DIY Clinical Examination UG BOOK

7/31/2019 DIY Clinical Examination UG BOOK

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a pocket book, incorporating methods of clinical diagnosis, anatomy, radiology, clinical procedures,

pathology, and a glossary of medical terms

John Lumley MS FRCSEmeritus Professor of Vascular Surgery

St Bartholomews and the Royal LondonSchool of Medicine and Dentistry

Honorary Consultant SurgeonSt Bartholomews Hospital, London

Member of Council, Royal College of Surgeons

England

DIY Clinical Examinationfor Medical Students


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Contents

Preface vii

Aims, Organization, and Clinical Skills ix

GENERAL EXAMINATION 1

Mental Status 5Clinical Syndromes 6

Hands 7Nails 14Clubbing 15Face 16Mouth 17

REGIONAL EXAMINATION 21Head and Neck 23

Anatomy 23Cranial Nerves and Special Senses 27Neck 61

Musculoskeletal System 71

Muscles 71Bones and Joints 71Back 77Upper Limb 97Lower Limb 142

Thorax 183

The Respiratory System 185Cardiovascular System 212

Arteries 234Veins 249Vascular Access 254Lymphatic System 261


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Female Breast and Axilla 273

Examination 275Axilla 280

Abdomen 285

Alimentary Tract 285

Abdomen 292Inguinal Region, Groins, Genitalia and Perineum 330

Neurological 345

Neurological Examination 348Motor Function 348

Sensory Function 363Peripheral Nerve Injuries 370Local Anesthesia 376

APPENDICES 393

Appendix 1: Anatomical Orientation 395

Appendix 2: Systemic History and Examination 403

Appendix 3: Tools of Examination and Diagnosis 414

Glossary 417

Index 445

Contents


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In an outpatient consultation, the pulse , blood pressure (figures 1 &2), and urine should be routinely recorded, together with a patientsweight (figure 3). The height (figure 4) is usually known, but whengrowth patterns are being studied, this should be measured, togetherwith span and segments (figure 5a,b). In hospital, examine the wardchart for patient details and dates. These commonly record temperature,pulse, respiration, blood pressure, weight, bowel habit, and the resultsof urine testing. Note all these records carefully, and personally examine

all abnormal specimens. The latter include sputum, urine, vomit, feces,the contents of surgical drainage bottles, and any discharges. Dischargemay be from ulcers, wounds or other sites, and smaller amounts can beobserved on dressings.

In the physical examination , keep the patient comfortable, relaxed andreassured. Talk through what is going to happen, if this is not obvious,and ensure minimal discomfort and inconvenience. A warm environmentis essential and your hands must be warm. The privacy of a small roomor a curtained area is desirable with optimal, preferably natural,lighting . The patient undresses down to underclothes and puts on adressing gown. They then lie supine on a couch with an adjustablebackrest, to provide head support, and are covered with a sheet or

blanket. Each area must be adequately exposed as required withoutembarrassment. A chaperone may be appropriate when examiningmembers of the opposite sex. Relatives are usually best excluded exceptwhen examining children.

Thoroughness of examination is important. Efficiency and speed developwith practice. The examination time should not be prolonged in sick or

frail patients; in an emergency it may be appropriate to concentrate ondiseased areas, completing a routine examination at a later time.

Stand on the right side of the patient. The general impression obtainedduring the history is expanded during the examination. Note thepatients physical and mental status , as well as the severity of theirpresenting problems, their shape , posture , state of hygiene , and

mental and physical activity , and abnormal movements . In the initial stage, examine particularly the exposed parts, i.e., the hands , and thehead and neck . This provides information of changes of nutrition andhydration , such as obesity, edema, weight loss, cachexia, loss of skinturgor, and skin laxity. Weight loss with an increased appetite is seen indiabetes , thyrotoxicosis , and malabsorption . Other potent causes of

weight loss are malnutrition (due to lack of food, inability to eat andlack of desire to eat), parasitic disease, particularly of the gut, andprogressive malignancy .

General Examination


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4 General Examination

Figure 1 Examination of the pulse.

Figure 3 Weight. Figure 4 Height.

Figure 2 Measurement of bloodpressure.


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In the general examination, the pulse , blood pressure , venous andarterial pulsation in the neck, and the respiratory rate andmovements , in the chest and abdomen, are part of the routine.However, they are considered in detail with their respective systems.

MENTAL STATUS

The patients behavior may be influenced by the unaccustomed situationof being a patient, or the effect of their disease, particularly if they arein pain. The latter shows through their facial expression , the degree of eye contact , restlessness , sweating , anxiety , apathy , depression , lack

General Examination

Figure 5 a,b. Span and segments.

a

b


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of cooperation or aggression . Stress may be indicated by rapidrespiration, but note whether the patients intelligence and personalityequate to what one would expect from the history or whether this couldhave changed in relation to the disease.

