bypass grafts (CABG).
• Anterolateral thoracotomy scar:located between the lateral border of the sternum and the mid-axillary line at the 4^thor 5^th intercostal space. This surgical approach is used for minimally invasive cardiac valve surgery.
• Infraclavicular scar:located in the infraclavicular region (on either side). This surgical approach is used for pacemaker insertion.
• Left mid-axillary scar:this surgical approach is used for the insertion of a subcutaneous implantable cardioverter-defibrillator (ICD).

PALPATION :

Palpate the chest to assess the location of the apex beat and to identify heaves or thrills.

APEX BEAT

• Palpatethe apex beat with your fingersplaced horizontally across the chest.
• In healthy individuals, it is typically located in the 5th intercostal spacein the midclavicular line. Ask the patient to lift their breast to allow palpation of the appropriate area if relevant.
• Displacementof the apex beat from its usual location can occur due to ventricular hypertrophy.

HEAVES

• A parasternal heaveis a precordial impulse that can be palpated.
• Place the heel of your handparallel to the left sternal edge(fingers vertical) to palpate for heaves.
• If heaves are present you should feel the heel of your hand being liftedwith each systole.
• Parasternal heaves are typically associated with right ventricular hypertrophy.

THRILLS

• A thrillis a palpable vibrationcaused by turbulent blood flow through a heart valve (a thrill is a palpable murmur).
• You should assess for a thrill across each of the heart valvesin turn (see valve locations below).
• To do this place your hand horizontallyacross the chest wall, with the flats of your fingersand palm over the valve to be assessed.

Valve locations:

Mitral valve: 5th intercostal space in the midclavicular line.

Tricuspid valve: 4th or 5th intercostal space at the lower left sternal edge.

Pulmonary valve: 2nd intercostal space at the left sternal edge.

Aortic valve: 2nd intercostal space at the right sternal edge.

AUSCULTATION:

Auscultate the four heart valves

A systematic routine will ensure you remember all the steps whilst giving you several chances to listen to each valve area. Your routine should avoid excess repetition whilst each step should ‘build’ upon the information gathered by the previous steps. Ask the patient to lift their breast to allow auscultation of the appropriate area if relevant.

1. Palpate the carotid pulse to determine the first heart sound.
2. Auscultate ‘upwards’ through the valve areas using the diaphragmof the stethoscope whilst continuing to palpate the carotid pulse:

• Mitral valve:5th intercostal space in the midclavicular line.
• Tricuspid valve:4th or 5th intercostal space at the lower left sternal edge.
• Pulmonary valve: 2nd intercostal space at the left sternal edge.
• Aortic valve:2nd intercostal space at the right sternal edge.

1. Repeat auscultation across the four valves with the bellof the stethoscope.

Accentuation manoeuvres

1. Auscultate the carotidarteries using the diaphragm of the stethoscope whilst the patient holds their breath to listen for radiation of an ejection systolic murmur caused by aortic stenosis.

2.. Sit the patient forwards and auscultate over the aortic area with the diaphragm of the stethoscope during expiration to listen for an early diastolic murmur caused by aortic regurgitation.

3. Roll the patient onto their left sideand listen over the mitral area with the diaphragm of the stethoscope during expiration to listen for a pansystolic murmur caused by mitral regurgitation. Continue to auscultate into the axilla to identify radiation of this murmur.
4. With the patientstill on their left side, listen again over the mitral area using the bell of the stethoscope during expiration for a mid-diastolic murmur caused by mitral stenosis.

Bell vs diaphragm

The bell of the stethoscope is more effective at detecting low-frequency sounds, including the mid-diastolic murmur of mitral stenosis.

The diaphragm of the stethoscope is more effective at detecting high-frequency sounds, including the ejection systolic murmur of aortic stenosis, the early diastolic murmur of aortic regurgitation and the pansystolic murmur of mitral regurgitation.

FINAL STEPS :

Posterior chest wall:

1. Inspection :

Inspect the posterior chest wall for any deformities or scars (e.g. posterolateral thoracotomy scar associated with previous lung surgery).

2. Auscultation :

Auscultate the lung fields posteriorly:

• Coarse cracklesare suggestive of pulmonary oedema(associated with left ventricular failure).
• Absent air entryand stony dullnesson percussion are suggestive of an underlying pleural effusion (associated with left ventricular failure).

