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ONLY FOR EDUCATIONAL PURPOSE
Prepared by Dr. IRFAN MIR
NOT FOR COMMERCIAL USE OR SALE
Prepared by Dr. IRFAN MIR
ONLY FOR EDUCATIONAL PURPOSE
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* Rapid change in wt over a few days suggest change in body fluid not tissue. * Wt loss with relatively high food In take suggest DM, Hyperthyroidism, mal absorption, consider also binge eating (bulimia) with clandestine vomiting. * Poverty, old age, social isolation, physical disability, emotional or mental impairment, lack of teeth, ill fitting dentures, alcohol or drug abuse increase the likely hood of malnutrition. * Tension and migraine headache are the most common kind of recurring headache. Progressively severe headache the likely hood of tumor or other organic cause. Extreme severe headache suggest subarachenoid hemorrhage or meningitis. * Nausea or vomiting are more common with migraine but also occur with brain hemorrhage and tumor. * Changing the position of head, cough, sneeze may increase the pain of brain tumor or sinusitis. * Refractory error most commonly explain gradual blurring, high sugar food may also cause blurring of vision. * Sudden visual loss suggest retinal detachment, vitreous hemorrhage or occlusion of the central retinal artery. * Slow central visual loss occurs in nuclear cataract, macular degeneration. Where as peripheral visual loss occur in advanced open angle glaucoma on other hand one side visual loss occur in hemianopsia and quadrantic defect. * Moving specks or strands suggest vitreous floaters, where as fix defect (scotomas)suggest lesion in the retina or visual pathway. * Flashing lights or new vitreous floaters suggest detachment of vitreous from retina. * Diplopia indicates the weakness or paralysis of one or more extra ocular muscles. Horizontal diplopia implicate the 3rd and 6th CN. where as diplopia in one eye with other closed suggest a problem in cornea or lens. On other hand vertical diplopia implicate problem in 3rd and 4th CN. * Hearing conduction loss result from problem in external and middle ear Where as sensori neuronal loss results from problem in inner ear, cochlear nerve & CNS. * Person with sensory neuronal hearing loss have particular trouble understanding speech, and complain that other noisy environment make it worst.(where as noisy environment may help in conduction hearing loss.) * Tinnitus is the common symptom increasing in frequency with age when associated with hearing loss and vertigo suggest Meniere,s disease. * Vertigo primarily point the problem in inner ear cochlear nerve or central connection. * Enlarge tender lymph node in neck often accompany pharyngitis. * A milky bilateral discharge from breast may be due to pregnancy or hormonal imbalance (Galactorrhea) where as non milky unilateral discharge suggest local breast dis. * Anxiety is the most common cause of chest pain In children. Among organic cause costochondritis is most common. * Pain over the sternum suggest angina pectoris. Where as finger pointing small area over heart suggest a non cardiac origin. A hand moving up and down from epigastria to neck suggest heart burn. * Orthopnea suggest left ventrical failure or mitral stenosis but may also accompany obstructive lung dis. * Paroxysmal nocturnal dyspnea describes as episode of sudden dyspnea and orthopnea that waken a pts from sleep. It suggest left ventricular failure or mitral stenos sand may be mimicking a nocturnal asmatic attack. * Wheeze a musical respiratory sound suggest airway obstruction. * Puffy eyelid and tight ring when associated with edema else where suggest, renal dis or hypoalbuminemia. * Cough is imp symptom of left side heart failure. * Hemoptysis originating in the stomach is usually darker than that from the respiratory tract. * Hemoptysis is extremely rare event in infant, children and adolescents seen most often in cystic fibrosis. * Dysphasia pointing to chest suggest esophageal disorder where as dysphasia pointing to the throat may occur in either a transfer or esophageal disorder. * Dysphagia of solid food suggest mechanical narrowing (obstruction) of the esophagus. Where as dysphgia of both solid and liquid suggest disorder of esophageal muscles.(eg.peristalsis problem). * Odynophagia describes as pain on swallowing. Sharp burning pain suggest mucosal inflammation vs. squeezing cramping pain suggest muscular cause. * Acute appendicitis exemplified both visceral perital pain. Early distention of inflamed appendix produce periumblical pain, which is gradually replaced by right lower quadrant pain due to inflammation of the adjacent perital peritoneum. * Visceral pain is poorly localized where as perital pain is caused by inflamed peritoneum and is steady aching pain that is usually more severe than visceral pain and also more precisely localized over the involved structure, aggravated by movement or cough. Pt with this kind of pain usually prefer to stay still. * Pain of duodenal or pancreatic origin may be referred to back. Where as pain from biliary tree may refer to the right shoulder or right poet chest. * Pain from pleurisy or acute MI may be referred to the upper abdomen. * Cramping (colicky) pain suggest the relationship to peristalsis. * Gastric juice is clear or mucoid.brownish or blackish vomitus with food particle like coffee ground suggest blood. * the frequency of bowel movement in normal adult is from 3 times a day to twice a week. * Occasionally constipation becomes complete with the passage of neither feces nor gas this is called OBSTIPATION it occur in intestinal obstruction. * Large diarrheal stool suggest disorder of small bowel or proximal colon. Where as small frequent stool with urgency to defecate suggest disorder of left 2 NOT FOR COMMERCIAL USE OR SALE
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colon or rectum. * Large yellowish or gray, greasy foul smelling and some time frothy and floating stool suggest steatorrhea (fatty stool) associated with mal absorption. * Relief by moving the bowel or by passing gas suggest a disorder in left colon or rectum. TENNESMUS suggest the problem in the rectum or anal canal. * Conjugated type hyperbilirubinemia is cause by viral hepatitis ,cirrhosis ,biliary cirrhosis drug induced homeostasis like oral contraceptives ,methyl testosterone ,chlorpromazine. * ACHOLIC stool (stool with out bile) are common in viral hepatitis or obstructive jaundice. * Itching favors cholestatic or obstructive jaundice. * Kidney pain felt at or below the costal margin posteriorly near the costovertebral angle may radiate anteriorly to ward the umbilicus. * Kidney pain is produce by sudden distention of renal capsule is typically dull, aching and steady. Where as urethral pain is severe colicky pain that originate in costovertebral angle and radiate around the trunk into lower quadrant of abdomen and into upper thigh, testicle, or labium. * Urethral pain results from sudden distention of ureter and associated distention of renal pelvis. * Bladder pain may cause supra pubic pain and is dull in quality and steady often due to infection. * Sudden over distention of bladder often cause agonizing pain where as chronic bladder distention is usually pain less. * Prostetic pain fell in the perinium and occasionally in he rectum. * Uretheritis and cystitis cause painful urination. * In women internal burning cause by arthritis or cystitis. * Urinary frequency suggest infection and irritation of bladder. * In man pain on urination without frequency or urgency suggest uritheritis. * urinary frequency with polyurea (day or night) suggest either a disorder of urinary bladder or impairment to flow or below the bladder neck. * Hematuria may cause by cystitis, malignancy, stone, trauma, tuberclosis, or acute glomerulonephritis. * Drug that may color the urine are laxatives (phenolophthaline), metronidazole, phenazopyridine. * Urinary incontinence (involuntary loss of urine) may occur when detrusor contraction are too strong, or poor general health or medication or environmental (functional incontinence).urinary incontinence also occur when intrauterine pressure is low (stress incontinence)or may be due to out let obstruction (over flow incontinence) which cause enlargement of bladder due to vol over load. * Stress incontinence occur while cough sneeze or laugh. * Hesitation ,dribbling ,or difficulty in start urine is commonly due to partial obstruction like BPH or urethral stricture. --------------------------------------------------------------------------------* Normal menstrual discharge is dark red where as excessive flow tend to be bright red and may include clots (not true fibrin clot). * Amenorrhea refer to the absence of menstruation. * Primary amenorrhea is failure to initiate menstruation. * Secondary amenorrhea is cessation of menstruation after have establishing it .(pregnancy ,lactation & menopause are physiologic form of secondary type). * Oligomenorrhea is infrequent menstruation common in first 2 year after menarche or menopause. * Polymenorrhea is frequent menstruation. * Menorrhagia is increase amount and duration flow. * Metrorrhagia is intermenstrual bleeding. * Postcoital bleeding occur after intercourse or douching. * Secondary amenorrhea occur due to low body wt mal nutrition, anorexia nervosa, stress, chronic illness, hypothalamic pituitary ovarian dysfunction etc. * postcoital bleeding suggest cervical disease like polyps, cancer, or in older women atrophic vaginitis or endometrial cancer. * Dysmenorrhea is pain with menstruation & usually felt a bearing down aching or cramping sensation in lower abdomen & pelvis. * PMS is refer to several symptom in some women during day 4 to 10 before periods. It include tension, nervousness, irritability depression, mood swing ,wt gain, abdominal bloating, edema and tenderness of the breast, and headache. these symptoms in some may be severe and disabling. * Amenorrhea followed by heavy bleeding suggest a threaten abortion, or dysfunctional uterine bleeding related to the lack of ovulation. * Dyspareunia is pain on intercourse. vaginismus is involuntary spasm of muscle surrounding the vaginal orifice that make penetration painful or impossible. (vaginismus may physiological or psychological). ----------------------------------------------------------------------------------* In erection disorder man cant attain or maintain erection that is adequate to complete the sexual activity. causes are organic psychogenic ,medication ,endocrine ,vascular, or Neurogenic.(a firm erection in any circumstances specially early in the morning suggest erectile dysfunction is psychogenic). * Premature ejaculation is very common in young man. * Reduce or absent ejaculation is less common & effect middle aged or older man, may be due to medication, surgery, neurologic deficit, or lack of androgen. * Lack of orgasm with ejaculation is usually psychogenic. ----------------------------------------------------------------------------------3 NOT FOR COMMERCIAL USE OR SALE
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* Severe pallor of finger often followed by cyanosis and than redness indicate Reynaud,s dis or phenomenon. * Aching cramping and possible numbness and severe fatigue that appears with walking and disappear with rest indicates intermittent claudicating. * Stretching or tearing of ligament called sprain. * Pain in small joints are sharply localized than large joints. Pain in hip joint is specially deceptive felt in groin or buttock or some time in ant thigh or solely in knee . * Hip pain felt in or near greater trochanter of the femur suggest trochantric bursitis. * Pain in only one joint suggest bursitis ,tendonitis, or monoarticular arthritis. * Rheumatic fever early gonnococcal arthritis often have a migratory pattern of spread, where as rheumatoid arthritis typically shows progressive or additive pattern and is symmetrical. * Usually severe and rapidly developing pain in a swollen joint not explain by injury suggest acute gouty or septic arthritis.( in children specially consider osteomyelitis that involve bone contigous to a joint) * Pain in the joint with out with out objective evidence of arthritis such as swelling, tenderness, or warmth are called arthralgia. * Stiffness after inactivity is common in degenerative joint dis but usually last only a few minutes .this is some time called gelling. where as Stiffness in rheumatoid arthritis and other inflammatory arthritis often last 30 min or longer. * Stiffness also accompanies ,fibromyalgia $, and polymyalgia rheumatica. * Tenderness, warmth and redness in a joint suggest acute gout , septic arthritis ,or possible rheumatic fever. * IMP CLUES IN MUSCULOSKELETAL DISORDER: Butterfly rash on cheek----------SLE Scaly rash ,pitted nail ,psoriasis---------------psoriatic arthritis. Few papules ,pustules ,vesicles on reddened base located on distal extremity ----------------gonococcal arthritis. An expanding erythmatous patch early in the illness---------------------lyme,s dis. Hives-------------------serum sickness and drug reaction. Erosion or scales on penis and crusting scaling papules on sole and palm---------------Reiter,s $ (Reiter’s $ also include arthritis uretheritis and conjunctivitis) Maculopapular rash of rubella--------------------arthritis of rubella Clubbing of finger nail----------------------hypertrophy osteoarthropathy. Red blurring and itchy eyes with arthritis---------------------Reiter’s $. Preceding sore throat----------------------------acute rheumatic fever and gonococcal arthritis. Diarrhea and abdominal pain---------------------------------arthritis with ulcerative colitis or regional arthritis. Symptom of arthritis---------------------------------------Reiter’s $ or gonococcal arthritis. ---------------------------------------------------------------------------------* In young people how loss consciousness temporarily consider vasodepressor syncope, hyperventilation, and tonic clonic seizures. Voices heard when passing out and coming suggest more vasodepressor syncope or hyperventilation. * Cardiac syncope starts and stops suddenly common in older person. * DYSESTHESIAS are distorted sensation in response to stimulus and may last longer than the stimulus it self. For example a person may perceive a light touch or a pin prick as a unpleasant burning or tingling. ----------------------------------------------------------------------------------* In pt with atherosclerosis anemia may decrease the threshold for angina pectoris or intermittent claudicating. * Patient with severe anemia may have headache, dizziness ,vertigo, syncope ,anorexia ,nausea ,intolerance to cold, amenorrhea ,menorrhagia, loss of libido, impotency. * Petechiae in skin and mucous mem and small bruises are common in pletelet disorder where as large bruises ,deep hematoma, hemarthrosis are seen in cloting disorder. * Obesity, weakness, fatigue, easy bruising, ankle edema, decrease or absent menstruation, suggest Cushing,s $. where as weakness, wt loss, nausea, vomiting darken skin and symptom of postural hypotension suggest Addison dis (adrenal in sufficiency). -----------------------------------------------------------------------------------HEADACHES * TENSION HEADACHES are aching and non painful tightness and pressure associated with anxiety ,tension, depression some time last weeks or month. * MIGRAINE HEADACHE are throbbing or aching often associated with nausea, vomiting, flash’s of light ,blind spot, sensory disturbance, relieve by dark quiet room some time last one to two days. * TOXIC VASCULAR HEADACHE shows variable severity provoke by fever ,CO, hypoxia ,withdrawal of caffeine. * CLUSTER HEADACHE one sided study ache high in the nose and behind and over the eye abrupt onset often 2 to 3 hours. associated symptoms are unilateral stuffy runny nose and reddening and teasing of eye. * HEADACHE WITH EYE DISORDER are ache around and over the eye may radiate to the occipital. Causes are far sightedness, and astigmatism but not near sightedness. Pain relieve by resting other eye associated symptoms are sandy sensations in the eye and redness of conjunctiva. 4 NOT FOR COMMERCIAL USE OR SALE
Prepared by Dr. IRFAN MIR
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* TRIGEMINAL NEURALGIA is sharp short brief lightening like recurrent severe pain may disappear for months. Pain typically occur over the distribution of the 3rd division of trigeminal nerve 5. * GIANT CELL ARTERITIS is chronic inflammation of cranial arteries often temporal and occipital arteries shows throbbing or burning often recurrent severe pain may persist weeks months associated symptoms are tenderness of scalp, fever, malaise, fatigue, muscular ache or stiffness and visual loss or blindness . * CHRONIC SUBDURAL HEMATOMA shows steady ache of gradual onset weeks to month, often injury progressively severe but may be obscured by clouded consciousness. Associated symptoms are personality change, hemiparesis, injury is often forgotten. * POST CONCUSSION $ shows rapid onset of steady or severe pain (throbbing) tend to diminish over months or years. Associated symptoms are poor concentration, giddiness (dizziness), vertigo, restlessness, tenseness, and fatigue. * SUBARACHENOID HEMORRHAGE cause abrupt onset of severe generalized pain “worst of my life” .associated symptoms nausea, vomiting, possible loss of consciousness, neck pain. * BRAIN TUMOR cause aching steady pain often brief, intermittent but progressive over time .associated symptoms are neurologic deficit, mental symptoms, nausea and vomiting may develop .aggravated by coughing sneezing or sudden movement of head. -----------------------------------------------------------------------------------VERTIGOS * BENIGN POSITIONAL VERTIGO is sudden onset of vertigo with brief duration may persist for weeks. tinnitus is absent some time cause nausea and vomiting (hearing is not effected). * VESTIBULAR NEURONITIS (acute labyrinthinitis) cause sudden onset of vertigos may durate hours to days, may recur. tinnitus is absent also shows nausea and vomiting.(hearing is not effected). * MENIERE,S DIS cause sudden onset of vertigo last several hours to days may recur, shows sensorineuronal loss of hearing that improves and recur eventually progress to one or both sides. Tinnitus, nausea, vomiting, and fullness of effected side are associated symptoms. * DRUG TOXICITY (amino glycoside, alcohol intoxication) shows acute onset of vertigo with hearing impairment of one side, tinnitus present . Associated symptoms are related to pressure on CN5 ,CN6, CN7. * Atherosclerosis ,tumor ,multiple sclerosis, ischemia may also cause vertigo. -----------------------------------------------------------------------------------* Pericarditis and pleural pain presents sharp knife like severe pain aggravated by breathing and changing position. It can be differentiate by; that pericarditis relieves by sitting where as pleural pain relieves by lying on the involved side. -----------------------------------------------------------------------------------* Dyspepsia shows symptoms similar to peptic ulcer disease but has no ulceration ,common in young age 20-29 yrs. * Duodenal ulcer may wake pt at night ,common in age 30-60 yrs ,it may recur. * Gastric ulcer is common in older age. * In peptic ulcer disease or dyspepsia pain occur at epigastria region and may radiate to back. * Pain in cancer of stomach is at epigastric region and do not radiate, common in age 50-70. * Acute pancreatitis cause pain in epigastria region and may radiate to back pain aggravate by lying supine and relieve by leaning forward with trunk flexed. .where as chronic pancreatitis cause fibrosis of pancrease with epigastria pain radiating through the back, pain is typically steady and deep. Pancreatic cancer cause same symptoms. Remember only chronic pancreatitis shows diarrhea with fatty stool (steatorrhea) and DM. * Biliary colic is sudden obstruction of cystic duct or common bile duct by gall stone produce steady aching not colicky of rapid onset and usually subside in few hours. * Acute cholecystitis cause pain with gradual onset longer than pain in biliary colic and aggravate by jarring and deep breathing. * Acute diverticulitis pain is of gradual onset first crampy than steady ,cause initial brief diarrhea than constipation. * Acute mechanical intestinal obstruction commonly cause by adhesion or hernia, cancer, diverticulitis the pain is typically crampy. * Small bowel obstruction cause per umbilical pain, vomiting and constipation, V/S where as large bowel obstruction cause lower abdominal or generalized pain constipation (obstipation) first than vomiting. * Acute arterial occlusion produce crampy pain first periumbilically than steady and diffuse cause vomiting, bloody diarrhea, constipation than shock. * Melena (black tary shiny stool) cause by peptic ulcer, gastritis, or stress ulcer, esophageal or gastric varices, reflex esophagi is, Mallory weiss tear. * Black non sticky stool may cause by ingestion of iron, Pepto-Bismol, licorice, and even chocolate cookie. * Irritable bowel $ may cause small hard often with mucous stool, with period of diarrhea, abdominal cramping, stress aggravate it. where as constipation cause by cancer of rectum and sigmoid colon. Rectal cancer cause tennesmus abdominal pain bleeding and pencil shape stool. * Fecal impaction is large firm immovable mass most often in rectum common in children. * Diverticulitis, volvulus, intusseseption, and hernia may cause colicky abdominal pain, abdominal distention, and in intusseseption often current jelly stool(red blood +mucous). * Red blood in stool may cause by cancer of colon, polyps, diverticula’s of colon , ulcerative colitis, infectious dysenteries, anal intercourse, ischemic colitis, hemorrhoids and anal fissure. -------------------------------------------------------------------------------------5 NOT FOR COMMERCIAL USE OR SALE
or urethral infection. ( it is basically due to decrease inhibition from cerebral cortex to detrusor contraction. common in strokes. -------------------------------------------------------------------------------------* Thirst is not present in polyurea if cause by excessive water in take. and causes of polyurea. nocturia is usually absent in these cases.In which detrusor contraction are insufficient to over come urethral resistance. It also cause by loss of nerve supply to bladder due to accident or DM. pseudofrequency ( voiding with out real urge). frrequent urgency with out polyurea and some time hematuria.sneezing when in upright position). tumor. 6 NOT FOR COMMERCIAL USE OR SALE . * Functional incontinence :. * Clot formation of deep venous vein cause deep venous thrombosis if pain present is usually in calf but process is most often painless and hard to determine. Common in women due to child birth and surgery. * Urge incontinence :. thigh.laughing .and other causes of frequency with out polyurea. stone. cramping. BPH. which last day or longer. coli .in which urethral sphincter is weak (momentary leakage of small amount of urine occur with stress like coughing .hypercalcemia. weakness. Sitting with leg dependent may provide relief. nocturia. Nephrogenic diabetes insipidus (renal unresponsiveness to ADH) . urtheral stricture. Another possible mechanism is reconditioning of voiding reflex due to frequent voiding at low bladder vol. The bladder is typically small and cant be detectable on physical exam. * FREQUENCY WITH OUT POLYUREA : * bladder sensitivity to stretch cause by inflammation due to infection. alcohol.staph aureus and giardia lamblia cause cramping. impaired bladder sensation that interrupt the reflex as in Diabetic neuropathy. It is associated with local redness. * Chronic diarrhea:. * elasticity of bladder due scar or tumor also results into burning on urination. unfamiliar setting (look for physical or environmental clue ). * Incontinence secondary to medication :. It may cause by hyperexcitability of sensory pathway due to infection tumor fecal impaction. anorexia. peripheral neuropathy as in DM. The bladder is typically large and tender on palpation even after the effort to void.Irritable bowel $ cause diarrhea which rarely wake the pt in night where as in ulcerative colitis and chrone dis diarrhea wake the pt in night . and potent diuretics. it shows frequency with out polyurea. CHF.In which Detrusor contraction are stronger than normal and over come normal urethral resistance. bed time alcohol or coffee.this is functional inability to get the toilet in time due to impaired health or environmental conditions. eg. urethral stricture. forign body etc ) . It may due to obstruction of bladder out let as in BPH and tumor. thirst. * Impaired emptying of bladder with residual urine in bladder due to obstruction. tenderness. motor disorder of CNS like in stroke.chronic venous insufficiency. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * Acute non inflammatory infectious diarrheas watery caused by viruses . * VENOUS DISORDER : * Clot formation and acute inflammation of superficial vein cause superficial thrombophlebitis which produce pain locally along the course of involved vein. * Nocturia with low vol may result from insomnia. * Burning on urination. * Motor disorder of CNS like stroke cause decrease cortical inhibition of bladder contraction cause frequent urgency with out polyurea. * Stress incontinence :.it also cause crampy pain. Rectal urgency. some time gross hematuria is because of bladder inflamation (due to infection. arthritis. In man stress incontinence may follow prostate surgery. tumor results into burning on urination frequent urgency with out polyurea and some time gross hematuria. atrophic vaginitis may be evident desire of urination is not associated with pure stress incontinence.Prepared by Dr.on physical examination bladder is not detected. * Nocturia with high vol cause by excessive fluid intake. nephrotic $. * Acute inflammatory infectious diarrhea cause by invasion of organism in intestinal mucosa produce loose to watery diarrhea often with pus blood and mucous. nerve weakness at the level of sacral region. also shows dribbling and decrease force of urinary stream. tennesmus may occur. before bed time coffee. results into hesitancy in starting the urinary stream. severe polydipsia. * Acute arterial occlusion due to embolism and thrombosis possibly superimposed on atherosclerosis cause distal pain of sudden on set involving the foot and leg may associated with absent distal pulses . it cause hesitancy in starting the urinary stream . hip. ( pseudo stress incontinence ). post menopausal atrophy of mucosa. * Overflow incontinence :. * Nocturia with high vol may cause by CRF. dribbling during and at the end of urination. urgency. fever. and foot. reduced size and force of stream. anticholinergic. poor vision. swelling. -----------------------------------------------------------------------------------* ARTERIAL DISORDER : * Pain occur in arteriosclerosis is fairly brief . dementia and lesion in spinal cord above sacral level. hypokalemic nephropathy.tranquilizers. chronic renal insufficiency. hepatic cirrhosis with ascitis . * POLYURIA :* Decrease of ADH (diabetes insipidus). wt loss. pain usually occur in calf but may also felt in buttock. and frequent urine with out polyurea. straining to void. * Frequency with out polyurea may also cause by BPH. renal dis or drug like lithium results into polyurea. palpable cord and possible fever.toxin produce by E.pain aggravate by work and relieve by rest in 1-3 min. depending on level of obstruction of large and middle size arteries.dribbling during or in the end of urination. brain tumor. * Persistent pain at rest which worst at night and aggravate by elevation of feet (as in bed) is due to ischemia. stone. sympathetic blocker.
excessive food. prolong typing. studying may also accompanying tension and depression when pain and tenderness are also present else where in the body consider fibromyalgia $. range of motion is not effected. pigmentation . common causes are peptic ulcer. and fever.s dis cause pain which is relatively brief but recurrent in one or more finger some time ulcer develop. 7 NOT FOR COMMERCIAL USE OR SALE . motion is limited due to pain. Stiffness present specially in morning there is no limitation of motion. It progress to other joint symmetrically. * Aching nocturnal back pain unrelieved by rest usually case by metastatic malignancy from prostate . tender. abscess. fatigue. * CHRONIC PERSISTENT LOW BACK STIFFNESS :. retroperitoneal tumor. ---------------------------------------------------------------------------------* Common lower back pain is often relieve by rest. * Chronic tophaceous gout is accumulation of sodium urate in multiple joint and other tissue (tophi) with or without inflammation. Show percussion tenderness over spinous process. * Osteoartheritis is insidious onset of degenerative bone and cartilage dis. but may be tender specially in morning. Associated symptoms are distal coldness.fasting. endometriosis. dissecting aortic aneurysm. streptococcal infection. Tenderness present with stiffness in morning & after inactivity may results into limited motion. warm. redness and tenderness with enlarge lymph node and fever. weakness. -----------------------------------------------------------------------------------* Acute lymphangitis cause by acute bacterial infection usually streptococcus results into red streak on the skin with enlarge tender lymph node and fever. * SCIATICA :. muscle spasm. typically the joint is tender hot and red. sense of depression. ulceration and gangrene at the tip of finger. limitation of motion is usually none may shows malaise. Tenderness. exposure to cold aggravate it and warm environment gives relief. common after age 60 (imp sign flexed posture). or chilling. joint pain. Pain may be insidious or abrupt even appearing over night. Pain occur in muscle of hip girdle and shoulder girdle symmetrically. cyanosis. surgery . * Fibromyalgia $ is a wide spread musculoskeletal pain may accompany other dis (mechanism unknown). chronic inflammatory poly arthritis common in young man.Chronic inflammation of synovial mem with secondary erosion of adjacent tissue (cartilage and bone) and damage to ligament and tendon. with often malaise. and redness may present with stiffness and limited motion.loss of sensation in dermotomal distribution. Associated symptoms are swelling. common with postural strain. It produce pain of sudden onset often at night after injury. acidosis. Intervertibral disc is involve in many cases. wt loss and low fever are common. pancreatic cancer.s dis) is inflammatory thrombotic occlusion of small arteries and vein in smokers result into intermittent claudication of the arch of foot (finger and toe) pain is fairly brief but recurrent may be worst at night. it manifest by loss of normal lumbar lordosis. swelling with crops. leg raising). * Acute cellulites and erythma nodosum mimic venous disorder (mistaken primarily for acute superficial thrombophlebitis). common in teenage yrs to 40. alcohol intake. Stiffness is prominent after a period of inactivity. excessive move. warm but seldom red. usual causes are herniated intervertebral disc with contraction and traction of nerve root. -------------------------------------------------------------------------------------* Rheumatoid Arthritis : . IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * Chronic venous engorgement secondary to occlusion or incompetency of venous valve may result into diffuse aching of leg. * Polymyalgia Rheumatica is dis of unclear nature seen in people in more than 50 yrs of age specially women may be associated with giant cell arthritis. excersize aggravate it and rest gives relief.may cause by ankylosing spondilitis. coughing. redness and warm. Local bone tender may be present. * Persistence dull aching in the back of the neck often spreading to occiput. limitation of ant and lateral flexion and immobility of spine of middle and older age man. * BACK PAIN OR SCIATICA WITH PSUEDOCLAUDICATION :. symmetric tenderness not recognized until examination. pancreatitis. do not mistaken with superficial thrombophlebitis. spinal tumor. bursae. * Acute gout is an inflammatory reaction to micro crystal of sodium urate commonly occur with first metatarsophalangeal joint (base of big toe) rarely occur in other joints. There is no palpable cord. * Thromboangitis oblitrans (buerger. numbness. sneezing.Prepared by Dr.It may shows chronic edema. Dermotomal sign and reflexes may be absent when one root is involved.is redicular nerve root pain radiate down to one or both leg usually below the knee with numbness. Swelling present in joints. TB. * Raynaud. sweating. renal stone. Where as diffuse idiopathic skeletal hyperostosis which effect middle age and older man. pain aggravated by prolong standing and relieve by elevation of leg . Little swelling may be present it is seldom warm and red. tenderness. Do not mistaken with superficial thrombophebitis. * Erythma nodosum a subcutaneous inflammatory lesion associated with variety of condition like pregnancy. Shows no swelling warm or redness. breast. and wt loss. kidney. Pain shift unpredictably in response to immobility. Pt may develop a symptom of renal failure. -----------------------------------------------------------------------------------* Simple stiffness is acute episodic localize pain in the neck often appearing on awakening and last 1 . thyroid and multiple myeloma. lung. Numbness tingling are common. spinal movement is not painful.4 day .psuedoclaudication is a pain in the back or leg that worsen with walking and improve with flexing of spine or bending forward. It progress to other joint but only one joint may be involve. anorexia. decrease to absent reflexes specially affecting the ankle jerk. causes include lumber stenosis which is combination of degenerative disc dis and osteoarthritis which narrow the spinal canal. * Acute cellulites is bacterial infection of skin and subcutaneous tissue result into diffuse swelling. * Back pain referred from abdomen and pelvis is usually deep and aching. Usually occur at ant surface of both lower legs manifest as raised red. limited motion. and pain worsen by spinal movement (like bending.possibly ulceration. chronic prostitis. tingling. fever may be present. and subcutaneous tissue. and fever. Pain is chronic with ups and downs without swelling.
coma (true syncope is uncommon). buzzing or odor.Manifest as funny feeling in the epigastrium cause nausea. Predisposing factors are metabolic disorder.acute and often recurrent neck pain that are often more severe and last longer than simple stiff neck may precipitate by whip lash injury. A. It improves on lying down.Is the neck pain as in cervical sprain but also radiate to dermotomal distribution(in arms. abscess or tumor. Causes are fatigue. * POSTURAL (ORTHOSTATIC) HYPOTENSION :. * ARRHYTHMIAS :.occur usually in elder or adult man with nocturia precipitate by emptying the bladder after getting out of bed to void (mech is unclear).In this neck pain present with associated symptoms of paralysis of leg. GI bleeding. cardiac out put and decrease BP. sweating. It manifest as a slump to floor recovery may be prolong . and possible sensory loss with muscular atrophy. or too fast > 180 B/min results into decrease cardiac out put. 8 NOT FOR COMMERCIAL USE OR SALE . pallor.the pain is typically sharp. polyurea. antihypertensive and vaso dialators. vibration in leg. degenerative dis. simple visual. prolong bed rest. abnormal behavior. flash back experiences. insulin therapy. hot humid environment which further precipitate by fear and pain.too low < 35 .predisposing factor are anxiety. bony spurring. older age decreases the tolerance of abnormal rhythm. DISORDER RESEMBLING SYNCOPE * Hypocapnia due to hyperventilation cause constriction of cerebral blood vesels . dyspnea. Onset is sudden which usually ends up with prompt return to normal. tumor or abscess. chest discomfort. bibinski response +.occur due to intrathorasic pressure due to severe paroxysm of coughing specially if person s muscular but prompt return to normal is usual. heavy lifting or sudden movement. or disorder of autonomic nervous sys. loss of sensation and position. dehydration. * Myocardial infarction can cause syncope with sudden arrhythmias or cardiac out put . Muscle spasm and tenderness with limited range of motion present.40 B/min . Consciousness is normal. * NECK PAIN WITH COMPRESSION OF CERVICAL SPINAL CORD :. Predisposing factors are peripheral neuropathies. * NECK PAIN WITH DERMOTOMAL RADIATION :. sneezing. B. hunger. fear or rage. confusion. causes are organic heart problem. * MICTURITION SYNCOPE :. Prompt return to consciousness when person lying down. * Hypoglycemia disturbs cerebral metabolism with resultant epinephrine release and manifest by sweating. yawning. salivation. weakness. recovery is slow after hyperventilation ceases. more complex hallucination. * massive pulmonary embolism cause syncope due to hypoxia or cardiac out put .. palpitation. Simple partial seizures with autonomic symptoms :. Simple partial seizures with motor symptom :*Jacksonian seizures are tonic than clonic that start unilaterally in foot hand and face than spread to the other part of body on the same side but maintain normal consciousness. * Postural (orthostatic hypotension may be cause by hypovolemia due to variety of situation eg. etc. nausea. Simple partial seizures with sensory symptoms :.Manifest as numbness tingling. fasting. * COUGH SYNCOPE :.Manifest as anxiety or fear. palpitation. auditory and olfactory hallucination such as flash light. the neck pain may be mild or even absent. tremor. flushing.Prepared by Dr. Bony spurring. * Aortic stenosis and hypertrophic cardiomyopathy when cause syncope is because vascular resistance falls but cardiac out put fail to rise. burning and tingling in quality. It manifest by restlessness. -------------------------------------------------------------------------------------SYNCOPE AND SIMILAR DISORDER * VASO DEPRESSOR SYNCOPE (common faint) :. diarrhea. * Hysteria fainting due to conversion disorder (mechanism is symbolic expression of an unexceptable idea through body language under stress full situation). Always prompt return of consciousness occur when lying down. There is no dermotomal radiation. tingling.Is a sudden peripheral vasodialation specifically in skeletal muscle with out compensatory rise in cardiac out put (BP falls). hunger.Syncope due to inadequate vasoconstriction reflex in both arteriole and veins with resultant venous pooling. vomiting. Prompt return to normal often occur. Simple partial seizures with psychic symptoms :. numbness. Prompt return to normal is usual. dreamy state. feeling of déjà vu or unreality. less commonly loss of temp and pain in leg. shoulder and back). D. light headedness but normal consciousness. possible causes are spinal cord compression due to herniated cervical disc. it manifest by light headedness palpitation on standing. Where as other motor seizures cause turning of head and eye to one side or tonic and clonic movement of one arm or leg with out jacksonian spread but maintain normal consciousness. SIEZURES ** PARTIAL SEIZURES starts with focal manifestation indicate a structural lesion in cerebral cortex. Pain increases with coughing. Causes include compression of one or more nerve due to herniated cervical disc or degenerative bone dis. Consciousness is normal. headache.predisposing factors are deep venous thrombosis. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * CERVICAL SPRAIN :. trauma. pallor. C.