Drugs, head injuries, and other diseases of the central nervous systemcan effect the level of consciousness , varying through alert, slow andconfused, lacking concentration, and reduced levels of response tospoken and physical stimuli. The patients orientation in time, place,and person should be noted. The Glasgow Coma Scale (GCS page 347)is a valuable way of documenting the level of consciousness for serial measurement. The patients speech may be impaired by disease of thecentral nervous system, producing dysphasia or dysarthria, and theremay be voice changes, such as hoarseness in laryngeal infection ormyxedema. Impairment of motor function can produce weakness orspasticity and these may affect speech.

The posture and gait should be noted, and other activities such asundressing. There may be added movements , such as the fine tremor of age, thyrotoxicosis, parkinsonism, and alcoholism, the flapping tremor of hepatic, respiratory, renal and cardiac failure, or more specificneurological abnormalities, producing lack of coordination andinvoluntary movements. If psychiatric abnormalities are present, orsuspected, note the patients general behavior, and disturbances of orientation. Record the emotional state, thought processes and content,hallucinations, delusions and compulsive phenomena, and include anassessment of cognitive and intellectual function.

CLINICAL SYNDROMES

A number of congenital and endocrine diseases have characteristicgeneral features amenable to spot diagnoses; but such changes alsooccur at the extremes of normality, thus be aware of the danger of

jumping to false conclusions. Congenital examples include Down, Turnerand Marfan syndromes, achondroplasia, and hereditary telangiectasia.Endocrine abnormalities include acromegaly (figure 6), Cushings disease,myxedema, and thyrotoxicosis. Other spot diagnoses are Paget disease,Parkinson, and myopathies. General disease states include weight loss ,dehydration , edema , and the features of hepatic and renal failure .

General Examination


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HANDS

The general examination starts with the hands. The initial handshakemay identify an abnormality , such as the large hand of acromegaly(figure 6) or a deformed hand due to abnormal development or previousinjury. There may be excessive sweating , due to anxiety, hyperhidrosisor thyrotoxicosis. Skin color changes are more easily seen in whiteskinned individuals, but they are usually visible in all races and must besought.

The palm gives some indication of the type of work undertaken (figure 7).Note pallor , cyanosis , and pigmentation ; stretch the skin of the palm toexamine the color in the skin creases, as this provides a better indicationthan the more exposed areas. Erythema of the palmar skin is most

marked over the thenar and hypothenar eminences. It is an importantfinding in liver disease, but may also occur in pregnancy, thyrotoxicosis,polycythemia, leukemia, chronic febrile illnesses and rheumatoid arthritis.

General Examination

Figure 7 Examination of the palms.Figure 6 Acromegalic hands. Note thestubby enlarged digits. However, suchhands may also be seen in the extremesof normality, and other clinical featuresand biochemical investigations are re -quired to confirm the diagnosis.

Figure 8 a. Examination for muscle wasting. b. The extreme atrophy of theinterossei in this patient is due to a long-standing ulnar nerve lesion.

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Figure 9 Examination for skin laxity.

Figure 11 Measurement of skinthickness.

Figure 12 Campbell de Morgan spot.

Figure 13 These three classic examples could all be missed unless a completesurvey of exposure of the whole body is undertaken as part of your general examination. a. Numerous areas of skin pigmentation and nodular appearanceassociated with neurofibromatosis. b. Skin changes of a herpes zosterinfection c. Malignant melanoma. An early diagnosis is essential if an excisioncure is to be obtained in this condition.

Figure 10 Senile keratosis.

b

ca


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General Examination

Erythema Collagen diseaseCarcinoidMitral valve (malar flush)Polycythemia rubra veraSuperior vena caval obstructionLiver disease

Erythema multiforme FeverInflammatory bowel diseaseRheumatoid arthritisThyrotoxicosisVirus and micoplasma infections

Urticaria Collagen disordersXanthomatosisHereditary angioneurotic edemaUrticaria pigmentosaHenoch-Schnlein purpuraCold agglutinins

Scaling Vitamin deficiencies

HypothyroidismAcromegalyMalabsorptionReiter syndrome

Papules and nodules Behet diseaseErythema nodusumErythema induratumGardner syndromeNecrobiosis lipoidicaNeurofibromatosisPolyarteritis nodosumPseudoxanthoma elasticumSarcoidTuberous sclerosisXanthoma

Blisters Dermatitis herpetiformisDrugsGlucagonomaPemphigusPorphyria

Vascular diseaseAngiomas Multiple vascular malformationsPruritus (table 11, p.339)Purpura

Table 1 SKIN MANIFESTATIONS OF NON-MALIGNANT SYSTEMICDISEASE


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Generalized muscle wasting can be detected by examination of the firstdorsal interosseous muscles (figure 8a,b).