Sacral oedema:

Inspect and palpate the sacrum for evidence of pitting oedema.

Causes :

• Heart failure (Right ventricular failure)

Legs :

• Inspectand palpate the patient’s ankles for evidence of pitting pedal oedema (associated with right ventricular failure).
• Inspectthe patient’s legs for evidence of saphenous vein harvesting (performed as part of a coronary artery bypass graft).

Further assessments and investigations

Suggest further assessments and investigations to the examiner:

• Measure blood pressure:to identify hypotension, hypertension or significant discrepancies between the two arms suggestive of aortic dissection.
• Peripheral vascular examination:to identify peripheral vascular disease, which is common in patients with central cardiovascular pathology.
• Record a 12-lead ECG:to look for evidence of arrhythmias or myocardial ischaemia.
• Dipstick urine:to identify proteinuria or haematuria which can be associated with hypertension.
• Bedside capillary blood glucose:to look for evidence of underlying diabetes mellitus, a significant risk factor for cardiovascular disease.
• Perform fundoscopy:if there were concerns about malignant hypertension, fundoscopy would be performed to look for papilloedema

Detailed examination of the gastro intestinal system

Approach to the patient

• To take thorough history
• Physical examination
• Laboratory investigations (blood,stool,Helicobacter pylori,etc )
• Ultrasound , Endoscopy , X-ray (plain film) ,CT, MRI
• Isotope scan,PET, selective enterography, capsullar video endoscopy

HISTORY

1. Complain:when, where, what is it like?
2. Abdominal pain
3. Alteration in bowel habit
4. Difficulties in swallowing, nausea, vomitus
5. Bleeding: hemathemesis, melena, hematochezia

• GENERAL MEDICAL HISTORY
• FAMILY HISTORY

Systemic examination of abdominal system:

Inspection

• Skin color, scar, suture marks.
• Shape of abdomen – normally boat shaped.

      – Distension of abdomen-fat, fluid, flatus, fetus, full urinary bladder, feces.

• Abdominal movements-look on both side absent in peritonitis.
• Abdnominal pulsation -normally not visible.

       -Aortic pulsation is anemic or nervous patient

-Expansible pulsation in aortic  aneurysm

• Umbilicus-normally it is centrally situated and inverted

-Normally the distance between xiphi sternum and umbilicus and

Umbilicus and symphysis pubis is same

Clinical importance :

-In cases of ascitis the distance between xiphisternm and umbilicus is increased.

            -In cases of ovarian tumor the distance between umbilicus and symphysis pubis is increased .

• Dilated veins

– Dilated veins on sides of the abdomen -Inferior vena cava obstruction.

-Dilated veins radiating away from umbilicus-portal vein obstruction.

-Caput medusae, sometimes called a palm tree sign, refers to the appearance of   a network of painless, swollen veins around your bellybutton. While it’s not a disease,     it is a sign of an underlying condition, usually liver disease.

• Visible peristalsis:

-Peristalsis is a series of wave-like muscle contractions that moves food to different processing stations in the digestive tract.

-Gastric/intestinal peristalsis -Stomach peristaltic wave moving from left to right

-Large colon –right to left

• Hernial orifices- impulse observe on hernial sites on coughing

• Skin over the abdomen:

-Smooth and glossy in abdominal distension

-Abdominal striae  (stretch marks) rupture of sub epidermal connective tissue

            -past abdominal distension. In pregnancy, obesity, massive ascites.

Palpation

• Superficial palpation

Tenderness:  note the areas involved and the severity of the pain

 Rebound tenderness-pain is worsened on releasing the pressure-peritonitis

 Guarding-involuntary tension in the abdominal muscles- localised or generalised?

Masses-large/superficial masses may be noted on light palpation

• Deep palpation

– Liver palpation

– Spleen palpation

 -Kidney palpation

• Temperature and tenderness.

-Try to locate the local rise of temperature with the dorsal surface hand.

• Tenderness:

Tenderness is pain on touch palpate the abdomen for superficially for tenderness

Clinical note:

-Tenderness in epigastrium – peptic  ulcer Tenderness in right hypochondria- hepatitis and cholecytitis

-Tenderness in rt iliac fossa – appendicitis

-Guarding – contraction of muscle of abdomen as a part of defense over tender region

-Rigidity-contractions of muscles of abdomen as part of defense over inflamed region   or organ

• Pre – requisite of viscera palpation

-Supine position of the patient.