C. * Flat effect and remoteness occur in schizophrenia.Invented and distorted word with new and highly idiosyncratic meanings observed in schizophrenia. A. After post tictal state (post seizure) confusion.A sudden breif lapse of consciousness with momentary blinking.Prepared by Dr. The movement may have personally symbolic significance and often don’t follow neuroanatomic pattern often variable post tictal state.ask pt to read loud.it begins with bilateral body movement or impaired consciousness or both suggest bilateral cortical disturbance either hereditary or acquired. drowsiness. Pt may remember initial automatic or psychic symptoms but is Amnesic for rest of the seizures. dancing. The has amnesic during seizures and recall no Aura. But speech changes are usually understandable association. Petit mal absence :---.last < 10 sec and stops abruptly. fatigue. Either prompt return to normal or brief period of confusion occur. Atypical absence :---. It observed into 9 NOT FOR COMMERCIAL USE OR SALE . hand wringing.speech that is largely incomprehensible because of lack of meaningful connection. * Neologism :. * Anger. Where as obtunded pts open there eye looked at you but respond slowly and are some what confused. slump posture.sudden loss of consciousness but no movement occur.an almost continuous flow of accelerated speech in which person changes abruptly from topic to topic and idea do not progress to sensible conversation. smacking lips. * Naming :. Tonic clonic (grand mal) usually starts in childhood or young adulthood. walking about. * One sided neglect occur from lesion of opposite prietal lobe cortex (usually non dominant side). * Incoherence :. Tongue biting and urine incontinence may occur. Myoclonus :. Absence seizures :. B. ** PARTIAL SEIZURES THAT BECOME GENERALIZED :. movement of lip and hands but no falling.these may mimic seizures but are due to conversion reaction (psychologic disorder). Two types are recognized 1. and slowed movement. * Hopeless. breathing resume and is often noisy due to excessive salivation.ask pt one stage command (point to your nose). D. unbuttoning cloths. 2. Tonic clonic seizures (grand mal) :. or skilled behavior such as driving a car). dementia. restlessness.speech characterize by indirection and delay in reaching the point because of unnecessary detail. and schizophrenia. manic episode and other psychiatric disorder. occur in agitated depression. Shift of meaning occur with in clauses.speech in which person shift from one subject to another that are unrelated or obliquely related without realizing that subject are not meaningfully connected. or two stage command (point your mouth than your knee). * Elation (fill with joy) and Euphoria (marked feeling of well being) occur in manic $. and anxiety. or evasiveness occur in paranoid pt.in which person losses consciousness suddenly and body stiffen into tonic extensor rigidity.. * Excessive fastidiousness (overly difficult to please) seen in obsessive compulsive disorder. like parts of watch. (many people speak circumstantially with out mental disorder). * Crying. breathing stops and person becomes cyanotic. -----------------------------------------------------------------------------* Dysarthia refer to defective articulation (like bar with dar and pen with den). Pt may not recall focal onset. * Writing :. * Tense posture.(disorder of language) * Word comprehension :.ask the pt names. They are often hereditary but when starts after 30 yrs often toxic or metabolic in origin. Observe in obsessional person. and fatigue suggest anxiety. pacing. found in mania. ** PSEUDOSEIZURES :.(Automatism include automatic motor behavior like chewing. and. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE ** COMPLEX PARTIAL SEIZURES with simple partial seizures or with impaired consciousness. -------------------------------------------------------------------------------“VARIATION & ABNORMALITY IN THOUGHT PROCESS” * Cercumstantiality :. muscular aching and some time persistent but temporarily bilateral neurologic deficit such as hyperactive reflexes. and expensive movement occur in manic episode. Than a clonic phase of rhythmic muscular contractions follows. Atonic seizures or drop attack :. occur in depression. staring. * Repetition :. if. * Apathy (lack of emotion with detachment and indifference) occur in dementia. * Flight of ideas :. * Reading :.). hostility. ** TESTING FOR APHASIA :. but).last > 10 sec post tictal cofusion occur. Automatism may develop. ** GENERALIZED SEIZURES :. bibinski response.ask pt to repeat a phrase of one syllabus word (no. depression.It resembles clonic seizures (grand mal). symptoms indicate a partial seizures that has become generalized that is recollection of an Aura and unilateral neurologic deficit during post tictal period. 2. Temporary confusion and headache mat appear.ask pt to write a sentence (a person who can write correct sentence does not have aphasia. Observed in schizophrenics. * Singing.sudden brief rapid jerks involving the trunk or limb associated with variety of disorder. psychotic disorder and aphasia. The seizures may or may not start with autonomic or psychic symptoms rather with impaired consciousness and person may appear confused. no aura recall . * Derailment (loosing of association) :. suspiciousness. -------------------------------------------------------------------------------* Lethargic pts are drowsy but open there eye and look at you respond to question and than falls a sleep. * Grooming and personal hygiene may deteriorate in depression.
Obsession often associated with neurotic disorder.delusion of being controlled by out side forces. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE severely disturbed psychotic person usually schizophrenic.apprehension. and on awakening are not classified as hallucination). ------------------------------------------------------------------------------* Thought process asses the logic. disorder. intelligence. eg my beautiful eye in your tie. anxiety and education. hallucination may be auditory.can be inquired by asking for eg when you heard those voices what did it says ? Or how did it make you feel ? ** ABNORMALITIES OF PERCEPTION :*illusion :. fixed.recurrent uncontrollable thoughts.cluster of delusion around single theme. It may occur in grief reaction. . and schizophrenia. mental retardation. it may occur in normal people phenomenon may be striking in schizophrenics. Hallucination may occur in delirium. falling a sleep. or has lost identity or become detached from one’s mind or body. Denial of impairment may accompany some neurologic disorder. * hallucination :. tel #. delusion is often associated with psychotic disorder. dementia (less commonly). psychotic state. images. visual.grandiose delusion . job. Always ask question like what bring u to the hospital ? What do u think is wrong to explain your illness or problem? * Judgment :.test the pt ability to concentrate by adding. . dementia. ----* feeling of unreality :. Occur In schizophrenia and manic episode.delusion of reference :-person belief that external events. subtracting. or unreal.somatic delusion :. or uneasiness that may be focused (phobia) or free floating (a general sense of ill defined dread or impending doom). Occur in schizophrenic and other psychotic disorders. * Confabulation :. mood disorder. disorientation occur when memory or attention is impaired. or impulses that a person consider unacceptable and alien. spelling back ward. zip code. olfactory. * Clanging :. mental retardation. personal belief that are not shared by others.fabrication of facts or events in response to question. The person may or may not recognized the experiences as false. Attention is poor in delirium. socioeconomic state. * attention :. * feeling of depersonalization :.assess pts response to family situation. education. fear. objects. Common in amnesia. . * anxiety :. -------------------------------------------------------------------------------* Perception :. gustatory.persistent irrigational fear accompanied by compelling desire to avoid the stimulus. Anxiety often associated with neurotic disorder. tension. Phobias are often associated with neurotic disorder. Feeling of depersonalization is often associated with psychotic disorder. changed .persistent repetition of words and ideas.a sense that one self is different. ** ABNORMALITIES OF THOUGHT CONTENT : * compulsion :. physical defect.repetition of the word and phrases of others . * Blocking :. person. delirium. and cultural values. unreal.a sense that thing in the environment are strange. depression. or people have particular unusual personal significance . Television might be commenting or giving instruction to a person. acute and post traumatic stress disorder. Pt with psychotic disorder often lack insight into there illness. as in delirium. Although expectation of such an effect is unrealistic.sudden interruption of speech In mid sentence or before completion of an idea.speech in which person chooses a word on the basis of sound rather than meaning . It can be assess by asking pt that how you will manage if you loss your job? Or what will you do if your class neighbor will threat you? Judgment may be poor in delirium. and schizopherenia. Compulsion often associated with neurotic disorder.systematized delusion :. tactile or somatic ( false perception associated with dreaming. * delusion :.repetitive behavior or mental act that a person feel driven to perform in order to produce or perform some future affair.eg . 10 NOT FOR COMMERCIAL USE OR SALE .delusion of having a dis.delusion of persecution .misinterpretation of real external stimuli. Feeling of unreality is often associated with psychotic disorder. -----. and coherence by word and speech. ---------------------------------------------------------------------------------** COGNETIVE FUNCTION :* orientation :. . place. * Perseveration :. interpersonal conflict.vs. judgment can also be effected by anxiety. * phobias :. * obsession :.is whether a pt is aware about his illness.what do you think about it in time difficult like that ? Or what do thing suppose to be done in that situation?. use of money.delusion of jealousy .false. relevance organization. dementia. post traumatic stress disorder. -------------------------------------------------------------------------------* Insight :. repeat number backward (person should be able to repeat at least 5 digit forward and 4 backward normally).can be determined by asking time. * Thought content can provide more information about the pts idea or thought by asking question like . to fill in the gap in an impaired memory. Etc.occur in manic episode and schizophrenia. * Echolalia :.Prepared by Dr.subjective sensory perception in the absence of relevant external stimuli.
* Concrete response is given by person with mental retardation. child and a dwarf etc. situation. feeling of worthlessness or guilt. helicopter and plane both fly is abstract but they both have tail is concrete. last 4 . In sever cases hallucination and delusion may occur. * mini mental state examination ( MMSE ) :-score < 24 increases the likelihood of dementia. period of intense fear or discomfort which develop abruptly and peak with in 10 min . decrease need for sleep.proverbs :. helicopter and a plan.in which depressed mood (irritable mood in children and adolescent). * cyclothymic disorder :. Ask question about it and note if he is confabulating. Symptom free period is no more than 2 month at a time. inflated self esteem or grandiosity.Prepared by Dr. 24 . etc. * manic episode :. best friend’s name. distractibility. * calculating ability :. inability to concentrate.is events of the day. Such situation are avoided or requires companion. recurrent thought of death or suicide ( or specific plan to attempt suicide ). unexpected panic attack. If vision and motor ability is intact.similarities :. feeling of unreality or depersonalization. fear of going crazy. insomnia or hypersomnia. dementia. injection.is anxiety about being in place or situation where escape may be difficult or help for sudden symptom may unavailable. During episode 3 of the following symptoms must present and persist at least for a week. paresthesia. -----------------------------------------------------------------------------** HIGHER COGNETIVE FUNCTION :* information and vocabulary :.gives rough estimate but is fairly good indicator of persons intelligence. chill or hot flashes.give the pt 3 or 4 word and ask pt to repeat. sweating. anxiety. Where as in mild to moderate dementia information and vocabulary is fairly well preserved. indecisiveness. depression. shortness of breath or sense of smothering. remote memory impairment occur in late stage of dementia.ask pt about the similarities of things like how following are alike. Recent memory is impaired in dementia. chest pain or discomfort.defined by recurrent. social security. triangle. * constructional abilities :. fatigue loss of energy. more talkative than usual.can be testing by two ways. trembling.marked persistent fear of specific object. nausea abdominal distress. delirium. or psychomotor agitation. * agoraphobia :. increase goal directed activity. or a little education. * new learning ability :. You can ask about name of president. Social phobia impair normal routine and relation ship. Major depressive episode usually last 2 weeks.is depressed mood and symptoms over at least 2 yrs (1 yr in children and adolescent).30 consider normal).in which distinct period of abnormally and persistently elevated. * hypomanic episode :. governor. * social phobia :. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * remote memory :.is a numerous period of hypomanic and depress symptom that last for at least 2 yrs (1 yr in children and adolescent). . Schizophrenics may respond concretely or with personal irrelevant or nonsense interpretation. eg dogs. * recent memory :. job. * obsessive compulsive disorder (OCD) :. Freedom from the symptoms last not > 2 mo.marked persistent fear one or more social or performance situation that involve exposure to unfamiliar people or scrutiny by others. feeling of chocking.involve obsession or compulsion that cause marked anxiety or distress. . or irritable mood occur. fear of dying. than after three or five min ask pt to repeat the those words again. information and vocabulary are usually effected in severely psychiatric disorder. * panic disorder :.5 president large cities or countries.can assess like copying figure like circle.ask pt what people means when says “ eye for an eye “ or “ squeaking wheel gets the grease “ or “ early to bed early to rise “ etc where as average pt should give abstract or semi abstract reason. aphasia. clock. affected one are not psychotic. Anniversaries. amnestic disorder.eg 9 x 4 = ? .inquire about birthday. * dysthymic disorder :. Beside that pt may shows significant wt gain or loss. * specific phobia :. square. poor construction ability suggest dementia or parietal lobe damage. ----------------------------------------------------------------------------** ANXIETY DISORDER :. --------------------------------------------------------------------------** MOOD DISORDER :* major depressive episode :. markedly diminish interest or pleasure are always present. psychomotor agitation or retardation. pencil and a pen.cause great distress and impaired function. expensive. rectangle. flight of ideas racing thoughts.panic attack include at least 4 of the symptoms.poor performance is may be the sign of dementia.symptoms resemble those in manic episode but less impaired last less than a week. and mental disorder. Exposure create anxiety or possible panic attack and person avoid precipitating situation. excessive involvement in pleasurable high risk activity. Ask simple other calculations like charging 55 cents out of dollar how much you give back ? * abstract thinking :. delirium. and mental retardation. Specific phobia impaired the persons normal routine. (out of max score of 30. education. Pt recognize it as excessive and 11 NOT FOR COMMERCIAL USE OR SALE . palpitation. dizziness fainting. In severe cases hallucination and delusion may occur. name of school attended. * mixed episode :.last one week meet criteria for both manic and depressive episodes. (eye for an eye is concrete where as justice is an abstract reason). Normally person remember if not suffering from amnestic disorder.
delirium tremens(alcohol withdrawal). disorganized speech. grossly disorganized or catatonic behavior (psychomotor abnormality). occupational. atropine poisoning. * schizoaffective disorder :. ** PSYCHOTIC DISORDER :. -----------------------------------------------------------------------------------* negative symptoms are flat affect.Prepared by Dr. Symptoms occur with in 4 weeks of event and last 2 days to 4 weeks. insomnia or unsatisfied sleep. contiguous sign of disturbance must persist for at least 6 months. Person tries to avoid situation that provoke the memories of event. these are delusion. Causes are -. avolition (lack of interest. these are delusion. * schizophrenia :. hallucination. Hallucination may occur. hesitancy or rapid speech. During or immediately after this event person has at least 3 of the following symptoms.excessive anxiety and worry which person find hard to control with at least 3 of the following symptoms. often flat depressed mood. acute cerebral vasculitis. person tries to avoid stimuli that may provoke response. frequent derailment or incoherence.is characterize by decrease level of consciousness. Fair orientation and attention (until late in course). (for this Dx should not occur exclusively during the course of delirium) ---------------------------------------------------------------------------------* DELIRIUM AND DEMENTIA :*delirium :. or in interpersonal relationship or self care. opioids etc. illusion. judgment impaired over the course of illness.recent memory specially new learning impaired. mutism. hallucination. absence of emotional responsiveness. unable to concentrate. Causes -. cocaine. * brief psychotic disorder :. The mood disturbance (depressed manic or mixed) is present during most of the illness and most of the time being concurrent with schizophrenic symptoms. 12 NOT FOR COMMERCIAL USE OR SALE . helplessness or horror. fatigued. Generalized anxiety disorder impair social.schizophrenia impairs major functioning at school. detachment. * schizophreniform disorder :. * acute stress disorder :. Functional impairment may not be present unlike schizophrenia. delusion. * Delirium may superimposed dementia some time. ( for this Dx should not occur exclusively during the course of delirium) * subs induced psychotic disorder :-prominent hallucination or delusion may be induced by intoxication or withdrawal from subs such as alcohol. Symptom of schizophrenia is not present except tactile and olfactory hallucination. behavior decreased (somnolence) or increased (agitated or hypervigilence).prominent hallucination and delusion may be experienced during medical illness. bizarre posture. acute hepatic failure. purposeless activity. feeling restless.vit B12 deficiency.has symptoms similar to schizophrenia but they last less than 6 months. The person must manifest 2 of the following for a significant part of one month.the traumatic event that threatened death or serious injury to one self or to other with resultant response of intense fear.psychotic disorder impair reality testing. difficulty concentrating or mind going blank. drive and ability to set and pursue goal). impaired judgment. OCD may interfere with persons normal routine and relation ship. work. Numbness. impoverished thought process. hallucination. * posttraumatic stress disorder :. alogia (lack of content in speech).characterized by non bizarre delusion that involve situation In real life such as having a disease or being deceived by lover.in which one of the following psychotic symptom must be present. disordered speech. impair social and occupational functions. difficulty in finding words(aphasia). uremia. and other imp functions. The disturbance cause marked distress. delusion. and negative symptoms. person functioning is not markedly impaired and behavior is not odd or bizarre. * dementia :.is traumatic event and fearful response and persistent experiencing of traumatic event as resembles acute stress disorder. amnesia for an event (imp part). hallucination often visual. irritability. * generalized anxiety disorder :. muscle tension. thyroid disorder ------------------> causes reversible dementia Alzheimer’s dis. * psychotic disorder due to medical condition :. disorganized catatonic behavior (psychomotor abnormalities like stupor. * delusional disorder :. and impair immediate and recent memory. feeling of unreality.is characterized by usually normal level of consciousness(until late in course). Delusion persist for at least a month.has a symptoms of both major mood disturbance and schizophrenia. excited ). PTSD last more than month. reduce awareness of surrounding as in daze. disoriented. disorganized incoherent thought process. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE unreasonable. normal to slow may be inappropriate behavior. feeling of depersonalization. During same period of time there must be delusion or hallucination for at least 2 weeks with out prominent mood symptom. vascular dementia ( due to infarct or trauma) ---------------------> cause irreversible dementia. The disturbance last at least one day but less than one month and person return to its prior function level. The event is persistently reappeared.
congenital heart dis. * Central cyanosis is cause by advanced lung dis. eg atopic dermatitis. * Purpura (petechia 1. chronic infection. bulimia. * Excoriation is an abrasion of scratch mark. anorexia nervosa. roughness of skin occur in hypothyroidism. EAR. * Lichenification is thickening and roughening of skin with increased visibility of normal skin furrows. It is frequently shiny specifically on legs. * Cherry angioma has no radiating legs occur with increase age. * Stare found in hyperthyroidism. Central cyanosis is best identify in lips. also seen in bleeding disorder. * Basal cell carcinoma seldom metastasize initially a translucent nodule spreads leaving a depressed center and firm elevated border and telengiectatic vessel around it usually over age 40 in fair skin persons. also occur in normal person. oral mucosa. * Wt loss found in malignancy. * Lift a fold of skin and note the ease with which it lift up (mobility). 13 NOT FOR COMMERCIAL USE OR SALE . * Small pit in the nail may be a early sign of psoriasis but not specific. pregnancy. hemoglobinopathies. * Peripheral cyanosis occur in venous obstruction. achondroplasia.superior rectus } 3rd CN superior oblique } 4th CN rd CN Inferior rectus } 3 lateral rectus } 6th CN rd CN Medial rectus } 3 Inferior oblique } 3rd CN * Vibration sound passes through the air transmitted to the ear drum to ossicles of the middle ear to the cochlea of middle ear to and than cochlea of inner ear. MOUTH * Palpable fissure is refer to opening b/w the eye lid. * Comedo refer to black head. Ulceration may occur. --------------------------------------------------------------------------------------EYES. flattened papule. HEAD. where as oiliness occur in acne. * Actinic keratosis is superficial. CHF.5 cm suggest neurofibromatosis.3 mm. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE SKIN. * Cold intolerance found in hypothyroidism. usually occur in trunk and face of older people or young black women. * Seborrheic keratosis is benign yellow to brown raised lesion that feel slight greasy. * Increase in melanin may be due to Addison’s dis (hypofunction of adrenal cortex) or pituitary tumor. hypoglycemia. * Ecchymosis (is of purple color) are often secondary to trauma. * Burrows of scabies look like short. where as long limbs in proportion to the trunk found in hypogonadism. marfan’s $. It is benign & may give rise to summons cell carcinoma. where as trunkal fat found with relative thin limb found in cushing’s $. * Muscle of eye movement :. velvety. hypothyroidism. or warty. * Sound passes from external ear to middle ear this is known as conductive phase. * Dryness. * Hypothermia refer to below 35 degree C or 95 degree F of temperature. DM type 2. where as pt with COPD prefer leaning forward with arm braced. vit B deficiency. It may be linear or round as in scratched insect bite. * Unlike jaundice carotene does not effect sclera which remains white. DM. linear or curved gray line and may end in the tiny vesicle ( burrow is slightly raised tunnel). diuresis. where as immobile face found in Parkinson’s dis. depression. * Squamous cell carcinoma occur in sun exposed skin look redden and firmer than basal cell carcinoma usually occur over age 60 in fair skin person. * Clubbing of finger suggest chronic hypoxia due to cancer of lung etc. purpura are larger) suggest bleeding disorder and emboli to skin. * Dry skin (asteatosis) is flaky rough and often itchy. * Fast frequent muscular movement found in hyperthyroidism. * Pt with left heart failure prefer sitting up right. successful dieting. * Hypothermia may cause by starvation. * Atrophy is thinning of skin with loss of normal skin furrows the skin look shinier and more translucent than normal eg arterial insufficiency. * Spider angioma is fiery red with radiating legs almost never occur below the waist suggest liver dis. liver cirrhosis. and speed with which it return to its place (turgor). * Generalized fat found in simple obesity. AND NECK * Very short stature found in turner’s $. where as slowed activity found in my edema. hyperthyroidism. * Terry’s nail are mostly whitish with a distal band of reddish brown suggest aging. * Café-Au-lait spot in six or more in quantity of diameter >1. covered by dry scale occur in fair skin old person. * Beau’s lines in the nail are transverse depression associated with acute severe illness. NOSE. * Decreased mobility of skin occur in edema and scleroderma and decreased turgor found in dehydration. where as when sound passes from cochlea to cochlear nerve known as sensorineuronal phase. * Cyanosis depend in level of oxygen in arterial blood. If this level is low cyanosis is central if its level is normal cyanosis is peripheral. CHF(with pulmonary edema it may also be central). renal or hypopituitary dwarfism. and tongue.Prepared by Dr. It may develop actinic keratosis.
where as bone conduction stimulate cochlea describe normal sensorineuronal phase. or Ectropion (outward drop of lower eyelid). * In paralysis of left 3rd nerve.Prepared by Dr. retinoblastoma (in children). * Lesion of retina can be related to optic disc and are measured as disc diameter for eg cotton wool patches at 2 and 3 o’ clock. In hyperopia light focus post or behind the retina. * In elderly the lens continuous to grow it may push the Iris forward. * LIGLAG is when eye move from above downward found in hyperthyroidism. * Enlarge blind spot occur in condition affecting the optic nerve. ptosis. these are non malignant over growth which may obscure the drum. where as in sensorineuronal hearing loss sound is 14 NOT FOR COMMERCIAL USE OR SALE . * Ant triangle of neck is bound. * Abnormal protrusion of eye occur in grave’s dis or occular tumor. * In paralysis of left 6th nerve. narrowing the angle b/w Iris and Cornea and increase the risk of Narrow Angle Glaucoma. and medially by mid line of neck. * Blephanitis is inflammation of eyelid along with lid margin often with crusting or scaling.inferior branch occlusion ---------------> upper eye field defect (diagram here) * Non tender swelling cover by normal skin-deep into the ear canal suggest Exostosis. * In refractive error. * Labyrinth with in the inner ear sense the position and movement of the head and help maintain balance. * Fine hair found in hyperthyroidism where as coarse (inferior quality) hair found in hypothyroidism. * In paralysis of left 4th nerve. conjuctival inflammation. laterally by stern mastoid. detached retina. & inferiorly by clavicle. Retinal structure in myopic eye look larger than normal while using ophthalmoscope. impaired drainage. * Mydriatric drops are contraindicated in head injury. * WEBER TEST is the test for lateralization to find out the hearing loss from turning fork. * Lateral sharpness of eyebrows suggest hypothyroidism. nasolacrimal duct obstruction. * Underlying skin of eye brows with scalyness suggest seborrhea dermatitis. the opposite eye respond consensually. posterior by trapazius. and tonic pupil. above by mandibles. etc. * Excessive tearing may be due to increase production. interiorly by sternomastoid muscle. * Post triangle of neck is bound. less than half disc diameter or more than one disc diameter or two times than disc diameter. * Loss of accomodation power is called Presbyopia usually become noticeable in one’s 40 where as hearing loss in aging is called Presbycusis. light do not focus on retina.temporal). In Myopia light focus ant to retina. a rim of sclera is seen b/w the upper lid and Iris and the lid seems to lag behind the eye ball. * Bullous myringitis is a viral infection characterize by painful hemorrhagic vesicle on tympanic mem. * Pupilary inequality called Anisocoria. where as each parotid gland empties into mouth near upper 2nd molar via stensen duct. left eye look out ward in effort to look straight. . also upward downward inward movement is impaired. * Absence of red reflex while using ophthalmoscope suggest cataract.inequality of less than 0. In normal person air conduction is more sensitive. * With weber test sound can be hear in impaired ear suggest unilateral conductive hearing loss. * Normally reactive equal pupil is called Isocoria . * Red bulging drum occur in Acute purulent otitis media where as Amberdrum occur in serous effusion.5 mm is consider normal however one should rule out Horner $. left eye cannot look down left. artificial eye. * In conductive hearing loss sound is heard through bone as long as or longer than it heard through air. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * Air conduction describes normal conductive phase. * Poor convergence is also found in hyperthyroidism. * when optic nerve is damage. * In lidlag of hyperthyroidism. * In retinal examination arteries are light red and veins are dark red in appearance. Shows blood tingled discharge from ear. * Occlusion of the branch of central retinal artery may cause horizontal (altitudinal) defect. narrow angle glaucoma. Occulomotor nerve paralysis. This respond is afferent papillary defect called Marcus gunn pupil. * The presence of venous pulsation at the optic disc suggest but does not prove that the CSF is normal. optic neuritis & papilledema. * Submandibular gland opens on papillae via Wharton’s duct that lies on the each side of lingual frenum. * Unusually prominent short process of Malleus or more horizontal short process of Malleus suggest a retracted drum. or by sudden change in atmospheric pressure from flying or diving called Otitic Baro trauma. corneal irritation. coma. eg glaucoma. papillary dilatation occur. where as if sound can be hear in good ear suggest sensorineuronal hearing loss . * Enlarge cup in optic disc suggest chronic open angle glaucoma. * Lens thicken and yellow with age that’s why older people need more light to do fine work.superior branch occlusion ---------------> lower eye field defect . the sensory (afferent) stimuli to brain is reduced so the pupil respond less vigorously and become dilated. * Serous effusion of middle ear cause by otitis media(viral) . (normal blind spot occur at 15 degree . eye can conjugate in right lateral gaze but not in left lateral gaze.