The back of the hand is best to assess skin turgidity and look forgeneralized pigmentation, bruises, rashes, and spider nevi . Skin laxityis seen in older subjects, but it may indicate dehydration at all ages(figure 9). Similarly, areas of bruising and senile keratosis (figure 10)are normal features of aging, but may also indicate non-malignant andmalignant disease (tables 1 & 2) and there may be local or generalizedskin discoloration (tables 3 & 4). Skin thickness is a useful measure of nutritional status, particularly in children (figure 11). Skin nodules ,moles , and red Campbell de Morgan spots (figure 12) are common; skinabnormalities may be encountered anywhere on the body and thegeneral examination must scan all areas (figure 13ac).

In thefingers

, note nicotinestaining

, and thenutrition

of the skin inscleroderma, rheumatoid arthritis, other collagen disorders and ischemicconditions. There may be loss of pulp and small areas of ulceration

General Examination

Primary skin malignancyGardner syndromeSecondary malignant invasion (leukemia)Paget disease of the breastPruritis (lymphoreticular disease)Clubbing (lung)Hypertrophic pulmonary osteoarthropathy (lung)Superficial, deep venous thrombosis (occult often lung, gut)Dermatomyositis (50% associated with malignancy)Acanthosis nigricans (gut, bronchus)Ichthyosis (gut)Alopecia (gastric)Purpura (thrombocytopenic)Exfoliative erythroderma (lymphoma)Erythema gyratum repens (breast, lung)Erythema nodosum (gut, lung)Erythema multiforme (gut, lung)Eczematous dermatitis (gut, lung)Herpes zoster (lymphoreticular)Flushing (carcinoid)Pyoderma gangrenosum (leukemia, multiple myeloma)Palmar keratosis (bladder, lung)Disseminating intravascular coagulation (leukemia, lymphoma,

pancreas, generalized terminal malignant event)Hypertrichosis lanuginosa (gut)

Table 2 CUTANEOUS MANIFESTATIONS OF MALIGNANCY


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around the fingertips. Painful nodules around the fingertips are seen ininfective endocarditis (Oslers nodes) and deformity in rheumatoidarthritis and osteoarthritis (Heberdens nodes). Warts (figure 14) arecommon findings in children. Thickening of the palmar fascia(Dupuytrens contracture figure 15) may be idiopathic, hereditary, orassociated with cirrhosis, and various gut and pulmonary disorders.

General Examination

Hemorrhage/ Traumabruising Blood dyscrasias

Increased capillary fragilityOld age

Lower limb venous hypertension

Purple Campbell de Morgan spotsCapillary nevus port wine; strawberrySpider neviTelangiectasiaPyogenic granuloma

Stria pregnancy, Cushings, sudden weightloss

Yellow XanthelasmaPus

Brown Freckles moles, melanoma, basal cell

carcinomaCaf-au-lait spots neurofibromatosisOral spots PeutzJeghers syndrome (with

multiple small gut polyps)Erythema ab igne fires and hot water bottlesPregnancy areola and midline abdominal Ultraviolet light

RadiotherapyWarts, senile keratosis, keratoacanthoma,callosities

Black Eschar, burns and other scabsGangreneAnthrax

Pyoderma gangrenosum

Table 3 SKIN DISCOLORATION LOCAL

LOCAL SKIN CAUSEDISCOLORATION


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Purpura Bleeding disordersVasculitides collagen diseases, diabetesSepticemia especially meningococcal Systemic malignancies

Cushing diseaseEhlers-Danlos syndrome

Yellow JaundiceMepacrine

Orange CarotenemiaPale brown/yellow Chronic renal failure

PolycythemiaBlue Methemoglobin

CyanosisPolycythemia

Brown UV lightAcanthosis nigricansAddison diseaseNelson syndromeCushing diseaseACTH hypersecretionHemochromatosis (bronze diabetes)Arsenic and silver poisoningGardner syndromePellagra nicotinic acid deficiencyRheumatoid arthritisGaucher syndromeLichen planusFixed drug reaction

Pallor AnemiaHypoalbuminemia

Depigmentation Albinism (absence of melanocytes)Vitiligo (destruction of melanocytes)Pernicious anemiaGastric cancerHypo and hyperthyroidismAddison diseaseLate-onset diabetesAutoimmune disease (Hashimoto)SclerodermaSyphilisLeprosyIdiopathic