-To relax abdominal muscles – leg should be semiflexed at knee joint and hip.

 -This is the ideal position for the palpation of viscera and deep palpation

Deep palpation

• Liver palpation

1. Classical method

-Start deep palpation from right iliac fossa upwards, towards right hypochondrium

At the height of inspiration press fingers firmly inwards and upwards .

1. .Hooking method

-Try to make hook of fingers and insert under right lower costal margins.

1. .Deeping method

-Used in ascites patients as fluid is accumulated in the abdominal cavity.

-Do same as classical method tat press more deeply.

Clinical note:

-Normally liver is not palpable.

-Liver is palpable : Hepatomegaly-infective hepatitis, hepatic tumors

• Spleen palpation :

1. Classical method :

-Start deep palpation from right iliac fossa toward left hypochondrium

            -As spleen enlargement occurs in direction of umbilicus.

1. Bimanual method

– put one hand on posterior surface of left lower ribs and try to deep palpate With other hand in left hypochondrium

1. Hooking method

– try to make hook of fingers and insert under left lower costal margine

1. Deeping methos

– Used in ascites patients as fluid is accumulated in the abdominal cavity

– Do same as classical method but press more deeply

Clinical note:

– Normally spleen is not palpable palpable

-Spleen is palpable :Spleenomegaly – malaria, kala- azar, leukemia

• Kidney palpation :

1. Bi-manual method

            -For right kidney put one hand on posterior side of right lumbar region and do deep

palpation with the other hand on the anterior side of right lumbar region

Clinical note:

-Not palpable-normal

-Palpable in  – Renomegaly -acute renal failure, amyloidosis, renal lymphoma

Pyogranulomatous nephritis

Percussion:

• Tympanic note over abdominal percussion
• Tidal percussion
• Horseshoe shaped dullness
• Shifting dullness
• Fluid thrill
• Tidal percussion
• Percussion
• Tympanic note over abdominal percussion

Tidal percussion for the identification of the upper border of the liver Identify and ICS, start percussion downwards till resonant note is converted to doll note. This is the upper border of the liver.

– Borders of the liver: Right;5^th ICS in mid Clavicular line

                                               Right 7^th  ICS in anterior axillary line

Right 9^th ICS in scapular line

Horseshoe shaped dullness:

-Percuss outward from umbilicus,Mark the point when tympanic note is converted to dull note due to the presence of fluid as in case of ascites patients.

-It is only present in ascites patients

-Marking points formed as u shaped so only it is appeared as horseshoe shaped dullness

Shifting dullness:

-Percus out wards from umbilicus.

-Mark the point when tympanic note is converted to dull note due to the presence of            case of ascites patients

-Wait for 15 second,put your finger on the same point and tell patient to rotate on the            opposite side ,percuss same point again you will hear tympanic note as fluid has been         moved to the opposite side.

Fluid thrill :

– Supine position of the patient.

-Tell patient to put ulnar border of hand midway over the abdomen.

-Make a stroke with middle finger on one side of the abdomen while placing other   hand on opposite side where you have to feel fluid thrill.

AUSCULTATION

Peristalsis :

– A distinctive pattern of smooth muscle contraction that propels foodstuffs distally       through the oesophagus and intestine.

– Stomach peristalsis occurs at the rate of 3 waves per min, each wave moves at the      rate of 0.5 cm/sec .

-Intestinal peristalsis occurs at the rate of 6 waves/min.

            they may be loud enough to be heard with bare ears and are known as stomach rumble or borborygmi.

Rectal examination¹

The rectal exam is important to make sure cause of rectal bleeding such as hemorrhoids,rectal prolapse etc are not missed.

A rectal exam should be performed on most patients with abdominal pain and any concern for blood loss. Here, we review some important steps of a compete rectal exam.

Rectal Exam Technique

Positions

There are multiple positions that you can ask your patient to stand or lie. These include:

1. Standing position: patient standing with toes pointing in, then leans over a table
2. Right lateral decubitus (Sims position): patient lies on right side with right hip/leg straight and the left hip/knee is bent
3. Knee to chest: patient with lying on table facing down with knees up to chest bent forward

Inspection of Anus

Look for external hemorrhoids, fissures (90% of time they are located in midline posteriorly), skin tags, warts or discharge.

Palpate Rectum.