Also the uvula deviated to opposite side. Wt of herniated fat may cause senile ptosis. its occur in HTN. Grayish spot often seen at its base. * The Physiologic cup is a small whitish depression in the optic disc from which the retinal vessel appear to emerge. Where as Hair and eye brows are dry coarse. In HTN arteries wall thickened and become less transparent. * Ptosis is the drooping of upper eyelid suggest Myasthenia gravis. where as in sensory hearing loss pts own voice tend to be loud. trauma. * Papilledema in which venous stasis engorge and swell the vessel with resultant swollen disc and blurred margin. * Nasal polyps are pale semi translucent masses that usually come from middle meatus. * Corneal Areus is thin grayish white arc or circle at the edge of cornea. mobil. * Swelling b/w lower eyelid and nose suggest inflammation of lacrimal sac. * Myxedema (severe hypothyroidism) has puffy dull facies. * Glaucoma may result into increased cupping (depression) of disc and atrophy. * Failure to rise soft palate by saying Ah or yawn suggest 10th CN lesion.Prepared by Dr. * The retinal arteries are normally transparent. * RINNE TEST compare the air conduction and bone conduction by tuning fork. * In nasal septum fresh blood or crusting may suggest septal perforation. * Tender node suggest inflammation where as hard and fixed node suggest malignancy. * CHALAZION is chronic inflammatory lesion meibomiam gland it usually point inside the eyelid and is painless. * In conductive hearing loss pts own voice tend to be soft. common in elder may cause irritation or increase tearing. and sub conjunctival hemorrhage in which occular discharge is absent. * Cushing $ (increase adrenal hormone) produce moon face excessive hair growth may be present in mustaches or chin. * Ring and crescent are not the part of optic disc and is normal variation. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE heard longer through ear. cirrhosis. * Exophthalmos suggest Grave dis. * Periorbital edema suggest allergy. mediastinal mass. telecasts or a large pneumothorax. * In optic atrophy tiny disc vessels are absent. * Ectropion (outward turning of lower eyelid) and Entropion (inward turning of upper eyelid). * Small irregular pupil that do not react to light but do react to near effort indicate Argyll Robertsonian pupil it suggest neuro syphilis. Horner $. and interruption of sympathetic nerve fiber. discrete non tender node are frequently found in normal person. * Enlargement of the supraclavicular node specially to the left suggest possible metastasize from thoracic and abdominal malignancy. surgery. * Asymmetric tongue or deviated tongue suggest lesion of the 12th CN. acute glaucoma. hyperthyroidism. it may occur in normal person. * when artery loses its transparency the vein beneath it cant be seen . etc. * Pinguewla is yellowish some what triangular nodule in the bulbar conjunctiva appear with aging and is harmless. * Medullated nerve fiber appear as irregular white patch with feathered margin obscure the disc edge and retinal vessel it has no pathological significance . periorbital edema that does not pit with pressure. * Small. * Tracheal deviation may signifies mass in the neck. * Acute iritis. * Regurgitation of mucopurulent fluid from the punta of the eye with increase tearing suggest nasolacrimal duct obstruction. impaired parasympathetic nerve supply to eye. * In viral rhinitis the nasal mucosa is reddened and swollen where as in allergic rhinitis it may be pale bluish or red. with thin and dry skin. where as when Anisocoric is greater in dim light the smaller pupil cannot dialate properly suggest Horner $. diabetes. * Horner $ in which Iris is lighter than its fellow called Hetrochromia. myxedema and nephrotic $. unilateral exophthalmos may suggest. * Copper wire arteries shows bright coppery luster when reflect to light and Silver wire arteries occur after narrowing of arteries with no blood visible in it both condition found in HTN. local inflammation. * Corneal scar is superficial grayish white opacity secondary to old injury or infection. or coulometer paralysis. the larger pupil cannot constrict properly suggest trauma. * when Anisocoria ( unequal pupil ) is greater in bright light. 15 NOT FOR COMMERCIAL USE OR SALE . * Xanthelasma suggest hypercholesterolemia. vs. * Chronic unilateral enlargement of parotid gland suggest neoplasm where as a chronic bilateral enlargement of parotid gland associated with obesity. * Retracted eyelid or lid lag often suggest hyperthyroidism. * Redness of the gum occur in gingivitis where as black line of gum occur in lead poisoning. It accompanies normal aging but not in black where as in young people corneal areus suggest possibility of hypolipoprotinemia. * Light in a good eye produce direct reaction to the eye and consensual reaction to blind eye where as light direct to blind eye cause no response to either eye. vs. cocaine or amphetamine use. * A localize systolic or continuous bruit may be heard in hyperthyroidism. * STY is the painful tender red infection look like pimple around follicle of eyelashes. * PTERYGIUM is triangular thickening of bulbar conjunctiva that grows slowly across the outer surface of cornea. tumor . * Transillumination technique is useful in Dx of sinusitis. open angle glaucoma. inflammation of orbit. * Epicanthal fold normal in many Asians it may also suggest Down $.
Altered distance may suggest. or tumor. it is harmless. Side of teeth are tapered toward the biting edge. Inferior angle of scapula ends at 7th rib . IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * Superficial retinal hemorrhage are flame shaped seen in HTN. * Trachea bifurcate at the level of sternal angle interiorly and 4th thoraxic spinous process posterior. * Generalize hyper resonance may be heard over the hyper inflated lung of emphysema or asthma. * Preretinal hemorrhage develop when blood escape into space b/w retina and vitreous. atelactasis . * Dullness replaces by Resonance when fluid or solid tissue replace air containing lung or occupies the pleural space beneath your purcussing finger. Where as retinal hemorrhage of small round. (normal breathing is 14 . * Koplik’s spots are rash of measles (rubeola) resemble to grain of salt on the red back ground appears with in days of infection. * Trachea may displace laterally by a pleural effusion . Always hear frimitus from post chest. * Watch the Divergence of your thumb during inspiration at post chest wall at the level of T10 unilaterally diminish expiration suggest chronic fibrotic dis. ** Normal lung sound :* vesicular sound :. Unilateral hyper resonance suggest pneumothorax or large air filled bullae in the lung.(diaphragm is primary muscle of inspiration). * Multiple nodular goiter suggest metabolic rather than neoplastic process. * Visceral pleura is a serous mem cover the lung. pneumothorax or tumor. * Fremitus is palpable vibration transmitted through the bronchpulmonary tree to the chest wall when pt speaks. * Gingival hyperplasia caused by Dilantin therapy. * Age may accentuate the dorsal curve of the thorax spine producing KYPHOSIS result in barrel chest (increase anteroposterior diameter of the chest) . or diaphragmatic paralysis. * Torus Palatinus is mid line bony growth in the hard palate and is harmless. However barrel chest has little effect on function. pneumothorax . (Divergence is to feel the range and symmetry by your hand and finger of respiratory movement). papilledema. It is harmless. It suggest obstructed bronchus. emphysema. coastal cartilage of only first 7 ribs articulate with sternum. fibrous tissue.20 times/min). * Fordyce spots are normal sebaceous gland appear as small yellowish spot in the buccal mucosa or on lips. * Fremitus increases when transmission of vibration increases. heard over the most of the lung * Broncho vesicular sound :. also called soft exudates. suggest consolidated lung of lobar pneumonia. Normal distance is 5 . Abdominal muscle assist in expiration. * Simple nodule in thyroid gland is may be a cyst or benign neoplasm specially if there is rapid growth hardness and immobility. lobar pneumonia.Prepared by Dr. * Prolong expiration suggest narrow lower airway. 5th intercostals space is in the line of Xyphoid process . * The lower boarder of lung crosses 6th rib at mid claviicular line and 8th rib at mid axillary line and posterior at 10th thoraxic spinous process on inspiration it descends further. * Diaphragmatic excursion may be estimated by noting the distance b/w dullness on full expiration and full inspiration. May be due to vit B deficiency. causes are lobar pneumonia. In erect pt RBC settles create a horizontal line in hemorrhage. * In chest always inspect first than palpate and percuss and at last auscultate.It is inspiratoey sound that last longer than expiratory and has soft intensity. * Hutchinson’s teeth (W W) are sign of congenital syphilis . puberty. ------------------------------------------------------------------------------THORAXIC CAVITY AND LUNG * 2ND rib and sternal angle is on same line . * Stridor is inspiratory wheeze suggest airway obstruction in the larynx or trachea. telecasts. pleural effusion. * Epulis is a pregnancy tumor originate in interdental papilla with accompanying gingivitis. * Retinal micro aneurysm are tiny red spot found in Diabetic retinopathy. * Fremitus is typically more prominent in interscapular are than in lower lung and in right than left in normal subject. * Actinic cheilitis in which lips loses its normal redness and may become scaly thickened and slightly everted cause by solar damage in fair skin people. tumor. bronchial obstruction. fibrosis (pleural thickening). occlusion of retinal vein vs. Causes include sudden increase in intracranial pressure. Space b/w perital pleura and visceral pleura is pleural space. * Angular cheilitis is softening of the skin at the angle of mouth cause fissuring. Sternomastoid is more imp among these. * During exercise accessory muscle join the inspiratory effort. * Retinal neovascularization found in late stage of Diabetic retinopathy. low pitch. it also lines the inner rib cage and upper surface of diaphragm where it is called parietal pleura.Inspiratory and expiratory sound are equal with intermediate expiratory intensity and pitch often in the 1st and 2nd space interiorly 16 NOT FOR COMMERCIAL USE OR SALE . * When diaphragm contract it descends. pregnancy. It decreases or absent when transmission of vibration from larynx to surface of chest is impeded. * Cotton wool patches result from infracted nerve fiber seen in HTN. * 7th cervical and thoracic spinous of vertebrae are most prominent processes . * Tori mandible is bony over growth that grow from the inner surface of the mandible like Torus platinus .6 cm. * Retinal exudate is hard and yellow occur in HTN and DM. * Increase anteroposterior diameter of chest (barrel shape chest) may suggest COPD. and leukemia. or dot shape found in DM. * Drusen are yellow tiny spot and is normal with aging.
CHF. intensity of expiratory sound is loud with high pitch heard over monubrium. * Cheyne-stokes Breathing is a period of deep breathing alternate with period of apnea (no breathing). (test always after deep inspiration). * Pt with COPD often prefer to sit leaning forward with lips pursed during expiration. may be normal in infant and old age. COPD. It may be fast normal or slow in rate. * Crackles are intermittent. * Compress sternum with one hand and thoraxic spine with other at the same time. Tactile frimitus normal. It also lower the level of diaphragmatic dullness posteriorly. respiratory sounds are normal.Inspiratory and expiratory sound are equal with loud intensity & high pitch heard over the trachea in neck. * Hyper resonance of emphysema may tatally replace cardiac dullness. chronic bronchitis. COPD.it is normal in children and old people other causes are heart failure. whispered sound word heard loud and clear called Pectoriloquy.Prepared by Dr. * stridor is a predominantly inspiratory wheeze suggest partial obstruction of larynx or trachea demand immediate attention. Spoken word muffled and indistinct spoken ee heard as an ee. * Traumatic flial chest suggest rib fracture. * Normal respiration rate is 14 -20 resp/min and 44 resp/min in infant. hypoglycemia (affecting mid brain or pons). upper airway obstruction. eg as in Bronchitis. in comatose pt consider infarction. * In chronic Bronchitis wheeze and ronchi often clear with cough. pneumothorax. * Wheeze occur in asthma may be expiratory or both expiratory and inspiratory. * Funnel chest ( pectus Excavatum ) caused by depression in the lower portion of sternum may compress heart. * Forced expiration time of 6 sec or more suggest obstructed pulmonary dis. * Sighing respiration (long and loud breathing) may suggest hyperventilation $. * Clearing of crackle. injured area caved inward on inspiration and more outward on expiration. COPD. * Increase transmission of voice sound in lung (Bronchophony) suggest air filled lung has become air less. wheeze. * Bradypnea (slow breathing) is secondary to diabetic coma.Expiratory sound last longer than inspiratory. * hyperpnea /hyperventilation (rapid deep breathing) suggest anxiety.drugs. and increase intracranial pressure. tactile fremitus and transmitted voice sound is normal. non musical & brief like a dot in time suggest pneumonia. * Breath sound may be decrease when air flow is decreased eg obstructive pulmonary dis or muscular weakness. . bronchitis & bronchiactasis. hypoxia. * Early inspiratory crackles soon after inspiration (do not continous late in inspiration) suggest chronic bronchitis or asthma. * If Bronchvesicular or bronchial breathing heard in location distal from the normal hearing site suspect that air filled lung has been replaced by fluid filled or solid lung tissue. elevated diaphragm. great vessel (may cause murmur). * Thoraxic Kyphoscoliosis is abnormal spinal curvature and vertebral rotation deform the chest with resulting distortion of lung. It suggest brain damage typically at medullary level and respiratory depression. uremia. brain damage (typically both side of cerebral hemisphere or diencephalons). pleuritic chest pain. * Wheeze occur due to narrow airway has high pitch and have a hissing. vs. * In chronic bronchitis and early CHF lung is Resonant. only a large effusion detected anteriorly. * Late inspiratory crackles usually at the base of the lung suggest interstitial lung dis or early CHF. vs. * Dullness replaces resonance when fluid or solid tissue replace air containing lung or occupy the pleural space (and posteriorly In supine pt). * Pleural rub or Friction rub sound is often cracking due to inflamed or rough pleural surface typically heard in both phases of respiration. * In normal air filled lung resipitory sound are predominantly vesicular. metabolic acidosis. * Tachypnea (rapid shallow breathing) suggest restricted pulmonary dis. whispered word faint and indistinct. Occasionally sigh are normal. Bronchitis. shrilling quality suggest asthma. * Kussmaul Breathing is deep breathing due to metabolic acidosis. * Biot’s Breathing (Ataxic breathing) has unpredictable irregularity. vs. * Pigeon chest ( pectus Carinatum ) caused by ant displacement of sternum. or ronchi by cough suggest that secretion cause them. * In some normal people crackle may be heard at the base of the lung after max expiration. a common cause of dyspnea and dizziness.& arm supported on there knee or table. It may be shallow or deep or stop for short period. * Lung affected by COPD often displaces the upper boarder of liver downward. and emphysema. * Mid inspiratory & expiratory crackles heard in Bronchiectasis wheeze and ronchi may be present. * Tracheal sound :. ee sound heard as aa called Egophony. * Ronchi are low pitch and have snoring quality suggest secretion in large airway. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE and b/w the scapula posterior. 17 NOT FOR COMMERCIAL USE OR SALE . * Bronchial sound :. Costal cartilage adjacent to the protruding sternum are depressed. Drugs. * In airless lung (eg in lobar pneumonia) spoken word heard louder and clear called Bronchophony. When inflamed surface separated by fluid sound often disappears. * Transmission of voice sound is poor when there is pleural effusion. Tactile frimitus increases. * Prolong expiration of 6 sec or more suggest asthma. * Abnormal retraction of the lower intercostals space during inspiration suggest asthma. fibrosis. increase local pain distant from your hand suggest rib fracture rib fracture rather than soft tissue injury. * Hamman’s sign (mediastinal crunch) is series of precordial crackles synchronous with heart beat not with respiration best heard in left lateral position is due to mediastinal emphysema (often a medical emergency0. * Barral shaped chest (increase anteroposterior diameter) suggest COPD.
Tactile fremitus and transmitted voice sound is absent. tectile fremitus and transmitted voice sound may be reduced to absent but may be present near the top of the large effusion. breath sound. Egophony. vs. * The difference b/w Systolic and diastolic pressure pressure is known as Pulse pressure. * In older people systolic bruit in carotid artery suggest partial atherosclerotic obstruction in young it is usually innocent. tactile fremitus and transmitted voice sound is decreased. * Advantitious lung sound are crackles (fine or coarse).(split occur on inspiration called A2 and P2). produce dullness on percussion. There is no advantitious sound. Inspiration increase and expiration decrease the preload. Adventitious sound is not present except a possible pleural rub. ( remember breath sound. * Late in pregnancy or during lactation many women have so called mammary soufflé secondary to increase blood flow in breast. hyper resonance over the pleural air. dullness on percussion occur. and transmitted voice sound is present only when atelactasis is in right upper lobe). * Ej early systolic ejection sound by aortic valve opening it is pathologic. * In arteriosclerosis large arteries become stiffen result in increase systolic pressure (systolic hypertension) and widened pulse pressure. Using a reg size cuff in a obese arm may lead to false Dx of HTN. Venous pressure falls when when left ventricle out put or blood vol significantly reduced. with whisper Pectoriloquy and late inspiratory crackles. ----------------------------------------------------------------------------------------------CARDIOVASCULAR SYSTEM * Inspiration prolongs ejection of the blood from right ventricle but shorten ejection from left ventricle that’s why S2 split (A2 P2) is physiologic on inspiration. than atrial filling ( v wave ). pleural rub * In pleural effusion trachea shift toward opposite side. * S2 is aortic valve closure suggest diastole. * A carotid bruit with or without thrill in a middle aged or older person suggest but not prove arterial narrowing. (vol of blood ejected in one min) * Storke vol = vol of blood ejected with each heart beat. * Ascultatory gap is a silent interval that may be present b/w systolic and diastolic pressure. A lose cuff or a bladder that balloon out side the cuff may lead to false high reading. than atrial relaxation ( x wave ). * Atelectasis ( collapsed alveoli ) result into shift of trachea toward involved side.occur in pneumonia. * Pathologic increase in preload called vol overload. pulmonary edema. * Thrill are huming vibration that feel like throat of the purring cat during palpation over carotid sinus but if you can feel with stethoscope is called bruit. * S4 over age 40 may be normal or suggest heart dis. wheeze. ( always prefer to check right internal jugular vein). * S3 over age 40 strongly suggest ventricular failure or vol overload due to valvular heart dis like mitral regurgitation. tactile fremitus. * Avoid carotid sinus pressing which lie at the level of the top of the thyroid cartilage. * Regardless of position sternal angle remains roughly 5 cm above the right atrium. Adventitious sound from non to crackles. * Venous pressure ultimately depend upon left ventricle contraction. * Asthma shows normal to diffuse hyper resonance with wheezing breath sounds. * The pressure in internal jugular vein can easily be detected when pt is sitting in 60 degree angle. Adventitious sound may be wheeze and crackles are present. Breath sounds are bronchial over involved area produce Bronchophony. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * Consolidation of lung replace normal resonance and produse dullness over the airless area. * In Pneumothorax trachea shift toward opposite side. Pressure more than 3 . * If the brachial is much below heart level BP appear falsely high and pts own effort to support the arm may raise the BP. * Afterload is vascular resistance against which ventricle must contract. * Atrial functional sequence :-Atrial contraction ( a wave ). * S4 atrial contraction suggest Diastole. and transmitted voice sound are reduced to absent. or ronchi from associated chronic bronchitis. * Cuff that are too short or narrow may give false high reading. Tactile fremitus and transmitted voice soud is decreased. or pulmonary hemorrhage. where as Pathologic increase in after load is called Pressure overload.wheeze. It rises when right heart fails or due to increase pressure in pericardial sac which impede the return of blood into right atrium. * Emphysema results in hyper resonance (diffuse). breath sounds are decreased to absent. than atrial emptying or atrial pressure fall ( y wave ). * The tortuous aorta occasionally raises the pressure in the jugular vein on the left side of the neck by impairing there drainage with in the thorax. There is no adventitious sound except a pleural rub. Not often heard if heard suggest heart dis inold. Which may cause reflex drop in pulse rate & BP. tactile fremitus. An aortic murmur may radiate to the carotid artery and sound like bruit. * S1 is a mitral valve closure suggest systole. * Jugular venous hum common in childhood in young adult. ronchi. * Cardiac output = heart rate x storke vol. * Preload is boold load that stratches the heart muscle prior to contraction. * A murmur of mitral valve cannot be consider innocent.4 cm above the sternal angle consider elevated. * OS opening snap sound usually silent but produce sound in mitral stenosis.Prepared by Dr. Unrecognized auscultatory gap may lead to serious 18 NOT FOR COMMERCIAL USE OR SALE . * S3 rapid ventricular filling suggest diastole (normal in young but suggest vetricle failure in old).
--------------------* The normal impulse last through first 2/3 of systole but never continuous to the 2nd heart sound (S2). * Rolling the pt to left side accentuate S3 and S4 and specially mitral valve murmur. 5. * Marked increase in amplitude of systolic impulse of right ventricle suggest vol overload of right ventrcle eg in atrial septal defect. S2 is persistently single (normal split can be heard late in inspiration). than left lateral decubitus. * If femoral pulse is smaller & later than the radial pulse suggest coarctation of aorta or occlusive aortic dis . * Sequence of cardiac examination :.150 ). * Venous pressure > 3 or 4 cm above the sternal angle consider elevated. * To figure out amplitude of impulse either hyperkinetic or sustained high amplitude type auscultate heart and palpate pulse together. * Late systolic murmur _____________ is murmur of mitral valve prolapse. * a wave disappearance suggest atrial fibrilation. Increase amplitude (hyperkinetic impluse) may suggest hyperthyroidism. * Systolic click is common in mitral valve prolapse. an impulse with increase amplitude and duration occur with pressure overload of the right ventricle suggest pulmonic stenosis or pulmonary hypertension. ( if you find auscultatory gap record your finding completely eg BP 200/ 98 with auscultotory gap from 170 . * A brief mid diastolic impulse indicate S3 and just before the systolic apical beat it self indicate S4. than supine with head elevated 30 degree again than last sitting leaning forward after full exhalation. * Cardiac impulse lateral to the mid clavicular line suggest cardiac enlargement or displacement. * S1 is louder at apex where as S2 is louder than S1 at base. * Leaning forward with breath out accentuate the aortic murmur.first supine with head elevated with 30 degree. * Expiratory split suggest abnormality for eg a loud P2suggest pulmonary hypertension.the vein collapse on inspiration . Occasionally even bilateral distention has a local cause.press firmly ball of your hand against the chest. ____________ * A sustained low amplitude impulse may be due to dilated heart of cardiomyopathy. * Apical impulse of diameter > 3 cm indicate left ventrical enlargement. * S1 is decrease in First degree heart block where as S2 is decrease in aortic stenosis. if there is more than 10 mmHg difference record both eg 150/80/68 mmHg. In aortic regurgitationsoung never disappear. breath out may improve observation. * Internal jugular vein give more accurate reading for jugular venous pressure and pressure in right atrium. vs. consider technical fault. * Unilateral distention of the external jugular vein is usually due to local kinking or obstruction. it suggest left ventricular hypertrophy from pressure over load. * Large v wave suggest trcuspid regurgitation.the finding does not indicate CHF. shock or arrythmia. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE underestimating of systolic pressure or overestimating of diastolic pressure. * Tectile fremitus are felt best through bone . 4. * During deflating the cuff sound first muffled than disappear. * A palpable S2 over left 2nd interspace suggest pulmonary hypertension. * Prominent a wave indicate increase resistance to the right atrial contraction suggest tricuspid stenosis. vs. * When either A2 or P2 is absent as in valvular dis. A palpable S2 over right 2nd interspace suggest dilated or or aneurismal aorta. * Leaning forward position enhance detection of aortic insufficiency. interspace. * Midsystolic murmur (cresendo decresendo murmur) ___________ is due to blood flow across semilunar valve. * If sustained high amplitude impulse is displaced laterally consider vol over load . 19 NOT FOR COMMERCIAL USE OR SALE . * Heart sound often heard best in epigastric area (subxiphoid). severe anemia. * Pansystolic (holosystolic) murmur _____________ is often due to regurgitation across atrioventricular valve . hypertrophied right ventricle (which is more common).BP is lower in legs than in the arm in this condition. * Amplitude of apical impulse is usually small and feel like a gentle tap. if not than ask the pt to exhale and stop breathing for a few second.Prepared by Dr. if it continous to S2 called sustained high amplitude impulse. ____________ Normal impulse _____________ hyperkinetic impulse _____________ sustained high amp impulse _____________ sustained low amp impulse * Systolic impulse of right ventricle can be felt over left sternal boarder at 3. * Apical impulse often is most easily felt in the left lateral decubitus position. In pts with emphysema ask pt to inhale and stop for few sec. pressure overload (eg aortic stenosis). * Korotkoff sound ( sound produse by sphigmomamometer) estimate the systolic pressure by palpation. vol over load (eg mitral regurgitation). * In pt with obstructive lung dis venous pressure may appear elevated on expiration.
Release of maneuver has opposite affect. hypertrophy cardiomyopathy. * Emphysematous or obese person diminish the intensity of murmur. Patent ductus arteriosus. notch on the desending slope is not palpable. rumbling. * Early diastolic murmur (decresendo murmur) ------------------------------------> aortic regurgitation * Mid systolic murmur (cresendo decresendo murmur) --------------------------> aortic stenosis (may be innocent). fever. * When person squats it increase the left ventricular vol due to increase venous return which decreases the prolapse of mitral valve. * Pan systolic murmur (holosystolic or plateau murmur) -------------------------> mitral regurgitation. * Presystolic murmur or cresendo murmur ------------------------------------------> mitral stenosis. * Valsalva maneuver decreases the venous returnto right heart with resultant decrease in left ventricular vol and arterial BP. aortic stenosis. S1 may be vary with heart rate . * Atrial fibrillation and Atrial flutter with varing AV Block shows irregular ventricular rhythm. vs. * Decrease left ventricular vol increases the obstruction of hypertrophy cardiomyopathy and also increases the murmur and intensity. P wave is absent ( S1 and S2 likely to be split ). IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * Early diastolic murmur (decresendo murmur) * Mid diastolic murmur (pre systolic murmur) _____________ occur in aortic regurgitation or across semilunar valve. or low . * Late diastolic murmur (cresendo murmur) _____________ * A loud murmur of aortic stenosis often radiate into neck. 20 NOT FOR COMMERCIAL USE OR SALE . or musical. aortic stenosis. vs. Or with sphigmomamo meter which shows decrease of systolic pressure by > 10 mmHg on inspiration. ( S1 and S2 sounds are normal ). In contrast murmur of of aortic stenosis decreases. * Murmur can be graded from 1 . * Paradoxical pulse can be detected by palpation. pitch as high. aging. decreases stroke vol. ( for short run ventricular rhythm may seen regular). it delay click and murmur and decreases intensity. hyperthroidism. bradycardia due to increase stroke vol. ( note rapid and brief peak ) * Bisferien’s pulse is increase pulse with double systolic peak. * Large bounding pulse is strong suggest increase stroke vol. _____________ suggest turbulent flow across atrioventricular valve. * The decrease of left ventricular vol occur when a pt stands from squatting position it increase the tendency of mitral valve prolapse. ( note double systolic peak ) * Pulsus alternan’s is alternate in amplitude from beat to beat even though rhythm is regular but shows one strong and one weak pulse suggest left ventricular failure. Suggest pure aortic regurgitation or combine aortic regurgitation. derease compliance of aortic wall. aortic regurgitation. Quality as blow. * Pulsus paradoxus (> 10 mmHg) indicate cardiac temponade. constrictive pericarditis. and is decrease in pulse amplitude on inspiration. obstructive lung dis. * Atrial or nodal premature contraction is beat of atrial or nodal origin come earlier than the next normal beat a pause follow and than a rhythm resumes. anemia. med. S1 varies in intensity.40 mmHg counter is smooth and round.6 . atherosclerosis. (note one weak and one strong pulse) * Bigeminal pulse is rhythm disorder cause normal beat alternate with alternate premature contraction. * Ventricular premature contraction is beat of ventricle origin comes earlier than the next normal beat . on other hand same squatting increases stroke vol & intensity of murmur of aortic stenosis. decrease peripheral resistance. AV fistula. (these changes mimick the squatting to standing position). It suggest pericardial temponade.( more common) obstructive airway dis. * Normal pulse pressure is abt 30 . constrictive pericarditis. * Small weak pulse suggest hypovolemia. increase peripheral resistance due to cold or CHF. In contrast increase in left ventricular vol decreases the out flow obstruction in hypertrophy cardiomyopathy and decreases the intensity of murmur. harsh. * Sinus arrythmia in which heart usually speeds up with inspiration and slows down with expiration. P wave is present.a pause follow than rhythm resumes.Prepared by Dr. vs.
increased anteroposterior diameter of chest in old age. ---------------------(heard best in 2nd and 4th left interspace) 21 NOT FOR COMMERCIAL USE OR SALE . clicking quality. not vary with respiration it suggest dilated aorta and aortic stenosis. * Accenuated S1 ____________ suggest tachycardia due to exersize. pulmonary HTN. It is high pitch and clicking in quality. it suggest cardiovascular disease. * Pulminic ejection sound heard best at 2nd and 3rd left interspace. its intensity decreased by inspiration causes include dialation of pulmonary artery. it occasionally heard in normal person. * Increase intensity of A2 in right 2nd interspace suggest systemic hypertension because of increase pressure or when aortic root is dilated. * If P2 is equal or louder than A2 suggest pulmonary HTN. (term gallop comes from cadence of the 3rd heart sound specially at rapid heart rate ) * S4 (atrial sound or atrial gallop) ocuur just before S1 it has dull and low pitch. * S1 split some time heard at the apex but consider also an S4. It heard best at left lateral decubitus position. -----------------------------------------------------------------------* S4 is also be associated with delayed conduction b/w atria and ventricle. * Decreased or absent P2 result from plutonic stenosis. mitral regurgitation. heard best at left lateral decubitus position.it occur little later than opening snap with dull or low pitch. coronary artery dis. early systolic click. myocardial failure. It is often louder with Inspiration. * Paradoxical or reverse splitting is refer to splitting of S2 which appears on expiration and disappears on inspiration suggest delayed aortic closure P2 before A2 occur in Left bundle branch block (LBBB). * Wide splitting of S2 through out respiratory cycle suggest delay plutonic valve closure due to RBBB. RBBB may also cause splitting of S1 (tricuspid valve). cardiomyopathy. where as right side S4 heard best at left sternal boarder below typhoid. -------------------------* Aortic ejection sound heard best at apex and base. * Systolic click ( C1 ) is usually due to mitral valve prolapse. eg in atrial fibrillation. it has high pitch. -----------------------------------------------------------------------* S3 a physiologic 3rd heart sound is frequent in children may persist in young adult upto age 35 . It occur early in diastole during rapid ventricular filling. aortic ejection sound. which indicate mild mitral regurgitation. * Summation gallop occur when pt has both S3 and S4 sound mixing with S1 and S2 producing Quadruple sound. other wise it is due to decrease compliance of ventricle. common in 1st trimester. -----------------------------------------------------------------------* A pathological S3 or ventricular gallop sound is just like physiologic S3 sound but heard in pt after 40 yrs of age. The click is often followed by late systolic murmur usually cresendo upto S2. and mitral stenosis. vol overload of ventricle due to mitral or tricuspid regurgitation. murmur increase in time when person stands from squatting position. Abnormal splitting of both heart sounds (S1 & S2) may be heard in right bunddle branch block (RBBB). or early aortic valve closure due to mitral regurgitation. or pulmonary stenosis. or when LV contraction is diminished as in CHF or coronary heart dis. hyperthyroidism. aortic stenosis. anemia. dilated pulmonary arteries or atrial septal defect. It is louder on inspiration. Left sided S4 heard best at apex in left atrial position. **EXTRA HEART SOUND DURING CONTRACTION (SYSTOLE) :* Ej (early systolic ejection sound) occur shortly after S1. very common in children & young adult may also be heard in old people. **MIDSYSTOLIC MURMURS:* Innocent murmur result fro turbulent flow probably generated by left ventricular ejection of blood into aorta usually decrease or disappears on sitting.Prepared by Dr. * S1 is diminished ____________ in first degree heart block (delayed conduction from atria to ventrical). This sound suggest decreased myocardial contractility. S1 is usually soft in this area when appear to be a loud you may instead hearing plutonic ejection sound. and premature ventricular contraction. On other hand right side S3 heard best below typhoid process. atrial septal defect. right heart failure. ______________ _______________ Standing _______________ Squatting ** EXTRA HEART SOUND DURING RELAXATION (DIASTOLE) :* Opening snap is very early diastolic sound with high pitch suggest mitral stenosis (produce by opening of mitral stenitic valve) It may radiate to plutonic area.40 yrs. heard best at 2nd& 4th left interspace. Causes of right side S4 is pulmonary stenosis and hypertention. S4 is never heard in the absence of atrial contraction. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * Normal S1 is softer than S2 in 2nd right and left interspace where as S1 is louder than S2 at apex. * Normal splitting of S2 heard on inspiration and disappeares on expiration but in young person it may be audible during expiration. mitral valve calcification. * Decrease or absent A2 in right 2nd interspace suggest calcific aortic stenosis.