Table 4 SKIN DISCOLORATION GENERALIZED

GENERALIZED SKIN CAUSEDISCOLORATION


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Skin rashes may be discrete or continuous (confluent) and the lesionsmay be primary or secondary. Primary lesions have specific features:

Macules are flat circumscribed areas of abnormal skin color. They mayalso have characteristic texture or markings

Papules are circumscribed raised areas of abnormal skin. Largerpapules are termed nodules or tumors; if greater than 1 cm across,raised abnormal areas may be referred to as plaques . They may bedue to increased cellular content or edema

Vesicles are raised papules containing clear fluid. Larger collectionsare termed blisters or bullae

Pustules are raised papules containing pus

Wheals are raised papules with pale centers

Purpura indicates hemorrhage within the skin

Annular lesions may indicate spreading and infiltration or may havea healing center

Secondary lesions develop from the expansion or decline of primarylesions, or may be related to their mechanical effect. Examples aredesquamation or crusting, infiltration, ulceration, and scarring.Ichthyosis is thickening of the skin, lichenification is depigmentationand there may be atrophy. Scratching produces specific longitudinal,reddened areas, and there may be some associated skin thickening.Although there are very many and diverse cutaneous lesions, only a few

are commonly seen. These include acne, dermatitis, psoriasis, urticaria,warts, skin cancers, and leg ulcers. In your general survey, also examinethe hair distribution (table 5).

General Examination

Figure 14 Digital warts Figure 15 Dupuytrens contracture.This typically involves the ring andlittle fingers with palmar nodularity.


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NAILS

Nails can be an indicator of local and systemic disease. There can bestunted growth, and they may be brittle and deformed. Nail biters(figure 16) can be identified from loss of the projecting nail in any of

the digits of either hand. Whitish spots under the nail (leukonychiapunctata) are associated with minor trauma. Pallor of anemia andhypoalbuminemia, cyanosis and polycythemia are usually well shown,and pitting of the nails is common in psoriasis. Splinter hemorrhagesare longitudinal brown strips along the length of the middle of the nail;they are found in bacterial endocarditis and vasculitic disorders. Spoon-shaped, central depression of the nail ( koilonychia ) is seen in irondeficiency anemia.

Transverse grooves at a similar level in a number of nails ( Beaus lines )can denote growth abnormalities related to the onset of a severe

General Examination

Decrease (alopecia) AgeGenetic-myotoniaDamage from chemical treatmentSevere illnessMalnutrition

Immunosuppressive drugsRadiotherapyLichen planusPsoriasisSystemic lupus erythematosusFungal

Increase Racial Endocrine (virilizing ovarian tumors)

precocious pubertyadrenogenital syndromeCushing syndromeacromegalydrugssteroids (anabolic steroids)

Anti-epileptic drugsMenoxidil; diazoxideAnorexia nervosa

Table 5 HAIR CHANGES

HAIR CHANGES CAUSE/REACTION


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systemic disease. The arch over the base of the nail may become brown

(Meis lines ) in renal insufficiency, poisoning, and some inflammatorydisorders. Infections around the nail ( paronychia figure 17) arecommon but always exclude a diabetic etiology.

CLUBBING

In finger clubbing , the tissues at the base of the nail are thickened andthe angle between the nail base and the adjacent skin on the finger (thisshould measure approximately 160 degrees figure 18a,b) becomesobliterated. Application of light pressure at the base of the nail isassociated with excessive movement of the nail bed. In clubbing, the nail loses its longitudinal curve and becomes convex from above downwards as

well as from side to side. In the late stages, there may be associatedswelling of the tips of the fingers. Hypertrophic pulmonaryosteoarthropathy may be associated with clubbing in bronchial carcinoma; involvement of the wrist joints can be looked for at this stage.

General Examination

Figure 16 A nail biter. Figure 17 Paronychia. Pus hasextended underneath the proximal nail bed with surrounding inflammation.

Figure 18 a. Examination for clubbing. b. Clubbing associated withcongenital heart disease.

a b


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Clubbing may also involve the toes , particularly the congenital variety.Common causes of clubbing are carcinoma and purulent conditions of the lung (bronchiectasis, lung abscess, empyema), congenital heartdisease, and infective endocarditis. Less common conditions arepulmonary fibrosis, fibrosing alveolitis, pulmonary tuberculosis, pleural mesothelioma, cystic fibrosis, celiac and inflammatory bowel disease,cirrhosis, malabsorption, thyrotoxicosis, and bronchial arteriovenousmalformations.