1. Use a small amount of lubricant on the index finger and ask the patient to take a deep breath and insert the finger facing down (6 o’clock position)
2. Appreciate the external sphincter tone then ask the patient to bear down and feel for tightening of the sphincter
3. Palpate the rectal wall starting from the 6 o’clock position clockwise to the 12 o’clock position. Then return to the 6 o’clock position and palpate the other half of the rectal wall feeling for masses, nodules and tenderness.

[i]References as end note

1.https://stanfordmedicine25.stanford.edu/the25/rectal.html[i] browsed on 3^rd jan 2022.

SKIN EXAMINATION:

HISTORY

1. General medical history

   Does the patient have any chronic medical problems or recent illness which may suggest a systemic cause of skin findings. Example: Viral exanthema such as rash of measle

2. History of allergies

   Known allergic reaction to medication, food, topical agents, hay fever and asthma

Eg: Egg, pea nut, pollen grains.

3. History of medications

   Essential to note both systemic and topical medications

   If any medication recently discontinued

   Even though new medications to cause drug reaction, even those taken continuously for years may cause reactions.

4. Family history

   To rule out contagious etiology, hereditory conditions.

5. Course of skin lesions
6. Acute/ chronic lesion
7. Recent rapid growth/ colour change. Eg: Measles begins on the face and then spreads to the trunk and limbs.
8. Any associated symptoms.

Observethelocationanddistributionofanyskinlesions:

• Acral – affecting distal areas, hands andfeet
• Extensor–extensorsurfaces,elbows,knees
• Flexural–flexuralsurfaces,axillae,genitalareas,cubitalfossa
• Follicular – arising from hairfollicles
• Dermatomal–correspondingwithnerverootdistribution
• Seborrhoeic–associatedwithareaswheretherearesebaceousglands,faceandscalp.

PALPATION OF SKIN LESIONS :

Assess surface characteristics of the lesion

Texture – smooth/rough – e.g. roughness in hyperkeratosis (scales)

• is it flat,raised, depressed ?

Crust – if present, are you able to remove crust and see what is underneath?

Temperature – is the lesion warm?

• assess deeper characteristics of lesion ?

Consistency – hard/soft/firm/fluctuant

Mobility – is the lesion attached to the underlying/overlying tissue?

Tenderness – is the lesion tender on palpation?

Primary Skin Lesions

1. Macule
2. Patch
3. Papule
4. plaque
5. nodule
6. Vesicle
7. Bulla
8. Pustule
9. Abscess
10. Wheal
11. Cyst

Features of lesion

1. MACULE

Aflatcircumscribedlesionshowingchangeincolorwithoutchangeinits consistency.

• Macules arenonpalpable.

-Theyare0.5cm-1cminsize.

-Discolorationmaybebrown,blue,redandhypopigmentedor hyperpigmented

2. PATCH

Alargemaculeiscalledpatch(>1cminsize).

– May havescaling.

Eg :- Vitiligo, melasma,pityriasis alba

3. PAPULE

• A small, solid lesion,<0.5 cm indiameter,

-raised above the surface of surrounding skin & hence palpable.

-Papules may be of various colors.

4. PLAQUE

-Itisanindurated(hard)areaofskinlargerthan0.5cmindiameterwhichmayberaisedor depressed from skinsurface.

-Thesurfaceareaisgreaterthanitsheight.Itisaplate-likelesion.

Ex:Psoriasis

Pityriasis rosea

Seborrheic dermatitis Tinea pedis

Eczema

5. NODULE

-A large ( 0.5 – 5.0 cm ), firm lesion raised above the surface of surrounding skin.

-It is the depth of involvement that differentiates a nodule from a large papule.

-Could be warm, soft,fluctuant,movable,fixed or painful.

-Surface-smooth,keratotic,ulcerated or fungating.

6. VESICLE

-A small, fluid filled lesion, <0.5 cm in diameter, raised above the plane of surrounding skin.

-Fluid is often visible and the lesions are translucent (semitransparent)

7. BULLA

-A fluid filled, raised, often a translucent lesion >0.5cm in diameter

8.PUSTULE

-AvesiclefilledwithpusItisformedduetocollectionofinflammatoryexudaterichin leucocytes.

-It may contain bacteria or may be sterile.(n0 signs of bacteria )

9.ABSCESS

-A localized collection of pus deep in dermis or subcutaneous tissue.