* Pathologically increase flow across pulmonic valve may present right side S4. ---------------------. The systolic murmur is associated with atrial septal defect.lsft interspace) ** DIASTOLIC MURMUR :* Aortic regurgitation results into left ventricular vol overload. Mid diastolic murmur during rapid venricular filling 2. dilated aorta (marfan’s $) . Ejection sound may be present. 22 NOT FOR COMMERCIAL USE OR SALE . early ejection sound is common heard best at 2nd & 3rd left interspace. Carotid artery impulse rise slowly with small amplitude. abnormality is usually congenital. ----------------------------(best heard at lower left sternal boarder) * Ventricular septal defect in which A2 amy observed by loud murmur with high pitch. S3 may be present S4 present at apex unlike mitral regurgitation. sound originate from flow. Inspiration does not affect sound. increased jugular vein pressure(large v wave) . ** PANSYSTOLIC (HOLOSYSTOLIC) MURMUR :* Mitral regurgitation cause the left ventricle vol overload with resultant dialation and hypertrophy. audible S3. -------------------------. Best heard at apex with blowing quality and may radiate to left axila. Causes include congenital.5th. Heard best in 3rd. Murmur heard best in pt with left lateran position with breath held in expiration. and mitral diastolic murmur (Austin flint) due to impingement of regurgutant on mitral leaflet. and hyperthyroidism. 1. Obstruction to flow may coexist. * Aortic stenosis cause turbulance and increase after load on left ventricle result into decrease and delayed A2 merging with P2 sound.left interspace with wide radiation. ----------------------------(best heard at apex may radiate to left axila) * Tricuspid regurgitation presents increased right ventricular impulse. Midsystolic flow murmur on Austin flint suggest large regurgitation. Right side ventrical impulse often increase in amplitude and may be prolong. pregnancy. * Pathologically increase flow across pulmonic valve may mimic the murmur of pulmonic stenosis. Mitral regurgitation and aortic valve dis may be associated with mitral stenosis.Prepared by Dr. It present with diminished S1 and S3 which reflects overload. and opening snap often follow S2. ---------------------------* In mitral stenosis.(best heard in right 2nd interspace) * Massive hypertrophy of ventricle muscle is usually associated with rapid ejection of blood durind systole. S3 S4 if present suggest severe regurgitation. ------------------------. bicuspid aortic valve. Two other murmur may associate midsection murmur because of increase forward flow across aorta.4th. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * Physiologic murmur results from turbulance due to temporary increase in blood flow to ventricle. left ventricular failure. rheumatic and degenerative heart dis.4th. Murmur is of blowing quatilty best heard at 2nd&4th left interspace with pt sitting. leaning forward and berath hold after expiration.(similar to inocent murmur) * Pulmonic valve stenosis increases the afterload on right ventricle it is congenital and most often found in children. anemia. Presystole murmur during atrial contraction. valve fail to open sufficiently in diastole the murmur has two component. An aortic ejection sound if present suggest congenital cause. Sound decreases when squatting and increases with straining down. ________________ (presystolic murmur disappear in atrial fibrillation) It present with accentuated S1 at apex. In pulmonary hypertention P2 is accentuated and right ventricle impulse become palpable. The carotid impule rise unlike aortic stenosis.5th. Unlike the murmur of mitral regurgitation the intensity may increase with inspiration. -------------------------(heard best in 3rd. Heard best in 2nd and 3rd left interspace. ------------------------heard best in 2nd and 3rd left interspace) * In severe pulmonic stenosis S2 is widely split & P2 is diminished no splitting is heard. other causes that may mimic the murmur of aortic stenosis are aortic slerosis. arterial pulse often lage and bounding.(best heard in 3rd&4th left interspace). usual causes are pulmonary HTN. S4 reflects the decrease compliance of hypertrophied left ventricle.
It presents continuos murmur with silent interval. Central lymph node---------------------------. 3. pubicand axillary hair before white girls. * Flattening of normally covexed breast suggest cancer. late menopause and exposure to ionizing radiation. Infraclavicular lymph node. ------------------------------------------------( continous murmur defind as one that begin in systole and continuos to 2nd sound into all or the part of diastole) -------------------------------------------------------------------------------------------------------------------------------BREAST AND AXILLAE * 2/3 of female breastis superficial to pectoralis major muscle and about 1/3 is superficial to serratus anterior muscle.drain most of the arm 4. mother or sister with breast cancer.Prepared by Dr. Masses may be 23 NOT FOR COMMERCIAL USE OR SALE . Supraclavicular lymph node. * Lymph node :1. 2. * Asymmetry of the direction of nipple suggest cancer. the skin and fascia ( that underlies the breast). Subscapular lymph node (post)----------. Common in children.(suspensory ligament are connected to skin and fascia of underlying breast when disturbed by cancer cause dimpling).deep in axila 5. * Dimpling or the retraction of the breast suggest cancer. early menarche. ------------------------------------------------* Venous hum is benign sound produse by turbulance of blood flow in jugular vein. late or no pregnancy. * In Adolescent male boy 2 out of 3 develop gynecomestia of one or both side. Atrial systole * Patent ductus arteriosus the sound is loud in late systole and silent in late diastole and is typically harsh and machinery like with loud intensity. Reasurance is indicated unless it is very marked. including suspensory ligament that is connected to both. Lateral lymph node---------------------------. * Axillary hairs usually appears about 2 yrs after pubic hairs. * Tender cords suggest mammary duct ectasia. * Recent or fixed flattening. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE ** CARDIOVASCULAR SOUND WITH BOTH SYSTOLIC AND DIASTOLIC COMPONENT :* Pericardial friction rub produce by inflammation pericardial sac usually heard best in 3rd left interspace. * Local infection or inflammatory carcinoma cause redness of breast. * Extra breast along milk line has no pathologic significance. long standing inversion is usually a normal variant. prior cancer in opposite breast.5. * Surface of areola has small rounded elevation are sebaceous gland called the gland of Montgomery. S2 obscure. Ventricular systole 2. Heard best in 2nd left interspace and radiate towad left clavicle. The huming roaring with soft intensity heard best above the medial third of the clavicle specially on right & radiate to 1st and 2nd interspace. * Menarche usually occur when girl is in SMR stage 3 or 4. Pectoral lymph node (ant)------------------. __________________________ 1. it resolves spontaneously with in year or two. * Risk factor for breast cancer include increase age. * Black girls tend to develop breast. * 1 out of 12 girls develop breast at different rate with considerable asymmetry which is usually temporary. * Thickening of skin and prominent pores suggest breast cancer. Intensity increase with pt leaning forward and exhaled the sound has 3 component. The sound has scratchy and scraping quality with high pitch. * Breast development is defined as Tanner’s sex maturity rate (SMR) from stage 1 . loudest in diastole.drain post chest wall and portion of arm 6. benign sometime painful condition with dilatation of the duct and inflamation around them.ventricular diastole 3.drain ant chest wall and much of breast * Breasts glandular tissue is supported by the fibrous tissue. or depression of nipple (inverted nipple) suggest underlying cancer.
* Epigastric bruit confined to systole only.irregular. If tenderness occur else where than the place you are trying to elicit rebound than that area must be 24 NOT FOR COMMERCIAL USE OR SALE . crust or erode.percussion 4. * Friction rub over liver and spleen suggest infection (eg goncoccal) or splenic infarction respectively. eccentric. Normal frequency of which is 5 . * If the mobile mass in breast become fixed when pt presses her hand against hips suggest the mass is attached to pectoral fascia where as if it is immobile when pt is relaxed suggest attachment to the rib and internal coastal muscle. * Examine painful and tender area at last. * Milky discharge unrelated to prior and lactation is called non puerperal galactorrhea. ------------------------------------------------------------------------ABDOMEN * Lower pole of right kidney an be feel in right upper quadrant but little deep. * Central lymphnodes are most often palpable they are small and <1 cm and non tender in normal person. * Striae these are silver stretch marks and are normal vs. * Abdominal pain on cough or with light percussion suggest peritoneal inflammation . * In male hard . * A dilated veins of the abdominal area. * Doudenum and pancrease lie in the upper abdomen normally not palpable. * Lymphnode >1 cm in diameter. It is round disc like or lobular soft or firm. * Bruit in the epigastric area and each upper quadrant in hypertensive pt with both systolic and diastolic component strongly suggest renal artery stenosis as a cause of HTN. * Deeply pigmented. Other reasons that ca causes of retraction sign include fat necrosis and mammary duct ectasia. * As breast cancer advances. * Simple and multiple cyst often round and tender with absent retraction sign. * thickening of the nipple and loss of elasticity suggest cancer. Or may be part of lymph adenopathy look for other nodes in this case. * Fibroedenoma single or multiple occur in puberty and young adulthood upto age 55. Its consistency is soft to firm and mobile and well delineated. * Involuntary rigidity of abdominal muscle (muscular spasm) typically persist despite all relaxing maneuvers. suggest peritoneal inflammation. regresses after menopause. change in contour. * Cancer most commonly occur from 30 . it causes fibrous scar tissue. Shortening of scar tissue cause retraction with resultant dimpling. irregular or stellate. where as pink or purple striae are of cushing’s $. retraction or deviation of nipple. Where as dullness (absence of resonance) is due to fluid or feces both sound should be assess by percussion carefully.suggest intestinal obstruction. * Non milky unilateral discharge suggest local breast dis.palpation in end.34 / min. * Normal bowel sound consist of click and gurgles. suggest hepatic cirrhosis or inferior vena cava obstruction. skin may also weep. * Borborygmi is loud prolong gurgle occur because of hyper peristalsis. * A protuberant abdomin that is lymphatic through out . * Rebound tenderness suggest peritoneal inflammation. may be heard in normal subject. cusetive agent is usually benign (benign intrductal papiloma) but it may be malignant in elderly women. * Increase peristaltic wave suggest intestinal obstruction.Prepared by Dr. * Peget dis of the nipple is uncommon form of cancer that usually start as eczema like lesion.90 yrs of age usually single but may coexist with other nodules. velvety axillary skin suggest Acanthosis. non tender mobile and retraction sign is absent.auscultation 3. * Hard irregular poorly circumscribed nodules fixed to skin or underlying tissues strongly suggest cancer. * Dullness in both flank indicate further assessment of asites. * Sweat gland infection (hideradinitis supurativa) commonly found in maxillae. or ulcerating nodule is not gynecomestia and suggest breast cancer. causes are hormonal or pharmacologic.Inspection 2. firm and hard. distract the pt with conversation when necessary. * Edema due to lymphatic blockage appear as thickened skin and enlarge pores called Peau . * Tympany (resonance sound) dominate in the area with gas in GI tract.d . or matted together or fixed to the skin or to the underlying tissue suggest malignant involvement. * Most of the normal gallbladder lies deep to the liver from which it can not be distinguished clinically. * Enlarge axillary node suggest infection of hand and arm. firm and hard not clearly delineated with surrounding tissue usually not tender. * Another stony hard lump that can some time mislead is normal xiphoid process. * Increase pulsation of abdominal aorta suggest aortic aneurysm or increase pulse pressure. * Always listen bowel sound in all quadrant. Suspect paget dis of any persistent dermatitis of nipple or areola.orange sign it first appear in the lower portion of breast and areola. well delineated. * Always examine in following pattern in abdomen 1. retraction sign may be present. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE associated. * Ant edge of the S1 vertebrae (sacral promontory) feel like a stony hard out line in supra pubic area do not mistaken as a tumor.
8 cm in mid sternal line and 6 . Where as pain in RLQ due to quick withdrawal of pressure called rebound tenderness. Increases pain during this maneuver constitute the Obturator Sign +ve . as well as by an appendix (in women). * The splenic percussion sign may also be +ve when pt is normal. bluntness & rounding of its edges & irregular contour suggest abnormal liver. * Place your hand just above the pt right knee and ask the pt to raise that thigh against your hand than ask turn on to the left side. * Fluid and solid food in stomach may produce dullness in Traub. * Hooking technique is helpful in obese pt. * The pain of appendicitis classically begins near umbilicus and than shift to the RLQ. * Span of liver dullness decrease when free air is present below the diaphragm as from perforated hollow viscus. * span of liver dullness displaced downward because of low diaphragm or COPD. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE the source of problem. so its size. This is not painful normally but pain suggest appendicitis. * Hook your left thumb or right finger under the costal margin at point where lateral border of the rectus muscle intersect with the costal margin. a increase in tenderness with sudden stop in inspiratory effort constitute Murphy’s sign of acute cholecystitis. (always measure in vertical manner) * Dullness of the right pleural effusion or consolidate lung. * Liver spans 4 . Increase pain on either maneuver constitute the Psoas Sign +ve it suggest appendicitis. This area is usually tympanic. hepatitis. that favors enlarge kidney over enlarge spleen are the preservation of normal tympani in LUQ. * Feel kidney deep into right upper quadrant just below the coastal margin place your left hand at the back than press tour right hand against your left hand in ant right upper quadrant (RUQ). * Right sided rectal tenderness in women may be cause by Inflamed adnexa or inflamed seminal vesicle. vs. now ask the pt to expire or release breath you may feel the contour size and tenderness. * In person over age 50 aorta is not more than 3. * The inspiration move spleen from superior to inferior position. If spleen is normal the area remains tympanic with and without inspiration. if adjacent to the liver may falsely increases the estimated liver size. Hook the right abdomen below the border of liver dullness with your finger up toward the coastal margin. * In older person a periumbilical & upper abdominal mass with expansile pulsation suggest aortic aneurysm or dilation of aorta. this maneuver contracts the obturator muscle. * Liver can be palpated by your right hand under right 11th and 12th rib at back with hand pushing upward while your left hand can palpate the liver tell your pt to take deep breath while you feel.Prepared by Dr. 25 NOT FOR COMMERCIAL USE OR SALE . rotate the leg internally at hip. * Traub’s space ( area b/w lung resonance above and coastal margin below) is good place for spleen percussion in supine pt. Search carefully. * Cutaneous hyperthesia is pain when you pick gently the fold of abdominal wall b/w your thumb and finger with out pinching it. * Spleen can also be palpable while asking apt to lying down at right lateral side with hip & knee some what flexed. * Tympany to dullness on inspiration lateral to left ant axillary line suggest splenic enlargement. * Liver span is greater in man than in women and in tall than in short person. Remember when kidney is enlarge the tympany stays same where as when spleen is enlarge tympany turn into dullness. Hepatic tenderness may also increase with the maneuver but is less localized. * Obstructed distended gallbladder may form a oval mass below the edge of the liver and merging with it. * Kidney enlargement suggest hydronephrosis. dullness typically exceeds ant axillary line suggest splenomegaly. * Hernia in the abdominal wall exclusive of groin hernia can be seen by asking a pt to raise both head and shoulder off the table. * Aneurysm is usually painless. * In ascitis dullness shift to more dependent side while tympany shift to the top. Palpable spleen below the left costal margin on deep inspiration suggest splenomegaly. tumor. (sue both hands) * Normal spleen should stay posterior below the mid axillary line in pt with supine position. Spans however stays normal. * Rebound tenderness suggest peritoneal inflammation as from appendicitis.the rupture of aorta.0 cm. * Span of liver dullness may increase in hepatomegaly or may decrease sue to CHF. try to estimate by pressing deeply in the upper abdomen with one hand of each side of aorta. * Localize tenderness any where in RLQ even in the right flank may indicate appendicitis. This is +ve splenic percussion sign. * Rosving’s sign is said to be +ve when cause Pain in the RLQ during the left side pressure it suggest appendicitis. * Straighten and stiffen the finger of one hand together place on the abdominal surface and make a brief jabbing movement directly toward the organ (liver) can reveal the surface of an organ. than flex the leg at the hip that make psoas muscle to contract. Gravity may bring spleen forward in this position. It is dull to percussion. Where as gas in the colon may obscure liver dullness and falsely decreases the estimated liver size. pain may herald its frequent complication -. * During palpation firmness & hardness of the liver. Ask a pt to take a deep breath. * Flex the right thigh at the hip with knee bent. * Pain with fist percussionist costovertebral angle suggest kidney infection but it may also have musculoskeletal cause. cyst. at the same time ask pt to take deep breath and hold.12 cm in right mid clavicular line . ask the pt to take deep breath.s space do not misinterpretate it. It suggest inflamed appendix. while you try to hold the kidney. Coughing increases the pain more pronounce in young than in adult. * In assessment of the mass in the left flank. bilateral involvement suggest polycystic kidney.
rebound tenderness rigidity may be present. * Epigastric hernia is a small midline protrusion through a defect in linea alba some where b/w xiphoid process and umbilicus. * Local cause of peritoneal inflammation include acute cholecystitis. * Pubic and genital excoriation ------------. or acute diverticulitis. * Epididymus locate poster lateral surface normally but in 6 . Where as Paraphimosis is a tight prepuce that once retracted cannot return result in edema. where as Balanoposthitis is inflammation of gland and prepuce. hernia. * In some normal people specially those with larky build (tall & thin) right lobe of the liver may extend downward till right illiac crest it is called Riedel’s lobe. * Phimosis is a tight prepuce that can not be retracted over the glan.> possibilities of lice and scabies. 26 NOT FOR COMMERCIAL USE OR SALE . Distention become more marked in colonic than in small bowel obstruction. venous congestion. where as smooth enlarge tender liver suggest inflammation due to hepatitis.5 cm or pubic hair to SMR 2 you can pronounce start of sexual development. acute appendicitis.5. * Diastesis recti is a separation of the two rectus abdominis muscle through which abdominal contents buldge to form midline ridge. where as left testicle lies some what lower than right. * Acute diverticulitis most often involve the sigmoid colon. * Tenderness due to acute salpingitis occur just above inguinal ligament. * Enlarge liver with firm hard irregular edge suggest malignancy there may be one or more nodules.7 % male it locate anteriorly.Prepared by Dr. right sided heart failure or block. Chlamydia or gonococcal perihepatitis. vs. * Boys often begin experience ejaculation as they approach SMR 3 (sex maturing rate stage 3) and some time mistaken nocturnal emission of urine or a discharge of STD.5 . acute pancreatitis. * Tenderness due to acute pleurisy may be due to pleural inflammation when unilateral may mimic acute cholecystitis or appendicitis. blood vessel all together make the spermatic cord. * Gas distention may cause by certain food or more serious are intestinal obstruction or paralytic (adynamic) ileus. diastesis recti) where as abdominal mass will obscure eg intra abdominal tumor. * When loop of bowel forces their way through weak area of inguinal canal they produce inguinal hernia. * High pitch sounds coincides with abdominal cramp indicate intestinal obstruction. Chest sign’s are les common. It represent variation in shape not in size or vol.5 yrs of age. * Before announcing absent bowel sound sit down and listen for at least two min. vs. * Vas deferens.13. * Vas deferens a cord like structure begin at the tail of the epididymus ascend with in scrotal sac and passes through the external inguinal ring > inguinal canal > internal inguinal ring on its way to abdomen and pelvis then behind the bladder join by duct to form seminal vesicle and enter the urethra with in prostate gland.5 cm in size in adult. * Venous hum (rare) is a soft huming noise with both systolic and diastolic component. * Arterial bruits with both systolic and diastolic component suggest partial occlusion of aorta or large arteries. * If boys testis reaches the size of 2. * Incisional hernia protrude through an original scar. Neither canal nor inguinal ring is palpable through abdominal wall. ant pituitary gland or testes. * Hepatic bruit suggest carcinoma of liver or alcoholic hepatitis. It may also be due to abnormalities in the hypothalamus. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * To distinguish abdominal mass from abdominal wall mass ask the pt to raise head or shoulder to tighten the abdominal muscle by this abdominal wall mass remain palpable (eg lipoma. suspect carcinoma of liver. It is frequently bilateral. * Balanitis is inflammation of gland vs. Noticeable increase in size of testis begin with 9. seminal vesicle. * When systolic bruit accompany the hepatic friction rub. -----------------------------------------------------------------------------------MALE GENITALIA AND HERNIAS * Normal testicle range from 3. * Friction rub is grating sound with respiratory variation it indicates inflammation of the peritoneal surface of the organ due to liver tumor. * Downward displacement of the liver due to emphysema in which liver span is typically normal. splanic infarction. * Umbilical hernia in infant usually close spontaneously with in a year or two. rebound tenderness and rigidity are less common. * Abdominal tenderness in abdominal wall persists when pt raises head and shoulder where as tenderness from deep abdominal lesion decreases when pt raises the head and shoulder. * Tenderness associated with peritoneal inflammation is usually more severe than visceral tenderness. * Cirrhosis may produce an enlarge liver with the firm non tender edge. & may or may not be tender. * Delayed puberty is often familial or related to chronic illness. * The internal inguinal ring is locate about 1 cm above the mid point of the inguinal ligament. recent liver biopsy. it indicates increase collateral circulation b/w portal and sys venous system due to hepatic cirrhosis.5 . Another potentiating route for a herniating mass is femoral canal it is below the inguinal ligament.
* Cryptorchidism (undescended testis) lies in the inguinal canal or abdomen. hernia do not Tran illuminate . originate from internal inguinal ring often into scrotum. * Poorly developed scrotum on one or both side suggest cryptoorchidism (undescended testis). Coexist with UTI and prostitis. * Femoral hernia less common. * Chronically infected vas deferens may feel thickened or beaded. Scrotum become red and edematous. Where as scrotal swelling with pain suggest epididymitis. nephritic $. * Normal ovary size average about 3. * Chancre is painless but when secondarily infected is painful. Scrotum may be reddened and vas deferens may be inflamed. hydrocele.5 cm.5 cm causes include Klienfelter’s $ (firm and < 2 cm). * Place the finger on ant thigh in the region of femoral canal ask pt to cough or strain down. hypopituitarism. rare in women. if not listen for bowel sound in herniated mass if you can hear it . more in women than men. * Induration of the ventral surface of the penis suggest a urethral stricture or carcinoma. It obstruct circulation. Peak incidence b/w 20 . acute orchitis. Suspect strangulation in the presence of nausea tenderness and vomiting. * A hernia is Incarcerated when its content cannot be returned to the abdominal cavity. tumor. vs. * In hydrocele finger can get above mass where as in hernia it cant. * Indirect inguinal hernia is common in both sexes often in children. * Any painless nodule in the testis raise the possibility of testicular cancer.5 x 2 x 1. * Swelling that contained serious fluid such as hydrocele Tran illuminate (they light up with the red glow) . Tenderness of the induration suggest periurethral inflammation due to urethral stricture. Hernia comes down in inguinal canal and touches the finger tip during cough and straining. * Acute epididymitis is tender swollen difficult to distinguish from acute orchitis. where as non gonococcal urethritis tend to be scanty white and clear. and lateral fornices. * Scrotum swelling caused by indirect inguinal hernia. * Invaginate scrotal skin to reach external inguinal ring (triangular slit like opening) and ask pt to cough or strain down note if you can feel any herniating mass with your finger. Common in adult. * An acute orchitis (inflamed testis) is painful tender and swollen difficult to distinguish from epididymitis. Originate near the external inguinal ring and rarely into the scrotum. * Tuberculous epididymitis produce a firm enlargement some time tender with thickening and beading of vas deferens. common in adolescent. It is hard to differentiate from lymph node (auscultate bowel sound). Hernia bulges anteriorly and pushes the side of he finger forward. and scrotal edema. where as soft < 3. * Hydrocele is fluid fill mass in tunica viginalis it transilluminate.5 cm Cirrhosis myotonic dystrophy.Prepared by Dr. When in the scrotum finger cant get above herniated mass auscultate bowel sound. * A bulge that appear on straining suggest hernia. painful and retracted upward in the scrotum. vs. strangulated inguinal hernia. * The uterus body (corpus) and cervix is joined together by the Isthmus. * Torsion of spermatic cord is acute. The scrotum may be reddened look for evidence of mumps (like parotid swelling) or other less common infectious causes. A cystic structure in the spermatic cord suggest hydrocele. * Testicular cancer is painless nodule do not transilluminate may feel heavier than normal in late stage. * Venereal wart most often mal odorous cause by HPV called Condyloma accuminata. * Carcinoma appears as indurated nodules or ulcer that is usually not tender it is rare and usually in uncircumcised person. while you note any palpable mass swelling or tenderness. its hernia not hydrocele. * Direct inguinal hernia is less common usually over age 40 yrs. swollen. * Palpable non tender hard plaque just beneath the skin usually along the dorsum of the penis with crooked painful erection suggest Payronie’s dis. vs. estrogen in take and post mumps status. * Non indurated ulcer on red bases suggest HSV infection it is painful. torsion of spermatic cord. When hernia is strangulated the blood supply to the entrapped content is compromised . vs. * Scrotal herniated mass return to abdomen as pt lies down if not get your finger above the mass in the scrotum if you suspect hydrocele. where as those that contain blood or tissue such as normal testis. * Bartholin glands are situated more deeply. ----------------------------------------------------------------------------------------FEMALEGENITALIA * Post portion of the vaginal opening is Introitus in virgins may be hidden by hymen. It increases the risk of testicular cancer.35 yrs of age. * Spermatocele and cyst in epididymus is pain less moveable mass just above the testis they both Transilluminate. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * The discharge of gonnococcal urethritis tend to be profuse and yellow vs. * Testis consider small in adult if it is < 3. * Scrotal edema may become taut with pitting associated with venous obstruction. CHF. * Vericocele refer to the varicose vein of the spermatic cord usually feel like a soft bag of worms. * Epidermoid cyst is firm yellowish non tender cutaneous cyst up to 1 cm in diameter they are common and often multiple. post. 27 NOT FOR COMMERCIAL USE OR SALE . * The cervix protrude into the vagina dividing the fornix into ant. originate below the inguinal ligament in the femoral ring.