FACE

Generalized weight loss may be apparent in changing facial and cervical contours. Excess tissue fluid ( edema ) is subject to the effect of gravity

and although mostly observed in the lower limbs towards the end of theday, it may also be obvious within the face, particularly the eyelids,after a nights sleep. Regional edema of the head, neck and upper limbsis seen in superior vena caval obstruction and the edema of myxedemamay be particularly obvious in the eyelids, associated with skin and hairchanges.

Whereas pallor and cyanosis of the hands may be due to the cold orlocal arterial disease, these signs in the warm central areas of the lipsand tongue have a more generalized significance. The pallor of anemiais most noticeable in the mucous membranes, although the sign lacksspecificity. The inner surface of the lower eyelid is an important area fordemonstration (figure 19), as well as pallor of the mucous membranesand the palmar creases. Other abnormalities around the orbit includexanthelasma and an arcus senilis (figure 20).

Cyanosis is the blue discoloration given to the skin by deoxygenatedblood. However, hemoglobin of 5 g/dl is required to produce visiblecyanosis; it is thus not detectable in severe anemia. Cyanosis is bestobserved in areas with a rich blood supply such as the lips and tongue.

It may also be noted in the ear lobes and fingernails but these areas canreact to cold by vasoconstriction, producing peripheral cyanosis in thepresence of normal oxygen saturation.

Cyanosis is usually due to cardiorespiratory abnormalities, but may alsooccur at high altitudes, with methemoglobinemia andsulfhemoglobinemia. Cardiac conditions include a number of congenital

abnormalities with a right-to-left shunt, whilst cyanosis may be relatedto hypoventilation (head injuries, drug overdose), chronic obstructiveairway disease, and mismatched arterial ventilation-perfusion (pulmonaryembolism, pulmonary shunts, arteriovenous fistulae). Cyanosis is difficult

General Examination


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to elicit in dark skinned people with anemia. Polycythemia is an excessof circulating red cells and may produce a purple-blue skin discolorationmimicking cyanosis; however, it is also prominent in the cheeks and the

backs of the hands.

Jaundice is yellow discoloration, due to excess circulating bile pigment(table 8, page 315). Mild degrees of jaundice are easily picked up fromthe staining of the sclera (figure 21). Be careful not to confuse theuniform yellow colour of jaundice with the yellowish peripheral discoloration of the sclera that can be seen in normal individuals. As the

jaundice becomes more pronounced, there is yellow skin discoloration,and this may progress to yellow/orange or even dark brown with highlevels of plasma pigment.

MOUTH

The mouth is a valuable indicator of systemic disease, as well as local pathology. It has a complex embryological origin, being the site of the

junction of ectoderm and endoderm, and receiving contributions from

General Examination

Figure 19 Examining forsubconjunctival pallor in anemiabeneath the lower lid.

Figure 20 Arcus senilis.The prominentwhite discoloration around theperiphery of the iris commencessuperiorly and inferiorly but maybecome circumferential as in thisexample.

Figure 21 Examining for scleral pigmentation in jaundice .


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pharyngeal arch mesoderm. The tongue muscles are derived fromsuboccipital somites that have migrated forward around the pharynx,bringing their nerve supply with them. This origin is also reflected in thevariety of diseases. These include skin and gut mucosal abnormalities,together with other lesions that encompass a number of medical andsurgical disciplines.

General Examination

Figure 22 Examination of: a. thetongue and b. oropharynx.

Figure 23 Examining mouth with: a.torch and b. spatula.

a b

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The breath must be examined for halitosis (offensive or abnormal fetor oris). This is most commonly due to poor local hygiene, but may bean indicator of respiratory, upper alimentary or systemic disease, andlocal disease within the oral cavity. Alimentary odors may be related togastroenteritis, obstruction of the pylorus, and small and large gut, andover-indulgence of food and alcohol; the latter aroma depends on thetiming and quantity imbibed.

Systemic disease produces characteristic odors. The sweet smell of ketotic breath may be related to insulin deficiency, but also to anincreased metabolic rate, such as with a fever (particularly in childhooddisorders) and fasting. There are usually other signs accompanying thefetor of renal and hepatic disease. The ammoniacal smell of hepaticcoma has been likened to musty old eggs.

Ask the patient to put out their tongue to assess hydration and to sayah, to observe the oropharynx (figure 22a,b). A more detailedexamination may require a torch and spatula (figure 23a,b), asconsidered in other sections.

The general examination described is undertaken in all patients; it isfollowed by examination of one or more systems, depending on the

presenting problem, as considered in subsequent sections. On completionof the examination of each region and system, cover the patient andmake sure they are comfortable.

General Examination

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DIY Clinical Examination UG BOOK