• Due to deep seated location pus may not be visible on skin surface but would showsign of inflammation.

10. WHEAL

-It is a transient swelling of skin disappearing within 24 hrs.

-Itisformedduetosuddenextravasationoffluidinthedermis. Eg:urticaria

11. CYST

-Itisasphericalorovalsacoranencapsulatedcavitycontainingfluidorsemisolidmaterial. Itislinedwithtrueepithelium.

Eg:- mucous retention cyst

Secondary Skin Lesions

1. Scale
2. Crust
3. Erosion
4. Fissure
5. Sinus
6. Scar
7. Atrophy
8. Lichenification

1. SCALE

Excessdeadepidermalcellsthatareproducedbyabnormalkeratinization(theprocessin which cellsfrom beneath the skinare convertedto hairand nails.made of keratin) and shedding

Eg: Psoriasis, Icthyosis

2. CRUST

-Dried exudate of body fluids (blood / serous fluid)

• Whichmightbeeitheryellow/red

Impetigo

3. EROSION

-A focal loss of epidermis

-Erosionsdonotpenetratebelowthedermoepidermaljunctionandthereforehealwithout scarring

Eg:-Tineapedis

Candidiasis,

Eczema

Herpes simplex

4.ULCER

-A focal loss of epidermis and/or dermis

-Scarring depends on the depth of the ulcer

Eg:

Chancroid, Pyoderma

Gangrenosum,decubitus

Chancroid Pyoderma gangrenosum

5.FISSURE

Itisalinearlossofcontinuityofskinduetoexcessivetension.

Eg:-

eczema(fingertips)

Finger fissure

6.SCAR

-It is replacement of normal skin by fibrous tissue in the process of healing of damaged skin.

-Scars are of two types hypertrophic and atrophic.

Eg:- acne, burns, herpes zoster, keloid

Acnescar                                scar ofherpeszoster               Burnscar

7.KELOID

-areaofovergrowthoffibroustissuethatusuallydevelopsafterhealingofskininjury &extendsbeyondtheoriginaldefect.

8. ATROPHY

•  
• Itmaybelimitedtoepidermis,dermis,orsubcutaneoustissue.
• Eg:- leprosy, atrophodera, Lipoatrophy

9. LICHENIFICATION

Repeatedrubbingofskinresultsinthickeningandhyperpigmentationofskin The skin markings becomeprominent.

Eg:- Lichen simplex chronicus, Atopic Dermatitis.

Generalized itching (Pruritus )

Skin Diseases :Dry skin, scabies, drug eruptions, urticaria, dermatitis herpetiformis.

SystemicDiseases:Diabetesmellitus,uremia,anemia,liverdiseases,obstructivejaundice, internalmalignancy

Localized Itching: Dermatophytosis, neurodermatitis, atopic dermatitis, pediculosis, papularurticaria, lichen planus.

Nails, hands and elbows

Assess the nails, hands, elbows for signs associated with dermatological diseases.

1. NAIL PITTING:
   • Punctatedepressionsofthenailplate
   • Associatedwitheczema,psoriasisandalopeciaareata

2. ONCHYLOSIS :
   • Separationofthedistalendofthenailplatefromthenailbed
   • Associated with psoriasis and fungal nailinfection

3. KOILONYCHIA :
   • Spoonshapedindentationofthenailplate
   • Associatedwithirondeficiencyanemia,canalsobecongenital

4. NAIL CLUBBING :
   • Lossoftheanglebetweentheposteriornailfoldandnailplate
   • Associatedwithmanyconditionsincludinginflammatoryboweldisease,cyanoticheart disease, lung cancer,bronchiectasis.

:

Elbow

• Xanthomas–secondarytounderlyinghyperlipidaemia
• Psoriasis plaques onelbows

Hair and scalp

INSPECT HAIR AND SCALP FOR

LOSS OF HAIR

• Alopecia areata – well defined patches of hair loss with surrounding normalhair
• Alopecia totalis – loss of all hair from the scalp (affects 5% of those with autoimmune hair loss)

EXCESS HAIR

• Hirsutism–androgendependentexcesshairgrowthinfemales.
• Hypertrichosis–non-androgendependentexcesshairgrowth.

SCALP

• Psoriasisplaques
• Dandruff – e.g. seborrheicdermatitis

Common Clinical Tests:

Special tests are performed to elicit diagnostic signs.