A groove some time define border b/w urethrocele and cystocele but is not always present. it may bleed easily. * Small firm and round cyst nodule sometime yellow in the labia. It can be felt posterior either through post fornix or through rectum. 1. * Mucopurulent cervicitis produce yellow purulent drainage from cervical os usually due to C. * Myomas of uterus (fibroids) may be single or multiple outside or inside the uterus. 28 NOT FOR COMMERCIAL USE OR SALE . pale. 3. suggest epidermoid cyst. * For pap smear make sure pt is not menstruating or have held intercourse. tumor. * Adnexal mass include ovarian cyst.extension of this epithelium to the vaginal wall. douching. ovaries are usually atrophied & no longer palpated if you can feel the ovary consider tumor or cyst. * Bacterial vaginitis shows gray or white thin mal odorous coat of vaginal wall ( fishy or musty genital odor ) previously known as gardenella vaginitis. * Prolapse of the uterus result from weakening of the supporting structure it is often associated with cystocele and rectocele. * Prolapsed urethral mucosa look like swollen red ring around the urethral meatus usually occur before menarche or after menopause. and supporting structures. * Trichomonas vaginitis is often but not always acquired sexually. * Early frequent intercourse.( Dx with KOH potassium hydroxide preperation). soreness and dyspareunia. and HPV infection increase the risk of cervical cancer. Chlamydia. look for dark punctum marking the blocked opening of the gland. * Atrophic vaginitis manifest after menopause (due to decrease estrogen). It may bleed. * Slightly raised flat round and oval papule covered by the gray exudates suggest condylomata lata ( Sec syphilis). atrophic. * 3 . 3. 1. * Physiologic vaginitis may contain white clumps of epithelial cells but it is not mal odorous. gonorrhea. multiple partner. * Indirect inguinal hernia is the most common inguinal hernia that occur in women groin.48 hrs. may show curdy white thin or thick layer and is typically not mal odorous. 2. It presents yellow. progesterone. it may also be due to abnormality in hypothalamus. N. the swollen fallopian tube of PID. Femoral hernia is rank 2nd to frequency. a uterine myomas may simulate adnexal mass. (the upper 2/3 vagina is involved) * Cystourethrocele is the bulge from entire ant vaginal wall together with the bladder and urethra involved. In progressive stage the uterus become retroverted and descend down to the vaginal canal to the out side. 4. * Urethral caruncle is a small red benign tumor visible on the post part of the urethral meatus. * Stool in the rectum may stimulate a rectovaginal mass.frothy and mal odorous with pruritis and dyspareunia. rule out carcinoma and check for inguinal lymphadenopathy. * Retroversion of the uterus is refer to tilting backward of entire uterus. Vaginal adenosis :. weakened supporting structure are cause. * Candida albican (normal vaginal flora) when cause moniliasis. * A yellowish discharge on cervical swab suggest a mucopurulent cervicitis commonly due to Chlamydia trachomatis. * To relax anal sphincter ask the pt to strain down. ant pituitary gland or ovaries . these have no pathological significance. * Bright red soft and rather fragile polyp type growth arise from end cervical canal and becoming visible when protrude out of cervical os is cervical polyp. * Shallow small painful ulcer on red bases suggest herpes. Vaginal mucosa is dry. petechial. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * Adnexa refer to the ovaries. * Normal cervix can be moved with out pain where as pain on the movement of the cervix togather with adnexal tenderness suggest PID. occur in the post menopausal women with no symptoms. green. it appear as a tender hot very tense abscess. trachomatis. or gray. It also present pruritis. * normal Ovary is tender and produce ova and hormones. testosterone). or herpes infection may present with or with out signs and symptoms. Also shows petechiae on vaginal mucosa ( Dx with saline wet mount). * Daughter of women who took DES during pregnancy may show no of abnormality. tubes. In 1st degree prolapse cervix still well deep into the vagina. * When columnar epithelium is transformed into squamous epithelium (metaplasia) this change may block the secretion of columnar epithelium thus cause retention cyst called Nabothian cyst. that results from weakened supporting structure. In 3rd degree prolapse cervix and vagina is out side the introitus. N gonorrhea. In 2nddegree prolapse cervix is at introitus. but unlike a tumor mass can usually be dented by digital pressure. Less common is carcinoma of upper vagina. It is common variant in 1 out of 5 women and cannot be palpable. * A rectocele is bulging of the post vaginal wall together with the rectal wall behind it. Vaginal mucosa is usually normal. * Nodules on palpation on uterine surface suggest myomas. 2. * Bartholin gland infection include causes are gonococcal.Prepared by Dr.( estrogen. HSV. * A ulcerated red raised vulvar lesion in elderly women indicate vulvar carcinoma.5 yrs after menopause. A circular collar or ridge of the tissue of varying shape b/w cervix and vagina. Columnar epithelium (red & plushy) that covers the most or all of cervix. or suppositories during last 24 . (in late stage may look like a cauliflower like growth). tubal pregnancy. or candida vaginitis. * Cystocele is the bulge of the ant vaginal wall together with the bladder above it. presents pruritis burning and dyspareunia. * Delayed puberty is often familial or due to chronic illness.
-------------------------------------------------------------------------------------PREGNANT WOMEN * Normal pregnancy last 38 . Upper back also aches due to increase in wt. Cyst mass < 6 cm in young women are usually benign and often disappear after next menstrual period. fatigue. and secretion of vagina increases. vomiting. PID. * Some minor hair loss may be noted in pregnancy where as localized patches of hair loss should not be attributed to pregnancy. * Red velvety mucosa around the os during pregnancy is normal. fainting. * Best position for examining the pregnant women is semi sitting position with knee bent slightly. Nausea. * Menstrual age refer to 1st day of the last menstruation period (LMP) to calculate EDC. It is normal variant. Vaginal PH typically become acidic due to lactobacillus action on glycogen stored in vaginal epithelium.it ay cause bleeding for that reason Ayre wooded spatula or cotton tipped aplicator are appropriate. 29 NOT FOR COMMERCIAL USE OR SALE . if exceeds suggest hyperemesis. * In pregnancy hyperplasia of thyroid gland and breast occur. backache. It can interfere blood circulation. * Nausea.Prepared by Dr. * Leukorrhea a milky white discharge is also common during pregnancy. Uncomplicated cyst or tumor are not tender. constipation. * Conception age is refer to the date of conception in order to calculate the EDC (Expected date of confinement). may also accompany anemia. * High BP prior to 24 weeks indicate chronic HTN. * Palpate apical impulse it may be slightly higher because of Dextro rotation of the heart due to higher diaphragm. * The cervical brush is not recommended for pap smear in pregnancy due to increase vascularity of mucosa . * Beside pelvic exam all other examination position should be done in sitting or left side lying position. * Increase glycogen store may contribute the higher rate of candida infection in pregnancy. * Soft blowing murmur are common in pregnancy. ruptured tubal pregnancy. tachycardia and shock may be present reflecting the hemorrhage. acute dis may associated with very tender bilateral adnexal masses. * Ovarian mass (cyst or tumor) tend to be soft in cyst and hard incase of tumor. Tender area should be avoided until the end of examination. * From mid to late pregnancy Colostrums may expressed from the nipple. Movement of cervix produce pain. * Muscle tone diminished as pregnancy advances. * Hager’s sign refer to palpable softening of isthmus is an early diagnostic sign of pregnancy. But prolong period of lying in this position should be avoided. tingling in 1st trimester is due to hormones causing growth of breast tissues and increases blood flow. (its normal). Diastasis recti is seperation of rectus muscle at the mid line of the abdomin is noticeable in late pregnancy. * Breast tenderness. syncope. Although pain and muscle spasm make it imposible to delineate them. dating the pregnancy is done by palpation and subsequent monitoring of growth curve. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * Retroflexion of uterus refer to the backward angulation of the body of the uterus In relation to cervix.42 weeks. * The vaginal wall are relaxed during pregnancy they may felt medially. * Nasal congestion and nose bleed is common in pregnancy. Infection may also follow after gynecologic surgery or delivery of baby. * Facial edema after 24 weeks suggest pregnancy induced hypertension (PIH). * By the end of pregnancy uterus has a capacity of 10 liters apex. * In early and mid pregnancy BP is normally lower than the non pregnant state. Symmetrical enlargement is expected in pregnancy but marked enlargement or asymmetrical hyperplasia is not due to pregnancy. * Gingival hyperplasia is common in pregnancy. * Chadwick’s sign is Pronounced softening and cyanosis of cervix appear very early after conception and continuous through out pregnancy. * Chloasma is the mask of pregnancy presents brownish patches around eyes and across the bridge of the nose its normal. eg ovarian cyst. mucosal thickening. * Cervical canal is filled with protective tenacious mucous plug to protect fetus from infection. all is normal during pregnancy. * Purplish straie and linea alba are normal in pregnancy. vomiting in 1st trimester is due to hormonal changes which slows peristalsis through out GI tract. * Corpus luteum (ovarian follicle) may be felt on ovary as a small nodule usually disappear by mid pregnancy. * In early pregnancy vagina takes bluish or violet color. (its normal) * Urinary frequency. * In 1st trimester wt loss is due to nausea & vomiting & is common but should not exceed 5 lbs. Look for sign of cocaine use. * If women does not remember LMP. * PID may cause salpingo oophoritis. * Ruptured tubal pregnancy spills blood into peritoneal cavity causing severe abdominal pain and tenderness. * Nipple and areola are darker in pregnancy nad Montgomery gland become prominent. * Adnexal mass results from fallopian tube or ovarian disorder. heartburn.
* 2nd maneuver (sides of abdomen) :. * Prior to 37th week regular uterine contraction with or without pain or blood are abnormal suggest preterm labour. * Obtain knee and ankle reflexes. * A pink vagina suggest a non pregnant state. big baby. one hand should stay steady and other to palpate fetus body. * Through the ant wall of female rectum a uterine cervix can be felt. * 10 . inflammation scarring. For eg head in upper pole moves some what independently than rest of body. Lack of beat variability late in pregnancy suggest fetal compromise.15 B/min variance over 1 .Palpate for fetal buttock or head in upper pole. * Palpating prostate may provoke desire to urinate tell pt not to do so. * Fetal HR (FHR) if near term drops noticeably with fetal movement could indicate poor placental circulation.140 near term. scarring. bluish oval mass and is visible at anal margin due to dilated vein that originate below the pectinate line and are covered with skin. * Anorectal fistula is tract or tube b/w skin or viscus to anus or rectum often inflammatory. * 3rd maneuver (lower pole) :. * Cystocele and rectocystocele may be pronounced due to muscle relaxation in pregnancy.Prepared by Dr.Grab the part of the fetus of the upper and lower pole at the same time you can distinguished b/w head and buttocks. * The HR is usually in 160’s during early pregnancy and than slows to 120 . * Leopold’s maneuvers are imp to figure out the fetal position for successful birth and evaluate adequate growth. * Anteflexion or retroflexion of uterus is lost by 12th week and become globular. inspection may shows “Sentinel” Skin Tag just below it. * Note the sphincter tone while digital finger examination. or uterine myomatas. RECTAUM AND PROSTATE * Anorectal junction ( Pectinate or dentate line ) refer to boundary b/w somatic and visceral nerve supply. Or may be laxity (lose) in some neurologic dis. * Soft palpable tags of redundant skin at the anal margin are common due to post anal surgery. * Vaginal infection are more common during pregnancy and specimen may be needed for Dx. * Induration of anus may suggest inflammation. * Pilonidal cyst and sinus is fairly common probably a congenital abnormality located to mid line superficial to coccyx or the lower sacrum. * Early in pregnancy it is imp to rule out tubal pregnancy (actopic pregnancy). It is not palpable but can be visible on proctoscopy . * A parous cervix may look irregular because of leceration. ANUS. Feel back smooth and firm and front irregular and may be kicking. * External hemorrhoids are tender. growth retardation. * Irregular bordered lesion in or around anus suggest malignancy. Its two lateral lobes are separated by median sulcus or groove. previously thrombosed hemorrhoids. false pregnancy or small product. or morbidity of false pregnancy. * Rectal wall contain 3 inward folding called the Valve of Houston. It may exhibit small tuft of hair or surrounded by hollow of erythma. * If fundal height is > 2 cm than expected consider multiple gastation. extra amniotic fluid. * 4th maneuver (confirmation of presenting part) :. * Prostate can be palpable as rounded heart shaped structure about 2. If sphincter is spastic and painful local anesthesia may required.2 min is normal (late in pregnancy). it may prolapse through anal canal and appear as reddish 30 NOT FOR COMMERCIAL USE OR SALE . IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * If fetal movement cannot felt by or after 24th week consider error in calculating gastation. * In female rectal exam is usually done after genitalia. fetal death. It may be tight due to anxiety. It is clinically identified by opening of the sinus tract. * Extend your finger above the prostate gland to the region of seminal vesicle and peritoneal cavity if tenderness occur may suggest peritoneal inflammation or peritoneal metastasis. or malignancy. after 24 weeks reflexes greater then 2 + may indicate pregnancy induced HTN. * Some women have labial varicosities that become tortous and painful they may bleed. cervix and uterus may be palpable. It is normally. Normally the anal sphincter close snugly around finger.Place one hand on each side try to capture fetus body. * If fundal height is < 2 cm than expected consider missed abortion. * Irregular shaped uterus suggest myomatas or Bicornuate uterus (two distinct uterine cavities). * Fetal HR is audible after 18th week with fetoscope. * Seminal vesicle shape like rabbits ear above prostate and are not normally palpable. * Fetal HR is audible after 12th week with doptone. * General inspection may be done with the women seated or lying on left side. * Measure fundal height with tape if women is more than 20 week pregnant.Feel and palpate area just above symphisis pubis feel the head or buttock with both hand.5 cm in length. * After 20 week measurement in centimeters should roughly equal the weeks of gastation. * Normal prostate is rubbery or non tender. * Internal hemorrhoids occur below the pectinate line and it may cause bright and red bleeding. swollen. * Anal fissure is very painful oval ulceration of anal canal most commonly on midline posterior. lowest line can be felt at pts left side. buttock are irregularly softer than head which is firm and round. transverse lie. It is normally asymptomatic may show infection. * 1st maneuver (upper pole) :.
* Poplitial artery divides into two branches. Absent pulse may due to thrombus. * Horizontal group of nodes drain the superficial portion of upper abdomen & buttock and external genitalia (but not testes). * Superficial inguinal lymph node include two groups. postural color changes. * Feel for one or more epitrocheal lymph node with the pts elbow flexed to 90 degree. 1. * Press deeply below the inguinal ligament in the middle to palpate femoral pulse. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE moist protruding mass. * BPH starts at 5th decade of life. * Children and young adolescent normally have longer lymph node relative to body size than do adult. * Try to distinguish b/w generalized or localized lymphadenopathy by finding causative lesion in the damaged area or enlarge lymph node in at least two other contiguous lymph node region (generalized lymphadenopathy) . About the 3 cm above the medial epicondyle. 2. lower vagina. The gland is very tender. For eg if radial pulse is diminish compare the brachial pulse and also with other hand pulse. firm & slightly elastic. it may be present higher in the ankle congenitally. Enlarge node may suggest lesion in the drainage area or may be the part of generalized lymphadenopathy.exaggerated and wide pulse suggest aneurysm. * The deep vein of leg carry about 90 % of venous return from the lower extremity and are well supported by surrounded tissue. where as little and ring finger and adjacent surface of the middle finger and few area of arm go directly to intraclavicular lymph node. * Great saphenous vein originate from the dorsum of the foot and continuous anteriorly up till inguinal ligament medially. * Polyps in rectum are fairly common variable in size and number can be pedunculated or sessile and usually soft (do biopsy). Hardness may also results from prostatic stone. * Arteriosclerosis oblitrans most commonly obstruct arterial circulation in the thigh. It may shows circular fold on it when prolapse is large. All pulses distal to occlusion should be affected. * Rectal shelf is a wide spread metastasis from any source to ant to the rectum in the area of peritoneal reflection in male and rectouterine pouch in female. * Inguinal lymph node are often 1 cm in diameter and occasionally 2 cm in adults. result in pain 31 NOT FOR COMMERCIAL USE OR SALE . * Superficial vein are located subcutaneously and supported relatively poor. * Palpate the artery if it is widely dilated it is aneurysm. which may or may not be palpable due to altered counter of gland. * Axillary lymph node drain most of the arm where as epitrochlear node drain ulnar forearm and hand. * Chronic arterial occlusion causes intermittent claudication. Vertical group :. * Lymph edema of arm and hand may follow axillary dissection and radiation therapy. it is common due to atheroma. * Flex the pts knee about 90 degree while he is supine facing downward press the thumb of the both hand deep into popliteal fossa to fell popliteal pulse. * Prolapse of rectum appear as doughnut or a rosette of soft tissue. A decrease or absent pulse indicate dis of aortic or iliac level. firm and warm.Prepared by Dr.lie high below the inguinal ligament. and trophic changes in the skin. chronic inflamation. emboli. Superficial vein includes great saphenous vein and small saphenous vein. swollen. * Firm nodular rolled edge mass in rectum suggest carcinoma. * The dorsalis pedis pulse (at the dorsum of the foot) lateral to the extensor tendon of the great toe. * Cancer of prostate is hard nodular. * If you feel arterial insufficiency at point x try to feel and compare the pulse from early ( proximal of the body ) segment of artery. * Chronic prostitis does not produce consistent physical finding. smooth. vs. * Femoral artery travel down deep into the thigh passes medially behind the femur &becomes a popliteal artery behind the knee. Where as small saphenous veins originate from the side of the foot and passes upward posterior and drain into deep venous vein in the popliteal space. Horizontal group :. * Prominent vien in the ademous arm may suggest venous obstruction.lie near the upper part of saphenous vein. It is not common but in case is due to atherosclerosis. * Vertical groups of node drain the upper part of saphenous vein where as small saphenous vein is drained by nodes present in the same area. * Great saphenous vein and small saphenous vein communicate with deep venous vein (femoral vein) via communicating vein. canal. the femoral pulse is normal but popliteal pulse is decreased or absent. perinea area. * Look for post tibial pulse slightly below the medial malleolus of the ankle ( hard to feel ). Affected gland usually feel symmetrically enlarged. * Popliteal pulse is often difficult to find and feel --. ---------------------------------------------------------------------------------------------------PERIPHERAL VASCULAR SYSTEM * Radial & ulnar arteries are interconnected by two vascular arches with in the hand therefore doubly protected against possible arterial occlusion. it is not associated with inguinal lymph node. * Like hand the foot is also interconnected by these two branches the dorsal pedis artery & post tibial artery therefore protected. vs. ant branch continuous to the foot called dorsalis pedis artery and post branch passes behind the medial malleolus of the ankle called post tibial artery. * Acute prostitis and acute febrile inflammatory condition usually bacterial. * In Reynaud dis wrist pulses are typically normal but spasm of more distal arteries cause episode of sharply demarcated pallor of finger. The median sulcus may be obliterated. Decreased or absent foot pulse with normal femoral and popliteal pulse suggest occlusive dis of the lower branch of popliteal artery for eg as in DM.
warmth. * show dermatitis thickening of skin with brown pigmentation. prolong standing. other signs are increase jugular venous pressure. After that ask pt to sit with legs dangling down normally. * Venos distention suggest a venous cause of edema. * Persistent pallor hand with allen test suggest occluded artery. * Compress the calf against tibia with knee flexed. * Pale color cool temp. * Feel varicosities with pt in standing position. if ulnar artery is patent the palm flushes in 3 .is useful to assure the patency of ulnar artery before puncturing the radial artery for blood sample. 15 sec delay pinkness and venous filling suggest arterial insufficiency. Normally there is non these both tests term negative . ask the pt to make tight fist compress both radial and ulnar firmly than ask pt to open the hand in relaxed position. * No or mild edema . incompetent venous valve. * Feel two different part of same varicose vein for pressure wave. with thickened wall. * Local redness of the skin warn of impeding necrosis. * Pulse of the normal ulnar artery however may not be palpable. nail thickened and ridged. * Allen Test :. Dx always depend on the kind of tests. deep venous thrombosis. redness. If collateral circulation is good than only numbness & cold may results. * In deep venous thrombosis the extent of edema suggest the location of occlusion.(Anasarca) 32 NOT FOR COMMERCIAL USE OR SALE . * Rapid filling of superficial vein while saphenous vein is occluded indicate incompetent valves in the communicating veins. * In leg edema always discard CHF. **Chronic venous insufficiency (advanced) * None to aching pain on dependency (on standing). ulcers (gangrene may develop). or pos . now release your pressure over the ulnar artery. Normal temp with Brown pigment with chronicity.Elevate the leg to 90 degree to empty the venous blood while pt is supine than occlude the great saphenous vein by manual compression make sure that you are not occluding the deeper vessels. * Pressure sores results when sustained compression oblitrate arteriolar and capillary blood flow to skin usually occur in those who are confined to bed. in dis condition. and subcutaneous cord suggest superficial thrombophlebitis. vs.pos. Some time tenderness may not be present. tender liver and enlarged S3 sound. * Dependent edema may occur in back of the bed pt and do not appear in legs. **Chronic arterial insufficiency * Intermittent claudication pain at rest. It could be neg . usually occur with in a min. Normal response accompanied by diminished arterial pulses suggest good collateral circulation develop around arterial occlusion. pt dangle the leg to relieve pain * Edema often marked * Ulceration if present involve toe or points trauma on feet. Look for thin shiny atrophic skin. look for venous filling Normally it fills from below and take 35 sec. * Color normal or cyanotic on dependency. pale and cold.Prepared by Dr. * Edema due to hypoalbuminemia may first appear in the loose subcutaneous tissue of the eye lids especially after night but may also shows in feet and legs. * A brownish color or ulcer above the ankle suggest chronic venous insufficiency. After pt has stood for 20 sec release compression and look for any additional filling. It seems dilated. In blacks observe the feet for signs. * Hair loss. Shows decreased sensation and absent ankle jerk. * Feel the temp of feet and leg with back of your finger bilateral coldness is often due to cold environment or anxiety.negative in normal condition. lymphadema.neg. * Local swelling. * Thicker browny skin occur in lymph edema and advanced venous insufficiency. loss of hair on foot. * Persistent rubor of foot (sp if unilateral) on standing and pale on elevation suggest chronic arterial insufficiency. If palpable pressure vein is some its mean that the two part of vein is connected. Look for tenderness and cords suggest deep thrombosis there . * Diminished or absent pulse at wrist may suggest arterial occlusion due to buerger’s dis (thromboangitis oblitrans). shiny skin. some deep pressure sores develop without antecedent redness. Eg when iliofemoral vein is occluded the entire leg is swollen. * Edema due to CHF first appear in the dependent area of the body where hydrostatic pressure is high (ie feet and leg). Its tenderness with painful pale and swollen leg suggest deep iliofemoral thrombosis.5 sec. where as unilateral coldness with other signs suggest arterial insufficiency. * To check edema press your finger against skin for at least 5 sec. Similarly the patency of the radial artery may be tested by releasing the pressure from radial artery while compressing ulnar. Gangrene may develop Gangrene not present * In neuropathic ulcer pain is absent gangrene may or may not be present. normal Pulse but difficult to hear due to edema. * Palpable femoral vein just medial to femoral pulse (below inguinal ligament). drugs. or pos . Now ask pt to stand while you keep the vein occluded. tingling. vs. * Look for sacral edema in bed pt ( press firm for 5 sec). tortous.pos. In advanced cirrhosis edema become generalized. Decrease Or absent pulse. marked pallor on elevation suggest arterial insufficiency. * Ulceration if present develop at side of ankle often medially. thickened & ridged nail. * Trendelenburg Test :. * Raised the both legs at about 60 degrees until max pallor of the feet develop. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE numbness. * Sudden additional filling superficial vein after release of compression indicate incompetent valve in the saphenous vein.
Transversetarsal joint .Proximal phalanx .Proximal phalanx Metacarpophalangeal joint (MCP) . IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * Edema due to renal retention of salt and water usually start In the dependent area (legs) or may become generalized.Distal phalanx . incompetent valve. 2. Medial & lateral compartment of tibiofemoral joint. * Prepatellar bursae lie b/w skin and convex surface of joint. * Most mobile portion of spine is the neck. * Edema due to lymphatic stasis (lymphedema) is characteristically non pitting usually limited to the local area cases include tumor. * The Gleno humeral joint (not palpable) covered by 4 muscles called Rotator cuff. Teres minor 4. fibrosis etc. * Movement of the shoulder are adduction. * The prepatellar bursae lies b/w the patella and overlying skin.Tibia. pronation. Infrasupinatous Muscle 3. it lies under the ischeal tuberosity on which person sits (schiatia nerve lies close to it). * Two cruciate ligament cross obliquely with in the knee give anterioposterior stability. Where as lateral to the greater trochanter is trochanteric bursae. * Deltoid muscle lie at subacromion bursae and subacromion bursae lies over supraspinatous tendon.Distal interphalangeal joints (DIP) . * Thumb lacks the middle phalanxs. * The alteration of disc and vertebrae in old age contribute to KYPHOSIS and increase the anterioposterior diameter of chest in women. * Fatty legs are not edema.Distal phalanx . Flexion and extention occur b/w head and C1 vertebrae. * Inversion and Eversion of foot by subtar (talocalcarneal joint) and transverse tarsal joint. * When foot swing medially femur rotates externally & when foot swings laterally femur rotates internally at hip joint. * Bursae of elbow lie b/w Olecranone and skin. * Use back of your finger to feel and compare heat in symmetrical joints if both are involved than compare with tissue near them. fibrosis. * Rotation occur b/w C1 and C2 vertebrae. * Edema due to increase capillary permeability is typically local (inflammatory). * Range of motion varies among individual and it decreases with old age . abduction.Prepared by Dr.Proximal interphalangeal joints (PIP) . inflammation.Subtalar joint . It contain 3 compartments 1. * A line drawn b/w the iliocrest crosses the spinous process of L4. osteomyelitis. Also occur in those who get up after prolong bed rest. * One can palpate tibiofemoral jointby press the thumb downward in the joint while the knee is flexed about 90 degree. * An imaginary line along the foot bones extending from the head of the metatarsalto the calcaneus is called longitudinal arch. ----------------------------------------------------------------------------------MUSCULO SKELETAL SYSTEM * Synovial mem cover the articular cartilage and secret synovial fluid in synovial cavity. Where as lateral bending occur b/w C2 and C7 vertebrae. * Posteriorly superior illiac spine crosses the sacral area. * The soft tissue in front of tibiofemoral joint is fat tissue.Carpal . * Edema due to venous stasis is limited to area of blockade (local). Supraspinatous muscle 2.Metacarpal . Patellofemoral compartment (b/w patellar & femur) * Patella rest on articulating surface of femur above tendon of quadriceps muscle from femur and insert on tibial tuberosity.Tibiotalar joint (Ankle).Radius. * Ankle (tibiotalar joint) consist of lateral and medial malleolus. * At the center of each disc is a nucleous pulpous (fibrogelatinous material) form a cushion or shock absorber . superficial infrapatellar bursae lie ant to the patellar tendon.Middle phalanx . extention. * Tenderness in or around the joint need mention specification like arthritis. vs. * Sequence of hand joints :. * Subacromial bursae lie in area where tendon and muscle rub against bone. 33 NOT FOR COMMERCIAL USE OR SALE . Subscapularis muscle. but blockade of superior vena cava may cause edema of entire upper part of the body causes include thrombophlebitis .Metatarsophalangeal joint . * Ant to the hip joint there is iliopectineal bursae (iliopsoas). ****** posteriorly calcaneus (Heel) . * Sequence of foot joints :. * Ischeal (ischeogluteal) Bursae not always present. external and internal rotation. * Tibiotalar joint (ankle joint) cause dorsiflexion and planter flexion. femer and tibia.1st metatarsal . * Elbow produce flexion. * Knee joint consist of patella. * Sensitive ulnar nerve can be felt posteriorly b/w olecranone and medial epicondyle. fluid filled synovial sac which is present at point of friction around joint to facilitate movement. tumor. * Bursae are disc shape. etc. * Orthostatic edema cause by prolong sitting or standing.Wrist joints (Radio carpal) . * Lymphedema is soft earlier but becomes hard later. bursitis. * Femoral head contain greater trichinae & lesser trochanter. * Strong Achilles tendon insert on heel posterior (calcaneus). ligament and other tendon and muscles. 1.Talas . usually occur in dependent area (legs). It may be generalized due to bee sting or drug related allergic reaction. and supination of arm. * Tendon travel in tunnel like synovial sheath which may become inflamed. tendonitis.
* Swelling. grasp the heel with other hand and invert and evert the foot. Where as acute inflamation of first metatarsophalangeal joint suggest gout. Bony ridge may suggest OA. * Involvement of only one joint increase the likelihood of bacterial arthritis. vs. * Immobile neck with head and neck thrust forward. acromioclavicular joint. * Unequal hight of the iliac crest cause pelvic tilt. Swelling suggest synovial thickening or fluid eg in OA. * Nodule suggest rheumatoid arthritis. Ristriction of internal rotation indicates hip dis in arthritis. * Palpate tibiofemoral joint by flexing the pt knee to about 90 degrees. * Squeeze the metacarpophalangeal joint (MCP) on both side from both thumb of your hand. * Crepitus palpable or audible crunching or grating produce over the joint suggest roughened articular cartilage of inflamed joint or osteoarthritis (OA). * Look for Olecranon process (at elbow) . contrasting with the Kyphotic thorax suggest ankylosing spondilitis . flexion of opposite thigh at the same time suggest flexion deformity of the hip or lumbar lordosis. Inability to extend fully ( flexion contractures ). IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * Tenderness and warm over a thickened synovium suggest RA. * Stabalize the ankle (tibitalar joint) with one hand . pain suggest local arthritis. * Compress the feet b/w your finger and thumb look for tenderness exert pressure just proximal to the head of 1st and 5th metatarsal (foot palpation). Scoliosis. tender and decrease range of motion in temporomendibular joint suggest arthritis. inflamation of tendon sheath (tenosynovitis) and fibrosis in the palmar fascia ( Dupuytren’s Contractures ).pain suggest bursitis. Now with your right thumb and finger feel the fluid entering the space next to patella and note when fluid returns back. where as Pateller bursitis cause a more localize swelling ant to patella. In sprain ankle inversion and planter flexion cause pain where as eversion and dorsiflexion is relatively pain free. or rheumatic fever. *Look for swelling in the popliteal space suggest bow leg. RA typically involve several joints symmetrically . pain suggest synovitis. * Paravertebral muscle spasm and ankylosing spondylitis may prevent flattening (lumbar concavity persist while flexion). * Pain along Achilles tendon suggest Achillis tendonitis or bursitis. * Redness of the overlying skin of the joints with tenderness suggest septic or gouty arthritis.press the right thumb and index finger on each side of patella and with your left hand press the suprapatellar pouch. vs. * Bilateral swelling of wrist from several weeks suggset RA. * Gonococcal inf may involve the wrist or tendon sheath of the wrist (Gonococcal tenosynovitis). * Ask pt to touch chin to chest and each shoulder than touch ear to corresponding shoulder. baker’s cyst (swollen bursae). subacromial area and bicepital groove for pain and look range of motion. Remember OA rarely involve MCP joints. * Tender below and on the trichinae suggest trochantic bursitis. * Inspect Bowlegs ( Qenu Varum ). knock knees.Displace any fluid with the bulge of your hand. * Balloon Sign :. * Osteoarthritis of DIP appear as hard dorsolateral nodule called Heberden’s Nodule. ask pt to tighten the knee against table any cripitant or pain suggest patellofemur disorder.Prepared by Dr. * Palpable PIP joint are involve more commonly in RA than in osteoarthritis. * Bulge Sign :. * Feel supra patellar pouch. * Making fist or extending finger when is impair or painful suggest arthritis. * Tenderness on ischial bursae and ischial tuberosity suggest ischial bursitis because of adjacent sciatic nerve pain from this bursitis may mimic sciatica. RA. * Bending of knee against chest and internal rotation should be done. * Tenderness below the inguinal ligament and lateral to the femoral pulse suggest Iliopecteneal bursitis or Iliopsoas abscess. 34 NOT FOR COMMERCIAL USE OR SALE . ( normally opposite thigh don’t flex ). * Plapate the groove b/w epicondyle and colcannon for any sign. Adduction or abduction deformity of the hip also cause pelvic tilt. * Ristricted abduction is also common in hip disease. * Tenderness on compression of the metatarsophalangeal joint is the early sing of RA. * Posterior of the knee can be best palpate when pt is standing. than finally extend the neck to evaluate mobility. 10 cm above superior border of the patella. knock knee ( Qenu Valgum ). A bulge of returning fluid indicate the effusion of knee joint. * A tender swollen tibial tuberosity in an adolescent suggest OSGOOD . * Subcutaneuos nodule with joint sign suggest RA or Rheumatic fever. palpate ligament note point of tenderness or any irregular bony ridge. * Palpate sternoclavicular joint. * Compress patella against underlying femur. * Palpate metatarsophalangeal joint individually to locate the origin of pain. * Ask pt to bent each knee against against the chest firmly observe the range of motion. * The most common cause cause of shoulder pain is rotator cuff tendonitis ( Impingement $ ). * Palpate ant aspect of ankle with your thumb. * Palpable bogginess or doughiness of the synovial mem suggset synovitis.SCHLATTER DIS. External rotation is also restricted. * Stabalize the heel than invert & evert the forefoot to localize the pain.
index. * Supination of elbow 30 degree ( 0 . Finger may show Swan Neck Deformity (hyperextention of proximal interphalangeal joint and fixed flexion of distal interphalangeal joint). Look for spindle shape swelling of proximal interphalanges. Finger may be deviate to ulnar side . paravertebral muscle. * Acute tenosynovitis is infection of flexion tendon sheath may follow local injury even of apparently trivial nature. vs.S1)may produce tenderness of the spinous process.golfer’s. Tenderness is max just below the tip of acromian. * Pronation of elbow is 45 degree ( 0 . * Medial epicondylitis (pitcher’s . In the Carpal Tunnel $ tingling or electric sensation over median nerve distribution suggest +ve Tinel. Knobby swelling around the joint some time ulcerate and discharge white chalk like water (uric crystal). * Hold the pts wrist in acute flexion for 60 secs. Gouty arthritis. Repeated event cause edema.Prepared by Dr. * For lower back pain with radiation into leg. than dorsiflex the foot.45 degree). * Tinel’s Sign :.30 degrees). * Sit behind the pt stable the pelvic ask pt to bend laterally. * Lateral Epicondylitis (tennis elbow) follows repetitive extention of wrist or pronation or supination of the arm. extension of wrist against resistance cause increase in pain. Metatarsophalangeal. Ext is painful. * Olecranon Bursitis may develop from trauma. Palpate boggy soft. Wrist flexion against resistance increases pain in medial epicondyle. arm elevate over the head cause sharp pain. This dis called Felon. * Trigger Finger cause by painless nodule in the flexor tendon in the palm near the head of metacarpal feel for nodule on snap. * Impingement or Rotator cuff tendonitis occur when rotator cuff (arm) impinge against the acromian and coracoacromial ligament. 35 NOT FOR COMMERCIAL USE OR SALE . Increase pain in effected leg when opposite leg is raised strongly confirm radicular pain and constitute + ve crossed straight leg raising sign. * Injury to the finger tip may case infection of finger pad result into painful swelling wih dusky redness. Sharp pain radiating from back down to leg in L5 . * Chronic tophaceous gout some time mimic OA and RA. * Rheumatoid arthritis may also cause tenderness of intervertebral joints. * Dupuytren’s Contractures (flexion contractures) caused by thickened plaque overlying the flexor tendon of the ring finger. forward and backward and than twist the shoulder one away from than other. and wrist are frequently involved. Tape should cross the knee on its medial side. Fluctuant swelling for tenderness. or little league elbow) Follows repetitive wrist flexion as in throwing. * Hypothenar Atrophy ulnar nerve disorder. This suggest +ve Phalen Test and so Carpal Tunnel $. * Arthritis of elbow cause bysynovial inflammation or fluid is felt best in the groove b/w Olecranon and epicondyle. * Tender painful stiff joints are characteristics of RA symmetrical involvement of both joints are typical. For eg * Elbow flex from 45 . * Herniated intervertebral disc (commonly b/w L4 -L5 or L5 . it also shows ulnar deviation of distal phalanx. * Ganglion are Cystic round usually nontender swelling around the tendon sheath in hand and joint capsule it may develop else where at ankle and feet. * Measures pts legs is done by measuring the distance b/w anterosuperior spine and medial malleolus. Radial deviation when finger deviate toward thumb and ulnar deviation when finger deviate toward little finger. Pain on lateral epicondyle. sciatica notch or sciatica nerve. * Explain the range of movement by degrees . Unequal length may explain scoliosis.may suggest kidney infection rather than musculo skeletal. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * As person flex the lumbar concavity should flattened out normally. * Thumping of spine with ulnar surface of your fist when produce pain suggest OA. * Thenar Atrophy suggest disorder of median nerve and its component eg Carpal Tunnel $ or Median Nerve Disorder. * Acute tenosynovitis may progresses to Thenar space or else where in the palm early Dx and Tx is important. Decreased mobility suggest osteoarthritis or ankylosing sodalities. * Pain & numbness in the hand specially at night suggest compression of median nerve in carpel tunnel. * Remember tenderness of costovertebral angle . malignancy or infection. * Chronic RA shows thickening of proximal interphalanges and metacarpophalangeal joints. Through the tunnel run flexor tendon & median nerve.Percuss lightly over the course of median nerve with your finger. Proximal interphalanges. and Boutonniere Deformity (persistent flexion of proximal interphalangeal joint hyperextension of distal interphalangeal joint). middle and part of ring finger.s sign and so suggest Carpal Tunnel $. thickened fibrotic cord develop b/w palm and finger. RA.90 degrees or elbow has flexion deformity of 45 degree and can be flex further to 90 degree. Metacarpopahlangeal joint are spared . * Nodules on distal interphalangeal joints (Heberden Node) and the proximal interphalangeal joint nodes (Bouchard’s Node) are usually present OA . flexion contracture ensues. Dorsiflexion of foot increases the pain in the effected leg.S1 distribution (radicular pain) suggest tension or compression of the nerve root often cause by herniated lumbar disc. ask pt to lie down and raise the leg straight up until pain occurs. hemorrhage. intervertebral joint. inflammation and fibrosis. * Rheumatoid nodules may appear in chronic and acute stage. * A spinous process of L5 or L4 that feel unusually prominent in relation to the one above it suggest Spondulolisthesis of prominent vertebrae. * Ankylosing sodalities may cause sacroiliac tenderness. If numbness and tingling develop over the distribution of median nerve which is palmar surface of the thumb.
more often in women. * Kyphosis is a rounded thorax convexity common in aging sp in women. suspect central or peripheral neuropathy like DM etc. 36 NOT FOR COMMERCIAL USE OR SALE . vs. Kyphosis (compensation effect). vs. * CN I and CN II are fiber tract emerging directly from brain. where as Hypothalamus maintain endocrine sys. * CN I -------. * Cerebellum coordinate the movement that maintain body up right in space. * Thalamus & Hypothalamus ( In Diencephalons ) is another cluster of Gray mater.vision. Usually it is painful. It cause Supraspinatus & Infraspinatus muscle pain and tenderness in partial tear where as complete tear cause characteristic shoulder shrugging. causes are herniated disc. look for muscle spasm in lumbar area and decrease spinal mobility these combination of signs suggest possibility of herniated lumbar disc or ankylosing spondylitis sp in men. It may develop on moist area called Soft Corn. * Calcific tendonitis refer to degenerative process in tendon it is associated with deposition of Ca++ salt. * CN II -------. When deformity can be seen with pt flex forward. * Basal ganglia (Straite nuc) is additional cluster of Gray matter (neuron) in the brain which initiate and execute movement. muscle spasm.Trochlear nerve (M) ----------. * Neuropathic Ulcer develop at sole on pressure points usually infected. opening of eye. It mimics impingement $. Acute gout may also involve the dorsum of the foot do not mistaken with cellulites. If the pt is adolescent consider Scheuermann’s dis. Tenderness is max in bicipital groove. * Hammer Toe commonly involve the 2nd toe characterize by hyperextension of metatarsophalangeal joint and flexion of proximal interphalangeal joint.Pupillary constriction. scoliosis. tuberculosis of the spine. * Bicipital Tendonitis is inflammation of the bicep tendon. * Gibbus is an angular deformity of collapsed vertebrae caused by metastatic cancer.70 yrs with often antecedent painful disorder of shoulder or possible Myocardial Infarction.Downward Inward movement of eye. It involve suprasspinatous tendon. * When there is flattening of lumbar curvature. and eye movement. It commonly involve great toe. Increase pain confirm disorder. It cause ant shoulder pain resembles rotator cuff tendonitis. indolent(painless). where as when scoliosis compensate for another abnormality such as unequal leg length called Functional Scoliosis. * Adhesive capsulitis (Frozen shoulder) is refer to mysterious fibrosis of the of the glen humeral joint capsule . that is one side of the thorax bulge posterior and other side bulge or displaces interiorly called Structural Scoliosis. Usually unilateral b/w age 50 . Normal skin line stop at the Warts edge unlike callus. * Consciousness depends on higher center and reticular activating (arousal) sys in Diencephalon and upper brain stem. * CN III -------.Sense smell. usually in pt over 30 yrs of age. * Metatarsophalangeal joint of the great toe may be the first joint involve in the acute gouty arthritis shows pain with hot dusky red swelling. * Spinal cord also maintain reflex activity. * Callus like Corn occur on thick skin due to pressure such as sole (planter surface) it is usually painless but if produce pain suspect underlying planter wart. It neither involve vertebral rotation nor thoracic abnormality and scoliosis disappear with forward flexion. Tenderness over acromioclavicular joint.Optic nerve (S) ----------.Occulomotor nerve (M) ---------. NERVOUS SYSTEM * Myelin sheath create the white color of brain contain tracts called Axons. Course is chronic resolve spontaneously at least partially. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * Rotator Cuff Tear repeated impingement cause partial or complete tear of acromian and coracoacromial ligament usually after 40 yrs of age. Myelin fibers converage from all part of the cerebral cortex into it and descend it to the brain stem. * Planter Wart (Verruca Vulgaris) located on thick skin of sole. Ask the pt to supinate the forearm against resistance with pt elbow flexed 90 degrees. Corn frequently develop over pressure point which is proximal interphalangeal joint.Prepared by Dr. * Corn develop due to pressure over the skin (dorsum of foot) cause pain. (Plumb line from spinous T1 fall in gluteal cleft but some time not). * List is lateral tilt of spine when a line drop from T1 (plumb line) it falls to one side of the gluteal cleft. Area may become inflamed and painful. Tenderness is max below the tip of the acromian. look like callus but look for small dark spot that gives a stippled appearance of Wart. * Scoliosis is the lateral curvature of the spine may cause thoraxic convexity of one side of the thorax. * Lordosis (lumbar lordosis) is accentuation of normal lumbar curve develop to compensate protuberant abdomen of pregnancy or obesity. It may present granulation tissue with purulent discharge. * Flat feet may cause tenderness from medial malleolus down along the medial planter surface of foot.Olfactory nerve (S) -------. * Hallux Valgus is the great toe abnormally abducted in relationship to the 1st metatarsal which is self deviated medially. * CN II to CN XII arise from Diencephalon and brain stem nuclei. * Acromioclavicular Arthritis is uncommon cause of direct injury to shoulder girdle with resulting degenerative changes. * Internal Capsule is a White matter. Thalamus process sensory impulse and relay them to cerebral cortex. * Ingrown toe nail may dig and injure the lateral nail fold resulting in inflammation and infection. Diffuse dull aching pain with restricted motion ensues. where as motion of the Glenohumeral joint is not painful unlike other shoulder condition. * CN IV -------.
2. * Three kind of motor pathway impinge on the ant horn cell. * All three higher motor pathway effect movement only through LMN called final pathway. * Each peripheral nerve has ant (ventral) root containing motor fiber and post (dorsal) root containing sensory fiber these both merge to form spinal nerve fiber than Spinal nerve fiber comingle with similar fiber to form peripheral nerve. Closing eye & mouth. L3. * Light touch takes one or two pathways. * Supinator or Brachiodorsalis Reflex :. * Triggering spinal reflexes known as muscle stretch or deep tendon reflex.correspond L5.Hypoglossal nerve (M) ----------. IRFAN MIR * CN V ONLY FOR EDUCATIONAL PURPOSE * CN VI * CN VII * CN VIII * CN IX * CN X -------. Extrapyramidal system is complexed include motor pathway b/w cerebral cortex. Corticospinal tract (Pyramidal tract) Control motor activity of muscle (skilled movement). C7. * Bicep reflex :. * Crude touch sensation precieved as light touch without accurate localization. -------. -------. T11. **Reflexes :* Ankle reflex :. S1. lateral movement of jaw.M) ----------.* A lesion in sensory cortex may not impair the preception of pain. Touch sensation often preserved despite partial damage to cord because touch sensation of one side of the body ascend by both side of cord. slow or lack of spontaneous or automatic movement (bradykinesia). T10. Its fiber from CNS when enter Spinal cord (lower motor neuron) called Corticobulbar tract.Lateral deviation of eye. where as cerebella damage impair coordinaton. brain stem. most often increase in tone.Hearing and balance. Sensory part of gag reflex.Muscle of tongue and Hyoid bone. C6. equillibrium and decrease muscle tone . Motor part of gag Reflex Sense larynx.Glossopharangeal nerve (S. * Planter reflex :.Abducen nerve (M) ----------. * CN XII -------.Trigeminal nerve (S. maintain equillibrium & control posture. Medial leminiscal sys). 3. Control Submendibular. * Damage to LMN cause Ipsilateral defecit result in decrease muscle tone and reflexes. touch.M) ----------. * CN XI -------.correspond C5. control body movement. disturb posture o gait. * Light and Crude touch fiber synapse at post horn ascend into spinothalamic tract of opposite side of thalamus. Facial expression. * Neither extra pyramidal nor cerebella dis cause paralysis but each can be disabling.correspond C6. parotid gland.Accessory nerve (M) ----------.correspond C5.Prepared by Dr.Vagus nerve (S.M) ----------. basal ganglia. and position but does impair fine descrimination. * Lower abdominal reflex :.correspond L2. Thus reflex relay over central and peripheral nervus sys.1. * Tricep reflex :. vs.Taste post 1/3 of tongue. T12. -------. Cerebellar system received both sensory and motor input. Carotid sinus reflex. * position and vibration pass directly to the post column ascend upward and cross midline at medullary level and continues to thalamus (MLS…. * Pain and temp sensation cross the spinal cord and pass upward in spin thalamic tract of the cord. * Upper abdominal reflex :.Facial nerve (S. sp automatic stereotype movement. abdominal and thoraxic viscera Autonomically. coordinate muscle activity. Motor Mastication. Because a selected segmental level sensory neuron fire the ant horn cell directly producing the reflex. 1. L4. C6.correspond T8.Neck movement (trapazius and sternocloid). gait. ----------. lingual & lacrimal gland. -------. * Loss of position and vibration sense with preservation of other senses suggest dis of post column. spinal cord out side the corticospinal tract. External auditory meatus.M) ----------. (eg walking). it uses spinothalamic tract. 2.correspond S1 primarily * Knee reflex :.Taste of ant 2/3 of tongue. * Imp Dermatomes :37 NOT FOR COMMERCIAL USE OR SALE .correspond T10. It enter into post column has accurate localizarion & finely discriminating (MLS). Sensation from soft palate or pharynx.Sense soft palate & pharynx. control swallowing. Extrapyramidal damage specially basal ganglia produce change in muscle tone. T9. * Loss of sensation of the waist down together with paralysis and hyper active reflexes in leg indicate transection of spinal cord.Sensory Ophthalmic sensation by V 1 Maxillary sensation by V 2 Mendibular sensation by V 3 -------.Acoustic or Vestibular nerve (S) ----------. It maintain muscle tone.
Tense pt shows increase resistense. Localized atrophy of Thenar and Hypothenar eminence suggest damage to medial and ulnar nerve respectively. 5. Look for blinking sensory part of the reflex carry by Trigeminal nerve V. note any weakness or asymmetry.innervate thumb and radial arm * C8 --. vs. * CN V (Trigeminal n) :. If u see none tap on the muscle with a reflex hammer you may stimulate them. * The join function of CN V. vs. or occipital cortex (eg stroke .Look for atrophy or fasciculation the trapazius muscle compare both sides. note the strenght. rotatory.perianal area * Aged person develop benign essential tremor. When trapazius is paralyzed the shoulder droop and scapula displaced downward & laterally. Show both lower and upper teeth. if it is asymmetrical look for neurologic abnormality. * Fasiculation suggest peripheral nerve damage as a cause of atrophy. X (Glossopharyngeal & Vagus n) :. where as motor part of reflex carry by Facial nerve VII. flattening of nasolabial fold and drooping of lower eyelid suggest facial nerve weakness. X. Reflexes.Ask pt to look upward touch the cornea not just the conjunctiva with fine wisp of cotton. vanilla.Screen the visual field by confrontation.Ask pt to clench teeth note the strenght weakness on one side suggest lesion of Trigeminal nerve V. Contact lens may abolish this reflex. Motor system. IRFAN MIR * C3 --. XII produce speech and sound. Ask pt to shrug both shoulder upward against your hand. Ptosis for ptosis (dropping of upper eyelid) which is Occulomotor nerve III palsy may also suggest Horner $ and myasthenia gravis. such sensory loss may also be associated by conversion reaction. smile puff out both cheeks. VII.Listen to the articulation of the pts words it depend upon CN V. Look for loss conjugate movement in any of 6 direction. Ask pt to yawn or say Aah watch movement of the soft palate and pharynx. Ask pt to respond when you touch the skin.(Acoustic n) Assess hearing than test for lateralization and compare air and bone conduction. soft palate normally raised symmetrically and uvula remains in middle and port pharynx move medially.innervate ring and little finger ONLY FOR EDUCATIONAL PURPOSE * T4 --. if there is any suggest Bell’s palsy.Listen to the pt voice does it have nasal quality or hoarseness if yes hoarseness suggest vocal cord paralysis vs. 38 NOT FOR COMMERCIAL USE OR SALE . * CN VIII (Vestibulochoclear n) :. Cranial nerve function. “Light touch test” can be done by fine wisp of cotton. the tremor is usually slightly faster with no muscular rigidity. X. * CN VII (Facial n) :. Any defect suggest visual extincton due to lesion in the parietal cortex. one nostril at a time. congenital. 1. Look for pts tongue lie on the floor of the mouth any atrophy or fasiculation suggest peripheral nerve dis. Ask pt to turn head on each side (laterally) against your hand force observe the contraction of stern mastoid. Look for pt tongue protrude out note symmetry and atrophy or deviation unilateral lesion of weak side is suggested. Ask pt to move tongue side to side and push the tongue against the cheek and palpate strenght externally and note symmetry.Test extraoccular movement in 6 cardinal direction of gaze. and jaw for pain with eye closed.heel * S5 --. * CN XII (Hypoglossal n) :. * CN IX.innervate front of neck * C6 --. * For neurologic examination organize yoyr thinking into 5 categories. * CN I (Olfactory n) :.umbilicus * L5 --. Weaknes with atrophy and fasciculation indicate peripheral nerve disorder. close both eye against the force of your hand. Bilateral weakness suggest periphera or central involvement. where as nasal sound suggest paralysis of palate or congenital partial palate. * CN II (Optic n) :. head hands may tremble at rate and amplitude with muscle rigidity suggest Parkinson * Age may also decreases the reflexes and senses (like vibration and position) symmetrically. IV & VI (Occulomotor. cheek. The test is difficult to interpretate when pt has no teeth. smooking.Sensory test -. Unilateral loss of sensation suggest lesion of Trigeminal nerve V or interconnecting higher sensory pathway. XII. frown. vertical. note strength and and contraction of trapazius. * CN XI (Accessory n) :. * Corneal reflex test :. where as Jaw.ant anle and foot (great and two other toes) * L3 --. first with open eyes than with close eyes.Take sharp and dull object to test all three trigeminal fields. * Muscle tone is a slight muscle tension during relaxation in normal muscle. Loss of smell may include trauma. stroke. * Lost of Gag reflex by stimulating the back of throat each side (it may be decrease or absent in some normal people) sugget lesion of Glossopharyngeal nerve IX or Vagus nerve X. palpate both muscles temporal and massetter.Test the sense of smell by presenting fimiliar odor like coffee.Inspect face at rest and also during conversation look for asymmetry tics or other abnormal movement.knee and distal thigh * L1 --. 3. If palate fail to rise suggest bilateral lesion of vagus nerve X.Examin the papillary reaction to light examin the near response. * Flatening on Thenar and Hypothenar aminence and furrowing b/w the metacarpel suggest atrophy. mixed). Forehead. Ask pt to report whether it is dull or sharp if finding are abnormal confirm it by “temp sensation test” with hot and cold water or tunning fork. Absence of sensory part of reflex suggset Trigeminal nerve V lesion where as absence of motor part reflex suggest facial nerve VII lesion. * Increase in muscle bulk with diminish strength is called pseudohypertrophy seen in Duchenne muscular dystrophy. Trochlear & abducen n) :. 4. Sensory system. Nystagmus may indicate vestibular dysfunction. Look for nystagmus and its direction (quick and slow component) and plane (horizontal. * CN III. * CN V (Trigeminal n) :. 2. lip.Innervate inguinal area * S1 --. tumor etc) called Anopsia.Prepared by Dr. Mental status and speech. paralysis or tumor. cloves. Ask pt raise both eye brows. This can be assessed by flexing and extending a muscle on both side.Motor test -. * CN II & III (Optic & Occulomotor n) :. cocaine use. Bilateral weakness cause difficulty raising the head of the pillow.Innervate the nipple * T10 --. VII.
tricep strenght.ask the pt to pull up and push down the feet against hand resistance.active movement against gravity and some resistence. extra pyramidal dis. quadriceps --. of extra pyramidal dis. L3.C6. * 4 --.place your hand firmly on the bed out side the pt knee and ask pt to spread both leg against the resistance. * 5 --.pull the flexed leg with one hand on the knee and other hand under the ankle and ask the pt not straighten the leg while you push the knee to straighten it.active movement against full resistance without fatigue. * Extention of wrist test --. Repetitive and consistent deviated to one side movement which worst with eye closed suggest cerebellar or vestibular dis. T1 --.L2.same as dorsiflexion test * Rapid alternating movement :. Planter flexion test --. Extention test --. C8. * 0 --. S2. * Position sense test :. median nerve --. Inaccuracy with eye closed suggest loss of position sense. * If muscle is too weak to overcome resistance test then against gravity alone or with gravity eliminated. For eg Dorsiflexion of the wrist can be tested against gravity alone and when forearm is midway b/w pronation and supination extention of the wrist can be tested with gravity eliminated. * Ask the pt to place one heel on opposite knee and than run it down to ward big toe. gluteus maximus --. Failure to perform suggest failure of position test cause by Labyrinth or cerebellar disorder. * Cerebellar disorder cause incoordination that may get worst with eye closed. Failure to do so suggest cerebellar dis. vs.L4.Prepared by Dr.L2. S1.L2. When finger over shoot its mark and than reach it fairly well such movement are called Dysmetria.S1. C7.no muscle contraction detected.support the knee in posteriorly in flexed position and ask pt to straighten his leg against your hand. In cerebella dis movement are clumsy. * Opposition of thumb test --. * 1 --. upper motor neuron dis. L5. L5. Normal people perform it well. T1. L5 --. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * If you suspect decrease resistence (muscle tone) hold forearm and hand loosly back and forth normally the hand move freely but never completely floppy. Both can be done by pusing and pulling against your hand at elbow. * Grip test --. irregular or clumsy than it is called Dysdiadochokinesia. gluteus medial & minimus --.L4. * Symmetrical weakness of the proximal muscle suggest myopathy. Floppiness indicate flaccid muscle. vs. paralysis of one half of the body is called Hemiplegia. * Flexion test --.L4.ask the pt to raise the leg against resistance on his thigh by your hand. adductors --. * Dorsi fexion test --. * Hip flexion test --. hamstring --.active movement with gravity eliminated.S1 --. paralysis of leg is Paraplegia. Pt should be in supine position. * 2 --. where as resistance that persist through out the range and in both direction is called lead pipe rigidity. * Ask the pt to tap distal joint of thumb with the tip of index finger rapidly failure to do so or slow clumsy movement suggest dysdiadochokinesia. * ask the pt to tap your hand as quickly as possible with the ball of each foot in turn note slowness awkwardness if present suggest dysdiadochokinesia of cerebellar dis.ask the pt to strike one hand on his thigh raise the hand turn it over and than strike the back of the hand on the same place again & repeat this alternating movement. Weakness suggest median nerve disorder or Carpal tunnel $. C7. L4. * Hip extension test --. C6 --. T1. * If one movement cannot follow quickly by its opposite movement (rapid alternating movement) or it is slow.C6.active movement against gravity. * Measure strength is graded from 0 . it suggest cerebellar dis. upper motor neuron weakness. L3. Weakness suggest central or peripheral nervous system disorder or painful disorder of hand. Repeat it with eye closed for position 39 NOT FOR COMMERCIAL USE OR SALE . radial nerve --.Ask the pt to touch your steady finger with the tip of his index finger and ask him to so with closed eyes. paralysis of all 4 extremities called Quadriplegia.ask pt to bring both leg together while you maintain resistance to keep them open. L4.C8. unsteady or inappropriate. Weakness suggest peripheral nerve disorder or radial nerve damage. iliopsoas --. L3. * Ask the pt to touch his nose with the tip of his finger.ask pt to touch the tip of the little finger with the thumb against your resistance . * Knee flexion test --. where as symmetrical weakness of distal muscles suggest polyneuropathy. ulnar nerve --.C5. L4. * Hip adduction test --. * Hip abduction test --. * To assess muscle tone in leg support the pt thigh with one hand and grasp the foot with other hand than flex and extend the knee and ankle on each side to note the resistance. C8. * Impair muscle strenght is called Paresis (weakness).C6. C8 --.C8. note accuracy and smoothness. weakness of one half of the body is Hemiparesis. * 3 --.spread the pts finger ask him not to adduct against you are forcing on them weakness suggest ulnar nerve disorder. * Increase resistance that varies commonly worsen at extereme of the range called Spasticity. * Finger abduction test --. S1.ask pt to push posterior thigh down against your hand resistance.can be done by asking pt to make fist and resist while your pulling it.bicep strength.5 scale. absence of strength is called Plegia (paralysis).ask pt to squees two of your finger hard and not to let them go while you pull them.barely detectable flicker or trace of contraction. * Knee extension test --.
tap the arm briskly downward. Difficulty suggest proximal weakness (extensor of the hip) or weakness of the quadriceps (extensor of the knee) or both. * Position sense :. When pronator drift test shows side or upward drift with searching writhing movement of the hand suggest loss of position sense. (Downward drift of the arm with finger flexed or elbow flexed during test called pronator drift). * Walk on the toe and than on to heel are sensitive test respectively for planter flexion and dorsiflexion of ankle as well as balance. * The pts eye should stay closed during sensory testing. or upper motor neuron weakness (UMN). and than touch the fork to stop it. * Little toe --. * Discrimination Sensation :. * Map out the boundaries of sensory loss or hypersensitivity in repetitive fashion from distal to proximal direction.This test depend on touch and position sense.S3. * Loss of position like loss of vibration suggest posterior column dis (mediallaminiscal sys) or lesion of preipheral nerve or root. alcoholism. * Rising from the sitting position with out support and stepping up on a sturdy stool are more suitable test than hoping or knee bend when pt is old. After that ask pt to keep arm up and eyes shut. clavicle. loss of position sense or intoxication. T1. 40 NOT FOR COMMERCIAL USE OR SALE . In atexia due to loss of position sense vision compensate for sensory loss. Analgesia refer to absence of pain.S1.C6. Touch the skin lightly avoid pressure calloused skin is insensitive should be avoided. ask pt to distinguish head From tail. * Note gait. * Thumb & little finger --. etc) * Vibration sensation is often a first sensation to be lost in peripheral neuropathy common causes include DM. People with proximal muscle weakness involving pelvic girdle & leg have difficulty in rising up & stepping up. Aging also decreases the vibration sensation. * Pain can be tested with pin by asking it is dull or sharp.hold the big toe by your index finger and thumb and pull it away laterally than upward and downard ask pt to tell position each time with eye closed. * Romberg test (position sense test) :.Spinothalamic tract Position & vibration -----. On coin it’s a sensitive test. * Hemisesory loss occur due to lesion in the spinal cord or higher pathway. C8. Start with.Prepared by Dr. * Temp sensation is often omitted if pain sensation is normal but include it if is there any question of hot and cold. * Vibration sensation also lost in posterior column dis as in tertiary syphilis .Pt should stand 20 .30 secs with both arm straight forward palm up and eye closed. Pt stand well with open eyes and loss balance with eye closed (+ve Romberg test). Hypogesia refer to decrease sensitivity to pain. * Shallow knee bend first on one leg and than on other on standing position. cotton ball. * Anesthesia is absence of touch sensation.30 sec with out support. If these are normal safely assume proximal area will be normal. arm usually return to normal horizontal position. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE sense failure to do so or over shooting target suggest cerebellar dis or vestibular dis. The pronator of one arm suggest contra lateral lesion of corticospinal tract. medial malleolus.abiliy to identify objects by feeling it eg coins.pt should stand with feet together with open eyes and than close both for 20 .use tunning fork tap it on your heel place it firmly over the distal interphalangeal joint of pt and than interphalangeal joint of big toe. * Steriogenesis test -. * Compare pain temp touch from distal area to proximal area of extremities. * When testing vibration and position sense first test the finger and toes. This response when weak in one arm suggest lack of position sense.C4. If position sense is impaired move the test proximally to detect spinal or peripheral lesion. spinous process. Failure suggest distal muscular weakness. * Inner & outer aspect of both arm ---. Conduct examination as efficiently as possible. * Medial aspect of each buttock --. * Bilateral sensory loss of poly neuropathy in gloves and stocking pattern often seen in alcoholism and DM.post column and cortex * Sensory testing may quickly fatigue pt and than produce unreliable results. * Pronator drift test :. * Evaluate sensory system test :. Hypoesthesia or Hyperesthesia is decrease or increase sensitivity to touch sensation. Ask what pt feels. * Test light touch with fine wisp of cotton. In cerebella atexia the pt has difficulty standing with feet together whether eyes are closed or open. Vit B12 deficiency. * Vibration sense :. ask pt to walk across the room. A person who can not stand may tested for pronator drift in sitting position.Spinothalamic tract and post column Discriminative sensation -------. Hypergesia refer to increase sensitivity to pain. * Medial & lateral aspect of both Calves --.Pain & temp -------. If gait lack coordination with reeling and instability is called Ataxia. Pts eye should closed all the time. Symmetrical distal sensory loss suggest polyneuropathy ** Suggested sensory examination pattern include. * Heel to toe walk (Tandem walk) it may reveal ataxia that was not previously obvious. * Testing vibration sense in the trunk may be useful in estimating the level of cord lesion. pen.C6. In cerebellar incoordination arm return to its original position but overshoot and bounce.L4. * Both shoulder --.Post column (medialleminiscal sys) Light touch ------.L2. Ataxia may suggest cerebellar dis. * Hop in place on each foot require good position sense and normal cerebella function. key. L5. If vibration sense is impaired proceed more prominent bony prominence (wrist. * Front of both thigh --. If pt is uncertain ask pt to tell when vibration stops. elbow. * Meticulous sensory mapping help to establish the level of spinal cord lesion or peripheral nerve or its branches.