• GRUTTAGE :

Scrapingthesurfaceofapsoriaticlesioninanonhairyareawithaglassslidereleasessilvery scales,asifoneisscratchingthesurfaceofacandle.Thisiscalled“candlegrease”sign.Onceallthe scales are removed a thin membrane is exposed and on removing this membrane multiple pinpoint bleeding is seen. This is called Auspitz’ssign and it is pathogenic of active psoriasis.Itmaynotbepositiveinahealinglesion.

• NIKOLSKY’S SIGN :

In cases of active pemphigus vulgaris, if tangential pressure is applied with the thumb on a normallookingskinoverabonyprominenceasonthemedialsurfaceofthetibia,theskingets separated from the underlying wider area than on the vesicles themselves. This test may be positiveintoxicepidermalnecrolysisandsomeformsofepidermolysisbullosa

.

• BULLA SPREAD’S SIGN :

Pressureisappliedovertheedgeofabulla.Thefluidwillspreadtothesurroundingnormal lookingarea.ThebasisisthesameasthatofNikolsky’ssign.

• DERMOGRAPHISM :

Strokingtheskinwithabluntobjectproducesanexaggeratedtripleresponse,theredline, flareandedema.Thisispositiveinsometypesofurticariaandalsoinmastocytosis.White dermographismistheoneinwhichpallordevelopsinsteadoftheflare.Thisisafeatureof atopy.

• DARRIER’S SIGN :

Rubbing the macular lesions in urticaria pigmentosa induces a wheal.

• DIASCOPY :

Thelesionispressedwithaflattransparentglassslide.Thishelpstodifferentiatebetween purpura and erythema. In purpura, the lesion does not blanch, but in erythema the lesion blanches on pressure and the color returns on releasing the pressure. In lupus vulgaris a yellowishbrownapplejellyappearancemaybeseenondiascopy.

• WOOD’S LAMP :

Itemitslongwavelengthultravioletradiation(360nm)whichwillcausehairandskinto fluoresce.Theexaminationshouldbedoneinadarkroom.

• INTRADERMAL TEST :

This is done to detect immediate type of allergy such as anaphylaxis and urticaria. 0.05 ml of suspected antigen is injected intradermally on the flexor aspect of the forearm. Several antigens can be injected simultaneously in different parts. A control with 0.05 ml of normal saline or the diluent should also be given on the other forearm. The test is read after30 minutes. Increase in diameter of the wheal and erythema are noted. If the diameter of the wheal is more than 1½ times the control, the test is considered positive.

• SCRATCH TEST :

It is similar to intradermal test. Here a drop of antigen is placed on the forearm and two scratches are made with a needle through the solution in the epidermis. Development of a whealatthesiteofscratchistakenaspositive.Thepatientshouldnothaveanyactivelesion andshouldnotbeonantihistaminesorsteroidsatthetimeoftest.

ss

• PATCH TEST :

This is done in cases of suspected allergic contact dermatitis. The antigen solution is applied  on 0.5 cm2 lint and pasted on the forearm or back and secured with adhesive plaster for 48 hours after which the reaction is noted for erythema, edema, or vesicles. Several antigens can be applied simultaneously. The antigens are applied in low concentrations which will not  cause direct irritation when kept under occlusion for 48hours.

• PHOTO-PATCH TEST :

Whenphotocontactdermatitisissuspected,thepatchtestisdoneintheusualway.Ifthereis no reaction after 48 hours, the test site is exposed to sunlight for 30 minutes and occluded againforafurther48hoursandthenread.

LABORATORY INVESTIGATIONS :

Demonstration of fungus by microscopy

• GRAM STAIN OF PUS :

Thisisdonetodifferentiatepyogenicinfectionsfromsterilepustulesofpustularpsoriasisand subcorneal pustulardermatoses.

MICROSCOPIC EXAMINATION OF HAIR :

Portionsofthehaircanbeexaminedonaglassslideaftercoveringthemwithadropofcedar woodoilandapplyingacoverslipontop.Conditionssuchaspiedra,trichorrhexisnodosaand pilitorticanbediagnosedbymicroscopy.

SKIN BIOPSY :

Awell-developedlesionshouldbeselectedforbiopsyexceptinvesiculobullousdiseasesin whichtheearlylesionshouldbetakenintotowithsomesurroundingski