s sign).flex pt arm at 90 degree with palm toward the body and pull it slightly across the chest strike the tricep tendon above the elbow posteriorly watch contraction of the trice and extention at elbow (ask pt to let the arm go before you strike). * Asterixis :. Sudden brief non rhythmic flexion of the hand and finger indicates Asterixis causes include metabolic encephalopathy in pt whose mental function are impaired. * Point localization test :. Use woodened end of the cotton tipped applicator or tongue blade (splitted) fro stimulus note contraction. or peripheral nerve is damaged. * 0 + no response. * Abdominal reflex may be absent in central or peripheral nervous system. S1 ) :.Ask the pt to extend his arm against your hand or wall (resistance).Stroke the lateral aspect of the sole curving medially toward the toe with sharp dull object. * Steriogenesis . * Two point discrimination test :. C6 ) :.If the Bibinski reflex seems hyperactive test for ankle clonus. * Hyperactive reflexes suggest CNS dis sustained clonus confirmed it. 41 NOT FOR COMMERCIAL USE OR SALE . if hip and knee flex suggest meningeal inflammation. T9. * Abdominal reflex :. * Bicep reflex ( C5. Irregularly with one point t touch (not too hard). Note movement of the toe which flex normally. * 2 + average normal * 1 + some what diminished . * When discrimination sensation is impaired pt can not respond appropriately to discrimination test it suggest sensory cortex dis. * 4 + very brisk hyperactive with clonus (rhythmic oscillation b/w flexion and extension) .Prepared by Dr.Ask pt to stop traffic by holding both arm forward with hand locked up and finger spread watched for one or two minutes. observe flexion of elbow. * Symmetrical diminish or even absent reflex may found in normal people. Dis of muscle or neuromuscular junction may also decreased reflexes.Touch a point on pts skin than ask apt to open a eye and point the placed touched. Watch and feel contraction of bicep muscle. Obesity may mask abdominal reflex. * Clonus can also be illicit in other joint eg sharp downward displacement of patella may illicit patellar clonus. Normally ankle does not react to the stimulus in most people but may be seen in tense and exercised pt. * Reflexes response depends partially on your force use no more force than you need to provoke a definitive response. and two point discrimination also impaired by post column dis (MLS). Test is Specially useful on the trunk & legs. * Winging of scapula :. C6 ) :. * A marked Bibinski response is occasionally accompanied by reflex flexion of hip and knee. Scapula may appear winged in very thin people too. * Knee reflex ( L2.Flex and extend the neck. * Planter response ( L5. and epilepsy also cause Bibinski Response. Alcohol intoxication. Usually hip and knee remain relax.use the side of two pins or clip touch a finger pad on two places alternate a double stimulus. pain and resistance suggest meningeal inflammation. * Reflexes are graded on 0 . Look and feel for rhythmic osscillation b/w Dorsiflexion and Planter flexion. * During extinction test only one stimulus may be recognized suggest lesion of the opposite sensory cortex.low normal. Suggest post column dis (MLS). note speed pf relaxation after muscle contraction. * Asteriogenesis is inability to identify the object with eye closed. * Extinction test :. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * Number identification test (Graphesthesia) :.pts hand should rest on abdomen or thigh (lap) with forearm partially pronated strike the radius about 1 2 inches above the wrist watch for flexion and supination of the arm. * Clonus :.Draw a number with blunt edge of pencil or pen on pts palm and ask. T11.Dorsiflexion of the foot at ankle with pt sitting strike the Achilles tendon watch and feel for planter flexion.Tap briskly the patellar tendon just below the patella with knee in flexed position note contraction of the quadriceps with extension at the knee. C7 ) :.test the abdominal reflex by lightly but briskly stroke on each side on abdomin above (T8. In winging scapula juts (lift) backward suggest serratus ant muscle weakness or muscular dystrophy or thoracic nerve injury. number identification. Observe the scapula normally scapula lies close to thorax. support the knee in partially flexed position with your other hand Dorsiflex and Planter flex the foot few time which encourage the pt to relax and than sharply Dorsiflex the foot and maintain it in Dorsiflexion . * Reflex may be diminished or absent when sensation is lost or spinal segment is damaged. * Ankle reflex ( S1 ) :. * 3 + Brisker than average (possible but not indicative of dis). * Lesion of the sensory cortex Increases the distance b/w two recognizable point. * Supinator and brachioradialis reflex (C5.4 scale. distance b/w the two points is < 5 mm on finger pad. T10) and below (T10.Simultaneously touch corresponding area on both side of the body ask pt whether he feel it or not. Sustained clonus may indicate CNS dis. * Meningeal sign :. L3. * Brudzinski’s sign :. Slowed relaxation phase of reflex in hypothyroidism is often seen and felt in ankle reflex. * Tricep reflex ( C6. T12) the umbilicus. * When reflex is symmetrically diminished or absent use reinforcement technique ( it involve isometric contraction of other muscle that may increase reflex activity ) for eg ask pt to clench his teeth or squeeze one side thigh with opposite hand while you check the arm reflex of other hand or ask pt to pull both hand against each other while u check the leg reflexes. arthritis or neck injury.When flex the neck note flexion of the hip and knee (brudzinski. L4 ) :.pts arm should be partially flexed 45 degrees place your thumb firmly on bicep tendon strike the reflex hammer on thumb toward bicep tendon (ant to elbow). Dorsiflesion of the big toe accompanied by fanning of the other toe constitute Bibinski Response often indicate the CNS lesion in corticospinal tract.
sternum. Repeat on opposite side after 3 minutes no response to stimuli suggest brain stem injury.Flexed a pts knee in a manner that heel rest on the bed & than with draw the support. turn the head quickly first one side than other. but usually in one leg. * II Lethargy : speak with pt in loud voice ask name etc. There is minimal awareness of self or the environment.Stimulus evoke abnormal posture response of trunk & extremities. In hemiplegia flaccid leg fall rapidly. Eye reflexes ( CN V.Flex the pts leg at both hip and knee and than straighten the knee discomfort behind the knee during full extension occur in may normal people but this maneuver should not produce pain. * To assess the consciousness there is 5 clinical level of consciousness (arousal). vertical or rotatory nystagmus. S3. metabolic coma (reaction to light often remain intact in metabolic coma). Bruises. * Flaccid Paralysis or no response :.If occulocephalic reflex (doll’s eye movement) is absent seek further assessment of brain stem. S3. CO poisoning. * I Alertness : speak to pt in normal tone an alert pt open the eye looked at you and respond fully (Arousal intact). IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * Kerning’s sign :. (never do this maneuver in awake pt) first make sure ear drums are intact and canal is clear. In hemiplegia the flaccid leg fall rapidly into extension with external rotation at the hip. pt lapses into unresponsive state when stimuli is ceases. * Facial paralysis (Bell’s palsy) occur due to lesion in the facial nerve VII . * Anal reflex ( S2. pons. * Normal --. +ve kerning’s sign when pain and resistance occur on extending the knee when it is bilateral suggest meningeal irritation. * Coma signals potential life threatening event effecting the two hemisphere.Grasping each arm near wrist and raising it to vertical position. S4 as in cauda equina lesion. * Deviation of eye to one side is term Gaze preference eg right or left. There is no evident response to Inner need or external stimuli. Alertness and interest in environment is decreased.apply a painful stimulus to tendon. * Check facial symmetry.apply painful stimuli and note. S4 ) :. CN VII ). suggest decorticate or decerebrate Rigidity. * Stereotype :. Doll’s eye movement suggest lesion of mid brain. * IV Stupor :. One should first assess ABC (airway. Flaccid arm drop like a flial. In comatose pt with an intact brain stem the pt eye move in opposite direction as if still gazing ahead in initial position (doll eye movement). Jaundice. * Occasionally nystagmus has no quick or slow phase rather have coarse oscillation it is said to be a pendular nystagmus. * Occulovestibular reflex ( with calorie stimulation ) :. With large syringe inject a ice water in the ear canal watch for direction of deviation of eye in horizontal plane (maneuver may need 120 ml of ice water to illicit the response). * Reaction to light often remain intact in metabolic coma where as structural lesion like stroke may lead to asymmetrical pupil and loss of light reaction. In facial paralysis pt cannot close the eye & eye ball rolls up. Get chest x-ray first rule out the vertebral fracture that could compress spinal cord. place kidney basin under ear to catch any over flow. or very deep coma. In hemiplegia the limp Hand drop to form a right angle 90 degree with the wrist. Alcoholism. or nail bed (no strong stimuli needed). * Posture and Muscle tone :. breathing. Where as in both leg (+ve kerning’s sign) suggest meningeal irritation. * Nystagmus is the Rhythmic Oscillation of eye analogous to tremor in the body.apply repeated painful stimuli. * III Ostentation :. Make sure there is no neck injury before doing this maneuver. Nystagmus has both slow and fast phase but it is defined by fast phase eg when pt has left nystagmus eye move slowly to right and than fast to left. and circulation) than establish the pts level of conciousness and than examin the pt neurologically try to find out metabolic and structural reason.Compare a fall of each leg while u support pts knee in flexed position. Blood CSF in ear or nose ( Suggest skull fracture ). * Do not flex the neck if there is any trauma to neck or head immobilize cervical spine. Loss of anal reflex suggest lesion in S2. pt cannot wrinkle forehead & raise eye brows. a comatose pt remain unarousable with eye closed. vs. Facial paralysis due to CNS lesion 42 NOT FOR COMMERCIAL USE OR SALE . Increase your stimuli in step wise manner.Prepared by Dr.shake the pt gently as if awakening a sleep. Tongue injury ( seizures ). It suggest corticospinal tract Lesion.Holding open the eye lid. In comatose pt with this maneuver eye drift toward the irritated ear. Uremia. vs. A stuporous pt arise from sleep on after painful stimuli.Using dull object stroke outward in the 4th quadrant from the anus watch for reflex contraction of anal musculatures. other are horizontal. Lethargic pt appear drowsy but open the eye & looked at you respond to question & than fall a sleep. Cyanosis. . Papiledema ( HTN ). * Compression of lumbosacral root may also cause resistance and pain in low in lower back and post thigh.Pt pushes the stimulus away. On other hand in irritative lesion due to epilepsy or early cerebral hemorrhage the look away from the lesion. * V Coma :. * Remember Cardinal DONT’s :* Do not dilate pupil very imp clue in structural vs. Laceration. An obtunded pt open eyes looked at you but respond slowly and confused. Elevate the pts head to 30 degree. verbal response are slow or even absent. The movement of nystagmus occur in plane of the movement not in direction of gaze. the brain stem or both. where as facial paralysis due to CNS lesion occur due to CVA affect motor neuron. * Occulocephalic reflex (Doll’s eye movement) :. * When occulomotor pathway is intact eye look straight where as in structural hemispheric lesion the eye look at the lesion.Avoidant :. .
barre $. abnormal movement including nystagmus. dermotomal sensory deficit on trunk and increase deep tendon reflex. Also show sensory deficit in stocking . thigh tend to cross forward on each other at each step and step is short. trunk. Underlying defect unilateral hemisphere dis as with stroke. That is sudden loss of tone that increase the ease of motion is called Mitgenen (moving with). * In spastic hemiparesis one arm is held immobile and close to the side with elbow. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE pt can close the eyes perhaps with slight weakness & can wrinkle forehead & raise eye brows. Fasciculation rare. Unlike tics they seldom repeat them selves normally involve face. ataxia. leg is externally rotated at hip. jerky. * Athetosis movement are slow more twisting and writhing than choriform movement and have larger amplitude. elderly.kinesia and dysmetria with normal to decreased deep tendon reflexes.Intentional tremor is absent at rest appear with activity and often get worst as target get neared causes include cerebella pathway dis or multiple sclerosis. * Tics are brief repetitive. * Oral Facial Dyskinesia :. Limb and trunk involve less often. benign (familial).knife resistance cause by upper motor neuron lesion of the corticospinal tract at any point from cortex to spinal cord. Athetosis is often associated with plasticity causes include cerebral palsy. result into motor weakness and atrophy more distal than proximal some time with fasciculation. protrusion of the tongue. initial hypertonia may give way suddenly as the limb relaxes. drugs (phenothiazine). The sensation is not effected. * Subcortical Gray matter :. also show sensory loss in nerve pattern. dysdiadocho . drugs (antipsychotic like phenothhiazine cause tardive duskiness).glove distribution. Flat nasolabial fold and paralysis of lower face occur in both types.Most prominent at rest may decrease or disappear with voluntary movement (Pill roll tremor) it occur in Parkinson’s dis (about 5 per second). edentulous. 2. DM. usually more proximal than distal. Causes include Psychosis. Causes include Guillian . spasmodic tort colitis. Pursing of the lips. also in intial phase of spinal cord injury (spinal shock) or stroke. * Spinal nerve and root lesion due to herniated disc results into decreased deep tendon reflexes. motor weakness and atrophy in root innervated pattern some time with fasciculation. Or sudden increase in tone that makes motion more difficult is called Gegenhalten (holding against) due to lesion in both hemisphere of frontal lobe usually cause by dementia. It is usually caused by lesion in extra pyramidal system specially the basal ganglia. wrist. Further more it cause contra lateral sensory loss on limb and trunk. causes include stroke specially late or chronic stage. * Peripheral nerve Mononeuropathy due to trauma results into motor weakness and atrophy in nerve distribution some time with fasciculation. Sensation not effected. motor weakness. amyotrophic lateral sclerosis results into decrease deep tendon reflexes. head. lower arm and hand causes include Sydenham’s chorea (with rheumatic fever) & Huntingtun dis. opening and closing of mouth. Intentional tremor :. and shoulder. plus CN deficit such as diplopia (from weakness of extra occular muscle) and dysarthria. mouth. * Cerebellar lesion due to stroke or tumor results in hypotonia. deviation of jaw). * LMN lesion due to polio. Anxiety. fasciculation. Also show sensory loss in nerve pattern. Resting tremor :. During rapid passive movement. sensation stays intact.Prepared by Dr. * Muscle dis due to Muscular dystrophy results into normal to decreased reflexes. * Rigidity is increased resistance that persistent through out the movement ( unlike plasticity ) and are independent of rate of movement is called the lead pipe rigidity. * Flaccidity (hypotonia) cause limb to be floppy due to lesion in LMN or ant root at any point from ant to peripheral nerve. motor weakness and atrophy in segmental and focal pattern. * Lesion in neuromuscular junction due to Myesthenia gravis results into fatigue more than weakness sensation stay intact and reflexes normal. This spastic catch and relaxation id known as Clasp . These type worsen with intention. contra lateral UMN weakness or spasticity. Sensation stay intact. * Scissors Gait is stiff. Pt appear to be walking 43 NOT FOR COMMERCIAL USE OR SALE . rapid. and interphalangeal joints flexed. Commonly involve face and distal extremities. * Paratonia is sudden change in tone with passive range of motion. stereotyped coordinated movement occuring at irregular level on face. Rigidity and tremor with normal to decreased deep tendon reflexes. jaw and tongue (grimacing.Are rhythmic repetitive bizarre movement chiefly involve the face. * Three Types of Tremors :1.(eg Parkinsonism). * Stroke or acoustic neuronal in brain stem results into weakness and spasticity (as above). * Stroke in cerebral cortex results into increase deep tendon reflexes. * Peripheral nerve polyneuropathy is due to alcohlism.Occur when affecting part is actively maintaining a posture for eg fine rapid tremor of hyperthyroidism. Flexion is stronger than extension in arm. * Chorea ( Choriform ) are brief. Postural tremor :. planter flexion is stronger than dorsiflexion in foot. irregular and unpredictable movement.Basal ganglia lesion as in Parkinsonism result into bradykinesia (slow movement). Each leg is advanced slowly. * Trauma of the spinal cord causing compression result into weakness spasticity but often effect both side (when damage is bilateral) causing paraplegia or quadroplegia. Leg is extended in the planter flexion of the foot often scraping the toe or circle it stiffly outward and forward (circumduction). also manifest deep tendon reflex with no sensory finding. fatigue. when you flex or extend the wrist or forearm a superimposed ratchet like jerkiness is called Cogwheel Rigidity. * Dystonia are some what similar to athetotic movement but involve longer portion of the body including trunk. Grotesque twisted posture may result causes include primary torsion dystonia. * Spasticity is an increase muscle tone (hypertonia). 3.
One side paralysis results into slack ( fall loosely ) arm and leg. * One large pupil that is fixed and dilated warn herniation of the temporal lobe causing compression of coulometer nerve III and mid brain. metabolic encephalopathy. * Sensory Ataxia is unsteady and wide base (feet wide apart) gait. wide base gait with exaggerated difficulty on turning. or pons although severe metabolic disorder such as hypoxia. may also produce it. Arm swing is decreased. It may be unrelated with fixed or dilated from cholinergic or hyperthermia. heroin). LSD. These pt cannot stand steady with feet together whether their eyes are open or closed.4 yrs.2. Level of consciousness changes after pupil changes. Subdural. one side face may paralyzed. or intracerebral hemorrhage. anorexia. * Abnormal posture in comatose pt :* Decorticate rigidity ( abnormal flexor response ) :. * Hemiplegia ( early ) :. Pt watch the ground for guidance while walking. Atropine like agent. In structural coma respiration is irregular specially cheynes stroke or ataxic breathing pupil are fixed and uncreative. Reaction to light is normal. hyperglycemia. * Infancy time 1st year of life. 44 NOT FOR COMMERCIAL USE OR SALE . hypoglycemia. * 5 min APGAR score of < 7 place the infant at high risk for subsequent CNS and other organ dysfunction. If pupil is pinpoint its from opiate or cholinergics. Arm are flexed at elbow and wrist. * The developmental mile stone in children is measured by DDST ( Denver Developmental Screening Test ). Steppage gait may involve one or both sides it is associated with foot drop. * Neonatal time 1st 28 days. * Abnormal pupil interpretation :* Small pupil ( 1 . * 1 min APGAR score of 7 or less usually indicate nervous system depression. phenothiazine. mid brain. It is associated with loss of position sense in leg from polyneuropathy or post column damage.20 yrs. hypothyroidism. * Early childhood 1 . pain.In decorticate rigidity upper arm are held tightly with elbow.Prepared by Dr. Level of consciousness change before pupil changes. Brainstem infarct or cerebral infarct. * Psychiatric disorder may mimic coma. drugs. metabolic coma is typically results from uremia. and finger flexed. The pt is slow in getting started. * Metabolic coma caused by arousal center poisoned or critical substrate depleted it result into normal to hyperventilation with regularity pupil is normal and equal to light. Reaction to light may be seen with magnifying glass.bilaterally fixed and dilated pupil is may be due to severe anoxia and its sympathetic effect as seen after cardiac arrest. or palpating abdomen should done near the end of examination. \ When this posture is unilateral suggest chronic spastic hemiplegia. Adolescent 13 . * Large Pupil :. * Late childhood 5 . the legs are extended and internally rotated.6 mm ) are fixed to light reaction and suggest structural damage to mid brain.5 mm ) suggest damage to sympathetic pathway in hypothalamus. ----------------------------------------------------------------------------------------------------------------------PEDIATRICS * Bibinski response in child is normal beyond the age of two years. This posture may occur spontaneously or only in response to external stimuli such as light. It is associated with bilateral spastic paresis of the leg. ischemia. noise. * Steppage Gait is when pt drag their feet and lift them high with knee flexed and bring them down with a slap on the floor thus appear walking upstairs. They are unable to on their heel. * Structural coma caused by lesion damaging brain stem arousal area either directly or secondary to more distal mass. Mid position fixed suggest mid brain compression where as dilated fixed pupil suggest compression of Occulomotor nerve III from herniation. tumor abscess. alcohol.12 yrs. structural coma usually suggest Epidural. encephalitis hypo or hyperthermia.In decerebrate rigidity jaws are clenched and neck is extended. It is associated with cerebellar or their tract dis. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE through water. Score of 4 or less indicate severe depression require immediate resuscitation. vs. amphetamine. * APGAR score should be done in 1 minute and 5 minute after birth. wrist. * Parkinson Gait is stooped posture with head and neck forward and hip and knee slightly flexed. * Pin point pupil ( < 1 mm ) suggest hemorrhage in the pons or drugs (like morphine. it is associated with basal ganglia defect of Parkinson dis. Legs are stiffly extended at knee with feet planter flexed. * In children looking the ear. Hemiplegia suggest unilateral corticospinal tract lesion. with forearm pronated. * Decerebrate rigidity ( abnormal extensor response ) :. These pt through their feet forward and outward and bring them down first on the heel than toe with double tapping sound. and tricyclic antidepressant may cause dilated fixed pupil. If ventilation is irregular is usually cheyne’s stroke. Arms are adducted and stiffly extended at elbow. pt turn around stiffly “all in one piece”. wrist and finger flexed. unsteady. both eye may looked toward the lesion. cerebral infarct or emboli. meningitis. this posture suggest destructive lesion in corticospinal tract or very near to cerebral hemisphere. where as bilaterally large reactive pupil may be due to cocain. * Mid position fixed pupil ( 4. It is caused by lesion in diencephalons. Feet are planter flexed. or other sympathomimetic nervous system agonist. liver failure. Usually secondary to LMN dis. * Cerebellar Ataxia is staggering. With eye closed they cannot stand steadily with feet together (+ Romberg sign) and staggering gait worsen. mouth. steps are short and often shuffling. drugs. Leg may externally rotated.
* When two or more siblings are to be examined start with older one. * Failure to pass tube in nasopharynx suggest Post Nasal Atresia also called CHOANAL.42 weeks Post term -------.5* C . Infant bundling may elevate skin temp but not core body temp.child interactional difficulties. * Pump the 10 cc gas in the stomach while intubation and ascultate in epigastria area to confirm patency.40.Birth wt > 90th % of intrauterine growth curve. * Anxiety ( eg elective hospital admission ) may elevate body temp.1499 gms. * Wt appropriate for gestational age (AGA ) . IRFAN MIR ** APGAR SCORE SYSTEM :1. emotional. blue extremities. * If resistance is inappropriate for childs age. Extremely Low birth wt is < 1000 gm. the examiner should consider the possibility of underlying developmental. by day 4 after birth if tremors occur at rest signals CNS dis.birth wt < 10th % of intrauterine growth curve. * explain like this for eg.gestation < 37 weeks Term ----------. sneeze. ONLY FOR EDUCATIONAL PURPOSE Score 2 > 100 Good crying Active movement Crying vigorously. and the leg of the frank breech baby are abducted and externally rotated. * During childhood temp elevation from 103* F . Both child and parent may appear over affectionate to one another in an attempt to hide the abuse.gestation > 42 weeks. where as failure to pass the tube in stomach suggest Esophgeal Atresia usually with an association of Tracheoesophageal fistula. parent . rectal temp may approach 101* F ( 38.5* C) is common even in mild temp. * Always examin when baby is not too satiated ( therefore less responsive ) nor too hungry ( therefore more agitated ). * Abused child usually demonstrate no separation anxiety when physically environmentally remove from parents. * In normal baby forearm supinate with flexion at elbow and pronate with extention. * Rarely for the childs sake or the parent it is necessary to discontinuous the exam and return to it another time as in extreme crying or resistance. * Dialogue with child will indicate the child level of receptive and expressive function. * The average rectal temp in infancy and childhood is usually 99 degree F* (37. * Beyond the one month of age a pulse greater than 180 usually indicates paroxysmal atrial tachycardia. * Normal full term new born lie in symmetrical position with the limb semi flexed and leg partially abducted at hip with head in the mid line or turn to one side.2499 gms. Heart rate 2. Low birth wt is 1500 . Preterm SGA or AGA or LGA. Muscle tone 4. Pale Score 1 < 100 Slow. Reflex irritability 5. Asymmetrical movement of arm & leg at any time alarm the possibility of CNS or PNS deficit. Respiratory effort 3. leg and head are extended. Color Score 0 Absent Absent Flaccid No response Blue. * Birth wt and gestational age . * Examining the hip abduction should be perform at last because baby to cry.gestation 37 . * Use command like roll over on the belly rather than will you roll over on your belly for me. Irregular Some flexion Crying Pink body.3* C ) in normal children. * Wt large for gestational age ( LGA ) .Prepared by Dr. Preterm ----------. * Regardless of age every sexual active female should have periodic pelvic examination and pap smear.Birth wt with in 10th and 90th % of intrauterine growth curve. * In Breech baby.2* C) until 3rd year. * Low amplitude high frequency tremor in extremities and body are seen with vigorous crying and even at rest during first 48 hrs.105* F (39. 45 NOT FOR COMMERCIAL USE OR SALE . Or Post term LGA or SGA or AGA . cough All pink * Normal birth wt is 2500 gms or more.8* C ). * Ballard Scoring system enables estimates of gestational age. * Wt small for gestational age ( SGA ) . Remember its not a measure of intelligence. Very Low birth wt is 1000 . birth injury or congenital problem. * DDST is design to reveal developmental attainment from birth to 6 yrs of age. At 18 month 15% of children have mean rectal temp of 100* F ( 37. Many children with mild developmental delay also score normal. * When examining the heart place your left hand on pts left shoulder for distraction and use right hand to ausculatate.
because in early childhood Korotkoff sound are not audible due to a narrow or deep placed brachial artery.12 month 115 B/min 75 . * If jaundice other than physiologic appear with in 24 hr of birth suggest possible hemolytic dis . * In female child Normal Systolic Diastolic Pressure is 5 mmHg lower than male except in 1st yr of life. 120 mmHg at 18 yrs.5 hr cyanosis become less marked. or neurologic insult ).155 * 1 . * Measurement of height and wt above 97th and below 3rd percentile on standerd growth chart may indicate growth disturbance and require investigation. * If striking color change occur in premature infant and those with congenital hypothyroidism and Down $ shows marbled or dappled reticular pattern on skin. * Skin desquamation at birth occur in babies born after 40 weeks of gestation in those with placental circulation insufficiency and various form of congenital Ichthyosis.78% * Renal arterial dis ------------------. * Renal dis ----------------------------. sweet potato. In border line cases press a glass slide against a cheek to help you detect the pressure of jaundice. subdural hematoma or tumor. * Use natural day light rather than artificial light to evaluate jaundice at any age.40 R/min * Late childhood 15 . 85 mmHg at 1 month. * In Infant BP reading from the thigh are approx 10 mmHg higher than those in upper arm. * The most common cause of HTN in infancy and childhood are. * Children who are fed yellow vegetable (carrot. in which the pulse will be slowed vs. native american. 110 mmHg at 13 yrs.6 yrs 103 B/min 68 . * The head circumference (growth) should be measured at every physical exam during first two yr of life. 90 mmHg at 6 month. 100 mmHg at 8 yrs. * Acrocyanosis may recur through out early infancy when baby is cold. If they are same or lower coarctation of aorta should be suspected. 46 NOT FOR COMMERCIAL USE OR SALE . congenital disorder. If it does not disappear with in 8 hr or warming consider cyanotic congenital heart dis.6 month 130 B/min 80 . or infection. * If head circumference is delayed consider premature closure of suture or microcephaly ( may be Familial or chromosomal abnormality. it usually disappear in childhood (occur due to pigmentation of deeper layer of skin).125 * 10 . sclera is spared In this. biliary obstruction. maternal metabolic disorder. When growth is too rapid consider hydrocephalus. * Normal systolic BP in male is in vicinity of 70 mmHg at birth. * Fine downy growth of hair called Lanugo over entire body shed with in two weaks.115 * Respiratory rate. * In new born hand and feet may be blue ( Acrocyanosis ) after 4 . parietal and frontal prominence to obtain the greatest circumference.Prepared by Dr.180 * 6 . pneumonia. * Generalized paler in new born may indicate either anoxia.138 * 6 . * ILL defined blackish bluish area located over the buttock and lower lumbar region often seen in blacks. Average Range * Birth 140 B/min 90 .190 * 1 . * In children unlike adult the point at which the sound first muffled (not the disappearance point) is recorded as diastolic pressure. Place the tape over occipital. 95 mmHg at 5 yrs. in sever anemia in which the pulse will be very rapid. asthma .25 R/min * Age Reach to adult rate * In children respiration rate > 100/min is associated with lower respiratory tract obstruction eg Bronchiolitis. one side of the body is red other side is pale and abrupt border separates the two sides at the mid line this phenomenon is called Harlequin Dyschromia it is transient with unknown etiology.2% * Pheochromocytoma -------------* Primary HTN become increasingly prevalent beyond age 6 * In adolescent HTN frequently accompanies obesity. * The diastolic pressure reaches 55 mmHg at 1 yr and 70 mmHg at 18 yrs. * In normal new born color change is often seen.14 yrs 85 B/min 55 .150 * 2 .60 R/min * Early childhood 20 . squash) may develop yellow color of skin this condition is called Carotenemia. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * Average heart rate in children. * Superficial desquamation of skin and also cheesy white material composed of Sebum and desquamation epithelial cell called Vernix Caseosa usually disappear by 2nd or 3rd day after birth.2 yrs 110 B/min 70 .10 yrs 95 B/min 65 . * Physiologic jaundice which is peak at 4th and 5th day usually disappear with in week but it may persist for month.12% * Coarctation of aorta --------------. Asians are called Mongolian spot. * New born 30 .
Localized bright spot may be seen with subdural effusion or Porencephlic cyst. 1 cm halo is present when it is over occipital area. Dx is made by Roentgenogram. white raised area with out surrounding erythema often on nose. * A large post fontanelle may be present in congenital hypothyoidism. It subside with 24 hr of life. Ant close b/w 4 . * Normal new born infant’s cranial bones may over lap the suture called Molding results from the passage of head through birth canal it disappear with in two days. * Bruit heard in non anemic older children suggest increase IC pressure.2 weeks. and vomit. * Chvostek’s sign when produce by many contraction and repeated contraction suggest hypocalcaemia (tetany). When halo is uniform over the entire head it suggest partially absence or thinning of cerebral cortex. IC arteriovenous shunt or an aneurysm. * Degree of hydration (turgor) can be evaluate by compressing the skin b/w thumb and finger. * Decreased IC pressure reflect in a depress fontanelle sign of dehydration. chin.Prepared by Dr. upper lip. * Transilluminate the skull in infant suspecting to have CNS dis in complete dark room. Increase Intracranial Pressure produce bulging. It present in many new born and persist till early childhood. eg in lead encephalopathy and brain tumor. Systolic and continuous bruit may be heard over temporal area in normal child until age 5. Purposeful elicitation of this finding is not recommended. A negative pressure (vacuum) produces distended capillaries. The delay return of skin to its original position is called Tenting suggest dehydration.Percuss at the top of the cheek just below the zygomatic bone in front of ear with index finger. * Percuss the parietal bone on each side by tapping your index finger directly. It is also disappears in 1 . the lesion disappear at about 1 yr of age. * In infant hypoglossal duct.Strugg Weber $. Pulsation of fontanelle reflect the peripheral pulse. Same way when the head is flexed on sternum in utero the microganthia may result. mental retardation and glaucoma . tetanus. * At birth most new born has relatively long occipital frontal diameter and narrow bitemporal diameter called Dolichocephaly it disappear by the end of year and in some it last indefinitely. * During transillumination in normal infant a 2 cm halo of light present around circumference of flash light when it is placed over the frontal area. Rickets or congenital syphilis. * Irregular pink area found in neck. It usually disappears later in life when body is more active. It can also be seen when baby cry. * Plagiocephaly is apt to be more prominent in infant with torticollis secondary to injury to stern mastoid muscle at birth in the mentally and physically handicapped and under stimulated infant. where as such lesion on larger area are not likely to be disappear or fade called Port . fistula or cyst may be seen or felt in mid line just above the thyroid cartilage. It disappears spontaneously vs.wine stain. 47 NOT FOR COMMERCIAL USE OR SALE . It produce one or two contraction of the facial muscle. * Normal fontanel’s are soft concavities. face. or tetany due to hypoventilation in children and adolescents. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * Milia is a pin head size smooth. forehead are caused by retention of sebum in the opening of sebaceous gland. It is normal in infant before closure of cranial suture. cyst or fistula. * Erythema Toxicum usually appear 2nd or 3rd day of life cosist of erythematous macules with central multiracial wheals or vesicle scattered over body appear like a flea bite. * The shape of the head may altered by premature closure of one or more of the cranial suture called Craniosynostosis for eg Saggital suture hypostasis produce long narrow head. * HIV infection is the most common cause of and associated with generalized lymphadenopathy. * Port wine stain innervated by ophthalmic portion of trigeminal nerve V or on vascular bed of the meninges and or orbit result in seizures.26 months of age where as post fontanelle close by 2 month of age. * Craniotabes may be results from increase IC pressure as in hydrocephaly. cough. It will produce crack pot sound (Macewen’s sign). * Increased Intracranial (IC) Pressure is found in infection and neoplastic dis of CNS and with obstruction of CSF pathway. Although they may reappear in adulthood when skin is flush from anger or embarrassment. This unknown lesion disappear with in week. * Inspect scalp of dilated veins it suggest long standing Increased IC pressure. This may be found in some normal infant. along with the ant border of the sternomastoid muscle. hemi paresis. eyelid. Ant fontanelle is imp indicator of IC pressure. * The area where major suture intersect called Fontanelles are soft concavities (ant & post). * Auscultate head until late childhood. where as Miliaria Rubra consist of scattered vesicle on erythematous base usually on face and on trunk usually caused by sweat gland obstruction. * Chvostek’s sign :. This condition is known as Craniotabes it is due to osteoprosis. * Remanant of the three lower brachial cleft may be seen as a tag. Similar finding may be found in older children who are significantly anemic. or forehead is due to proliferation of capillaries bed called Capillary Hemangioma. * Caput Succedaneum is newborn’s scalp with edema & bruising over the occipitoparietal region caused by drawing the scalp into cervical os when Amniotic fluid sac ruptures. vs. * Macewen’s sign can be illicit in older infant and children who have Increase IC pressure which cause cranial suture is separation. * Asymmetry of the cranial vault ( Plagiocephaly ) occur when infant lies constantly on one side. * If you press temporoparital or paritooccipital too firmly you can feel underlying bone momentarily ( feel like ping pong ball ).
it is mostly due to infectious origin rather than malignancy. * Concern of malignancy raised when supra clavicular node is enlarged or fever lasting more than a week with lymphadenopathy and wt loss in last 6 month.3 weeks the firm fibrous mass is felt with in the muscle which usually disappear in 3 . * In hydrocephaly ant fontanelle is bulging and eye may be deviated downward creating Setting Sun Sign. * Child with perennial allergic rhinitis has open mouth (cannot breath with nose) and edema and discoloration of the lower Orbitopalpabral groove ( allergic shiners ). rotate your self in one side this cause the bay eyes to open since eye looks in the direction. * Cephal hematoma :.4 months. umbilical hernia. * If lymph node is < 2 cm in diameter and not so hard or fixed to skin or underlying tissue and the chest X . * Nuchal rigidity suggest CNS infection.ray finding are normal. sparse eye brows. It is imp to note that the babies with congenital hypothyroidism have no physical stigmata. Papillary reactivity is poor to light during first 4 . a bacterial infection or a stone. * Alternating convergent strabismus persisting beyond 6 month become unilateral sooner or divergent strabismus ( laterally deviated eyes) occurring at any time indicate occular muscle movement or diminish visual acuity. fissuring of mouth and lips (Rhagades) and tibial periostitis (saber shin) dental dysphasia ( Hutchinson’s teeth ). acute and chronic mastoiditis. and mental retardation. enlarge tongue. Rather child assume the tripod position. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * Fracture of the clavicle may occur in vertex or breech delivery. * Baby with fetal alcohol $ are at increase risk of growth deficiency. Intermittent alternating convergent strabismus (crossed eyes) is frequently seen during first 6 months. * Inspect the orifice of parotid duct ( Stenson’s duct ) for redness and swelling suggest infection of parotid gland. In infectious mononucleosis (EBV) lymphadenopathy is generalized and tender. mucocutaneous inflammation. * Congenital Syphilis occur after 16 week of gestation and effect virtually all fetal organ. It may be small or even entire bone results from difficult delivery. * When Meningeal irritation is present the child can not sit with legs fully extended. Accelerated linear growth with staring eyes and hyper metabolism often suggest hyperthyroidism. * Survivors of congenital syphilis show flaccid stigmata include bulging of the frontal bones. coronary artery vasculitis. * In iris brushfield’s spot appear as a white specks around the entire iris and may be present in normal infant. and atypical mycobacterium infection. this has led to screening all new born in USA for depress thyroxin or increase TSH. Acute tonsillitis may cause enlarged ant cervical lymphadenitis which is very swollen and tender. rash. fixing the head with your thumb. In leukemia.3 days due to rapid Ca++ deposition.not present at birth may appear with in 24 hr after birth. * Small subconjunctival or sclera hemorrahge in new born are common. * Facial nerve palsy ( VII ) can occur during difficult delivery or due to inflammation of middle ear branch of nerve due to ostitis media. * Kawasaki dis ( mucocutaneous lymph node $ ) :. 48 NOT FOR COMMERCIAL USE OR SALE . it cause head tilted toward and twisted away from the injury side. Swelling develop a raised body margin with in 2 . Dry and cold extremities. Cat scratch dis. conjunctivitis. carditis. cervical lymphadenopathy. Shows short palpebral fissure. TB. During first 10 days of life if eye remain fixed (doll eye test) . Fig Here (leg extended and hand supporting upper body posterior and head look little up. wide and flattened Philtrum ( a vertical groove in the mid line of upper lip and thin lips). Child often push the nose upward and backward ( allergic salute ) with hand to relieve nasal itch. * Cervical lymphadenopathy may occur due to viral respiratory infection in which enlarge lymph node is usually nontender.Prepared by Dr. child may look sad and forlorn with physical sing of abuse. non Hodgkin lymphoma. * Move the neck in all direction it is usually supple injury or bleed In sternomastoid muscle during birth process result in WRY Neck ( Torticollis ) . microcephaly. * The corneal reflex is normally present but is not tested for unless neurologic deficit is suspected. mottled skin. * Cretinism ( congenital hypothyroidism ) has coarse facial features. In 2 . hodgkins dis. * Occipital lymphadenopathy may occur with scalp lesion and usually presents with rubella. If no treated 25 % of babies will die before birth and 30 % shortly after birth. bleeding and tumor. * Parotid swelling and tenderness suggest mumps. * Swelling of parotid gland due to any reason usually extend above and below the mendible at the angle of jaw where as swelling due to cervical adenitis occur only below those land marks. associated features include cry. due to subperiosteal hemorrhage involving the outer table of one of the cranial bone. It disappear with in few week leaving a residual osteoms which disappears in year or two. you move you can inspect the eyes. low set hair line. my edema. oral mucosal lesion. and cannot perform chin to chest maneuver) * Hold the baby in your arms. and metastatic cancer may cause enlarge lymph node.5 months. usually recovers. * Battered child $ occur in those who physically abused. arms in legs and chin touching chest. * Nystagmus in one or many direction is common immediately after birth. * Grave dis ( thyrotoxicosis and hyperthyroidism ) occur in 2/1000 kids under age 10. * Observe the papillary reaction by covering each eye with your hand and than uncovering it. * Nystagmus which persist after few days may indicate blindness. * Other reason for cervical lymphadenopathy are Kawasaki dis. nasal bridge depression (saddle nose) a circumoral rash. hematomas swelling is associated with fracture that does not extend across the suture.characterize by fever. Unlike Caput Seccedaneum swelling. tinea captis) cause acute posterior cervical lymphadenopathy. and mental retardation. scalp lesion (Pediculosis. Setting Sun sign also seen briefly in some normal newborns. Acute otitis externa.
* Perinatal problem that the risk for hearing defect include birth wt < 1500gms. * Retina (fundus) reflect red or orange by setting Opthalmoscope at 0 diopters and viewing it by the distance of inches normally in infancy . * A small skin tab. * Acoustic Blink Reflex is a blinking in response to sudden sharp sound produce at the distance of about 12 inches from the ear during infancy. persistent posterior lenticular fibro vascular sheath. blinking and extension of head in response to light (Optical blink response) and blinking by moving quick movement of an object toward eye. At 5 . inflammation of conjunctiva and purulent discharge. if this movement is absent chronic middle ear infection or acute Otitis media is suspected. Vision improve by this if refractive error is present. opacities of cornea or ant chamber or lens interrupt the light pathway give partial red or complete dark reflex.Prepared by Dr. exchange transfusion. * Common causes of Amblyopia Exanopia are Strabismus and Anisometropia where as obstructive Ambylopia is secondary to cataract. * Normally the upper portion of the auricle (Pinna) join the scalp on or above extension of the line drawn across of inner and outer acanthi of eye.Chart is adequate. Failure to progress along these ages may indicate developmental delay or diminish or absent vision. * Rarely in new born super numerary teeth are found these are soft have no enamel and shed with in few days. retinopathy of prematurely may cause dark light reflex. CMV. At the age of 1 yr normal visual acuity is in the range of 20/200. Which cause one eye to become lazy and stop functioning to its full capacity. * Application of silver nitrate (prophylaxis for gonococcal conjunctivitis) may cause chemical conjunctivitis later it characterized by edema of the lid. ototoxic medication (aminoglycoside) . And after age of 3 yrs the sutures will separate sufficiently to prevent papilledema. * Distinguish a simple refractive error from an organic cause of diminish vision by asking the child to look through a pin hole punched in a card. * Opticokinetic testing is the most accurate method of testing visual acuity in early childhood ( sp < age 3) and children of more than 3 yrs of age Snellen e . Purulent material some time can be seen behind the tympanic mem. * Paralytic and non Paralytic Strabismus are due to ocular muscle weakness and unequal visual acuity in the two eyes. Child may preferred it on bad eye on asking. tympanic mem moves in and out. * Vision assessment of the new born is based on the presence of visual reflex . * Vision testing in other wise normal child is recommended at the beginning of age of 4. it may accompany Otitis. congenital infection.4 month eye and head will turn toward the sound. tortuous retinal vein. lens at +15 diopters and fundus at 0 diopters. * Small retinal hemorrhage are often present. * Moving Pinna can cause pain in Otitis Externa and Otitis Media but produce no discomfort in purulent Otitis media. At to week of age infant may jump in response of sudden noise. * To detect Ambylopia one eye must be covered by patch. cleft or pit just forward to the tragus represent the remnant of first brachial cleft. * During fundal exam cornea may be seen at + 20 diopters. anoxia. 20/30 L) may lead to Amblyopic. Between 3 . * At 2 .3 days of life. * Dacryocystitis and nasolacrimal duct obstruct with occular discharge and tearing may follow chemical conjunctivitis due to silver nitrate instillation.5 yrs 20/30 and at age 6 . IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * Brush field spot with apicanthal fold strongly suggest Down $. * Acute Mastoiditis may cause pain on pulling the auricle of ear. because fontanelle and open sutures absorb the Pressure.6 weeks coordination of eye movement occur. Therefore erythromycin is recommended rather than silver nitrate for ophthalmic neonatrum. * When white retinal reflex is encountered called Leukokoria if occur during or beyond infancy suspect retinal detachment. * Amblyopia is reduced vision in other wise normal eye and is caused by disuse. * The normal visual acuity at age 3 + 20/40 and at age 4 . * Retinal anomalies. corneal opacity or severe ptosis. * In infancy light reflex on the tympanic mem is diffuse and does not become cone shape for several month. subdural hematoma or subarachinoid hemorrhage should be suspected.4 weeks fixation of object occur. * In infant cataract. They should be removed however to prevent 49 NOT FOR COMMERCIAL USE OR SALE . hyperbilirubinemia ( 20mg/dL ) and meningitis. If they are extensive. * Perform retinal exam in all children specially before 2 month and after 6 month of age.papillary constriction to light.7 yrs 20/20 any difference in visual acuity b/w the two eye (eg 20/20 R. chorioretinitis . * The Acoustic blink reflex is difficult to illicit ding the first 2 . * When air is introduced or removed from normal ear canal. * Papilledema rarely develop in children even with markedly increase IC pressure. * Pigmentary changes occur in new born with congenital toxoplasmosis. * The nasal passage in new born may be Obstructed in Choanal Atresia and by displacement of the nasal cartilage during delivery. congested. Because disconjugate fixation of one of the two images suppressed optic cortex. * In early childhood Amblyopia Exanopia is more prevalent and offer best prognosis with early intervention. * Washing ear canal is contraindicated in perforated tympanic mem in the first instance. retinoblastoma. Where as small deformed or low set auricle may indicate associated congenital defect specially Renal Agenesis ( Potter’s $ ). Rubella infection. * Acute Otitis Media or Serous Otitis media may cause significant temporary hearing loss for several months. * Acute Otitis Media in children is characterized by tympanic mem that is red bulging and has a dull or absent light reflex . * Retinal hemorrhage is associated with IC bleeding are accompanied by dilated. Improvement is unlikely if Tx is initiated after 6 yr of life. severe anoxia. But not with organic occular dis.
due to polyps. headache. pink . * Maxillary sinus can be seen by inserting the transilluminator light in pts mouth against the hard palate on both side while room is dark. or profound mental retardation. hemangioma. * A shrill or high pitched cry in infancy may indicate IC pressure. Permanent teeth start erupt b/w the age of 6 . cough. 50 NOT FOR COMMERCIAL USE OR SALE . boggy nasal mucous mem with or without presence of gelatinous. very rapidly give massage to adenoidal and surrounding lymphoid tissue 3 . * Normal infant glow observed during transillumination of frontal sinus (frontal sinus is not well developed for the procedure until 10 yrs). sore throat.22 yrs of age.grape appearing polyps in the post nasal passage which is found in chronic allergic rhinitis. * Black child tend to have earlier eruption of permanent teeth than do white child.7 yrs & ends by 17 . * The presence of Koplik. peeled. * Asymmetry and corresponding voice change are often observed from varying period often tonsillectomy. * Malocclusion or misalignment of teeth due to thumb sucking are reversible if habit is substantially arrested by 6 . * A gray discoloration of tonsillar tissue it self due to necrosis suggest infectious mononucleosis. a shortened mandible (microganthia) eventually ensues however in chronic cases. palpation reveal the enlarge boggy adenoid tissue massage produce copious amount of blood. * Mendibular overgrowth occur rarely in the initial stage of juvenile rheumatoid arthritis. mucous and pus. * Donot examine the throat when acute epiglottitis is suspected because gag reflex could cause complete laryngeal obstruction and death. * When child clamp their teeth push the tongue depressor through the lip and along the buccal mucosa and b/w the gums behind the molar. affecting the temporomendibular joint.7 yrs. croupy cough. Such cries also occur in new born infant born to narcotic addicted mother. hoarseness. * Tape three tongue blade together with your left hand place your gloved right index finger into the mouth behind the soft palate. * Epstein’s pearls are pin head size or yellow rounded elevation that are located along the mid line of the hard palate near the post border these are caused by retained secretion and disappear with in few weeks or after month. drooling and difficulty in swallowing may have acute epiglottitis in such case epiglottis is swollen and cherry red. * To examine the maxillary protrusion (overbite) or mendibular protrusion (underbite) do not ask the child to show teeth because the upper and lower teeth are align reflexly when presented for examination. * Children with markedly enlarge adenoid will mouth breath and snore and may have recurrent bouts of otitis media and sinusitis. * Maxillary over growth is associated with chronic hemolytic anemia. * Absence of cry suggest serious illness. Adenoid palpation should be carried out when there is Hx of recurrent fever. Normally the lower teeth with in the arch of upper teeth. This produce a gag reflex with complete view of pharynx. Low or diminish glow suggest sinusitis. * Normal shedding of primary teeth begin at age 6. At the age of 10 months most children have two upper and two lower teeth (central incision). or Hypothyroidism. Note absence of asymmetrical movement of soft palate in response to gaging and phonation which indicate paralysis and weakness. * Irregular white specks or patches on tooth enamel result from exposure to Fluoride where as grayish mottling of enamel results from tetracycline Tx of child under age 8 years. with generalized maculo popular rash with in 24 hr is confirmatory. * Petechiae are commonly found on soft palate after birth. If transilluminate is absent or diminished sinusitis is present. vocal cord paralysis. * In the case of chronic adenoiditis and adenoidal abscess. * Malocclusion is most often is due to hereditary predisposition but may be due to premature loss of primary teeth. Sinus tenderness and Hx suggest the Dx. * Smooth tongue is found in avitaminosis where as strawberry or raspberry tongue are seen at specific age of scarlet fever.Prepared by Dr. From that point on 4 teeth are added every 4 months. * Hoarse cry should make one suspect Hypocalcemia. or delay in the development of the cartilage in tracheal ring (Tracheomalacia).s spot on buccal mucosa opposite the 1st and 2nd molar in a child with fever coryza and cough suggest measles ( Rubeola ). A peritonsillar abscess is almost certainly present. * Child with high fever. ( Koplik spot appear as a grain of salt on individual erythmatous bases ). Rather ask the child bite down than part the lips and observe the true bite. * Pale. * A continuous expiratory or inspiratory stridor is caused by upper airway obstruction. * Little saliva produce during first three month of life the presence of large amount of saliva may be a sign of esophageal atresia since saliva cannot be swallowed. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE their aspiration into lower respiratory tract. Tetany. small larynx (infantile laryngeal stridor). * Thrush in infancy is difficult to distinguish from milk curd which wipes away easily where as thrush cannot. * The white exudates on tonsil suggest streptococcal tonsillitis particularly accompanied by a beefy red uvula and palate patechiae where as a tick gray adherent exudates on tonsillar tissue suggest Diptheritic tonsillitis. * The Adenoids also called Pharyngeal tonsil consist of hyperplastic lympoid tissue located on both side of nasopharynx medially to the Eustachian tube orifice. it suggest Chronic Adenoiditis or Adenoidal abscess. * When a tonsil is red and protrude forward and medially.4 time this will make you palpate posterior nasopharynx (this procedure produce vomit). * Tonsils usually have deep crypt on their surface which often have white concretion or food particles protruding from their depth this does no indicate dis.
and Eisenmenger $. * The murmur of coarctation of aorta adult type is also heard best at 2nd or 3rd left interspace. * Sinus arrythmia (heart rate faster on inspiration and slower on expiration) is almost always present in infancy & early childhood. * Pectus Excavatum may manifest in early infancy by marked mid line sternal retraction with normal inspiration. They are of no significance. * An inspiratory wheeze called stridor indicate narrowing high in tracheobronchial tree vs. Tricuspid atresia. The murmur is systolic and less than grade 2 in intensity. * New born infants normal breathing is 30 . In addition palpable liver pulsation may be present with Tricuspid Atresia and pure Pulmonic stenosis.Prepared by Dr. * 50% of children develop innocent murmur at some time during childhood but examiner must therefore distinguished b/w innocent or organic murmur. This alternating breathing pattern may have been observed in 30 . Completition of growth usually correct these inequalities. * Because of smallness of thoracic cage in infant and the ease of sound transmission. Splitting of S2 at the apex is found in 25 .3 which generate deep breathing. * Diminution of femoral pulse as compare to radial pulse or their absence may be the only finding to suggest forestation of aorta in infancy or early childhood. * Period of Apnea lasting longer than 20 secs and accompanied by bradycardia may indicate cardiopulmonary. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * Children with hyper nasal speech or no voice may have sub mucosal cleft palate. The murmur are located at the base of the heart. * In infancy breath sounds are longer than in adult because stethoscope is closer to the origin of sound.2. * Peripheral edema in children is more likely to be periorbital and cause by renal failure. vs. * Hemic Murmur are caused by blood flow through the heart. * Congenital heart dis heard best at the base of the heart. If not ask child to blow out the breath. * Normally S1 is Louder than S2 at the apex. effusion. * S2 is louder than S1 in plutonic area but when S2 is equal or greater than S1 at apex pulmonary HTN should be suspected. * Breast development in girl may begin normally as early as 8 yrs of age.5. * Super numerary nipple occasionally found on thorax and abdomen along vertical line. This occur when body require more oxygen than usual or when there is anemia. Asymmetrical growth of preadolescent is common. They are not well transmitted. * A venous hum with both systolic and diastolic component is common in childhood. * During first 48 hr of life the heart murmur is due to patent ductus arteriosus and foramen ovale. CNS dis or high risk of sudden infant death $. where as expiratory wheeze suggest narrowing lower down in the lung field. It disappear spontaneously after closure of ductus arteriosus and foramen ovale. * The percussion is normally hyper resonant and the in hyper resonance has the same significant as dullness in adult may be due to consolidation of lung and intrathoracic mass or pleural fluid. Pectus Carinatum (chicken breast) do not ordinarily become evident until early childhood. * Breathing in new born normally is slow and shallow than rapid and deep. In atrial septal defect a grade 1 . These murmur has no distinguishing characteristics and may be present in infancy. It also heard best at 2nd and 3rd left interspace. Alternating with Periodic Breathing is during which respiratory rate slowed markedly and may even cease (Apnea) 3 or more time for 3 seconds. * The breast of new born in both sexes often enlarged and engorged a white liquid some time called witch’s milk (due to maternal estrogen) last week or two.40/min. * Murmur of grade 3 or high are organic murmur indicate heart dis eg Acute RF or congenital heart dis. soft during systole and accompanied by tachycardia. are associated with Systolic murmur of grade 3 .3 coarse systolic murmur is heard at 2nd and 3rd left interspace. * In infant breath sound may be mistaken for murmur occlude the nares momentarily to clarify this issue. Premature ventricular contraction are quite common too. Transposition of great vessel. 51 NOT FOR COMMERCIAL USE OR SALE . may or may not be accompanied by thrill. It is louder and transmitted to the back medial to the scapula it may show palpable thrill at suprasternal notch. The short Apnic period is not accompanied by bradycardia. * Generate tactile fremitus by feeling the chest wall ask child to say 99 or 1. * The apical impulse (PMI) is often visible at the level of 4th interspace untill age 7 yrs. where as murmur of ventricular septal defect is more coarse and accompanied by thrill and is widely distributed. * Innocent murmur are less than grade 3 in intensity and is of short duration and low pitch (musical groaning quality) . consolidation of lung. * Tetralogy of Fallot. vs.33 % of infant and children but is of no significance. breath sound are rarely absent entirely even with atelectasis. * Extension or other movement of head with inspiration indicate use of accessory muscle of respiration and usually accompanied severe respiratory dis. pneumothorax. * Carotid bruit and pulmonary branch stenosis are other commonly heard murmur disappear after first few month as pulmonary branch arteries enlarge. emphysema. * When breathing is predominantly thoracic suspect intra abdominal or intra thoracic pathology that restrict the use of diaphragm Where as in abdominal breathing suggest pulmonary dis. It heard best with the bell of the stethoscope with pt supine. * Palpable and audible wheeze frequently occur in infant because of small lumen of tracheobronchial tree and is easily narrowed by slightly swelling of mucous mem or by amount of mucous. * Feel for tactile fremitus in infant by placing the hand on chest when baby cries than percuss the chest directly. It also present BP in lower and BP in upper extremities.95 % of premature babies and less often in full term infant.
* Congenital hart dis with no cyanosis are due to small Septal defect. * Many Umbilical hernia disappear by one year of age and almost all by age 4 . dehydration and shock may ensues with in first two week of life. locate testes. Ventral hernia and Diastesis recti all are easily detected by infants cry. A venous hum is the sign of portal HTN * Marked Abdominal distention with tenderness may indicate acute surgical abdomen. Mild Pulmonic stenosis. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * Murmur due to Rheumatoid heart dis are same as adult. Where as when appendix is lying retrocecally over the Psoas or Obturator Muscle.1 cm in male and 4. * Locate the urethral orifice and the shaft of the penis observe any abnormality like Hypospadius. * Bilateral Cryptoorchidism strongly suggest Adrenogenital $. This will reveal the pyloric mass roughly 2 cm in diameter. * In Hirshsprung Dis (congenital mega colon) a mid line supra pubic mass representing a feces filled recto sigmoid is found. * 20 yrs ---.4.3 cm in female. This maneuver can illicit pain in RLQ in Acute Appendicitis when the appendix is lying anteriorly.2. ( 1. Epispadius etc. * The pathological enlarge liver is usually palpate at or more than 2 cm below the coastal margin and has round firm edge. Psoas or Obturator signs are often present. * Bladder in infant often normally percuss at the level of umbilicus.Prepared by Dr.0 cm in male and 4. * Anew born with concave abdomen should immediately be investigated for diaphragmatic hernia with displacement of some the abdominal organ into the thoracic cavity. 52 NOT FOR COMMERCIAL USE OR SALE . * 6 yrs ---. Subendocardial Fibroelastosis. * The navel often fail to heal and glaucomatous tissue form at its base. * Metallic Tinkling every 10 .0 cm in female. * Palpate the abdomen in infancy is easy. Where as pulsation of the enlarge right ventricle may also be transmitted to the diaphragm and be visible in epigastria. The direction of venous flow in portal HTN is down ward in vein below umbilicus. * Ask the child to sit up from the supine position while you push down against the forehead with your hand. * Check no of vessel in umbilical cord normally there is two thick walled arteries and one thin walled vein. * The cutaneous portion of the umbilicus (umbilicus Cutis) retract to become flush with in abdominal wall where as gelatinous substance the Amniotic portion (Umbilicus Amnioticus) dries up with in one week and fall of with in two weeks.8 cm in female. * In 3% of male neonates one or both cannot felt in the scrotum by age 1 yr 2/3 of these testes will descended into the scrotum. the peristalsis wave goes across upper abdomen left right and than become increasingly enlarge and frequent as the feeding progress. It suggest generalized peritonitis.2 cm below the coastal margin is normal ). * You can palpate the spleen b/w the thumb and your forefinger of right hand . * When child is too ticklish place the child hand under your hand to increase the relaxation.5 cm in male and 5. * Dilated abdominal vein may indicate portal vein obstruction.1 cm in female. Patent Ductus Arteriosus. and tachypnea. If there is Pyloric stenosis. * Tenderness and spasm of abdominal musculature in childhood are usually diffuse when serious pathology occur in abdomen. They present with cardiac enlargement. place the Diaphragm of stethoscope just above the right coastal margin at mid clavicular line with your finger nail slightly scratch the skin of the abdomen along the mid clavicular line. * Avoid spasm and rigidity in palpating abdomen of crying infant giving bottle or pacifier.6. If there is only one artery it suggest variety of congenital anomalies. * Flex the knee and hip also relax the abdomen.7 cm in male and 6. * The lower border of the liver can be determined with the Scratch Test. Glycogen Storage.6 cm in female.7. Feed the infant a bottle of sugar water or milk and observe the abdomen closely. * Pulsation in epigastria cause by aorta can be seen normally. tachycardia. Relax the infant by holding the leg flexed at knee than palpate abdomen by other hand.8 cm in male and 3. at this point palpate deeply in the right upper quadrant with your extended middle finger. Inevitably baby will vomit with projectile force. if it found in the inguinal canal use steady gentle pressure to put them down into the scrotum. Coarctation of Aorta. * In Pyloric stenosis unclothe infant in supine position and stand at foot side of the table.30 sec is normally heard in abdominal auscultation. * Palpate the scrotal sac and inguinal canal.5 yrs. * Infant are prone to Umbilical hernia. * Abdominal reflexes are usually absent until after one yr of life. in which infant sex is female and Hyponatremia. * Heart dis in infancy with out murmur are called Anomelous Origin of left coronary artery. Vein is located at 12 o clock position.5. * An in pitch or frequency of bowel sound or a marked diminuition indicate intestinal obstruction or ileus respectively. * 3 yrs ---. ** Normal Liver Span By Percussion at Different Age :* 1 yr ---. * 12 yrs ---. moving from below the umbilicus toward the coastal margin when your scratching finger reaches the liver edge you will hear the scratching sound as it passes through the liver to your stethoscope.
This maneuver is known as Ortolani Test.10 yr. * The longitudinal arch in infancy is obscured by adipose tissue giving foot a flat appearance. If it persist Hydrocolops may occur and than Hematocolops may occur in adolescent girls ( both conditions are rare ) . * Detect a unstable hip (non dislocated hip but potentially dislocate able) by placing your thumb medially over the lesser Trochanter and your index finger laterally over the greater trichinae. Most Hydrocele detect in infancy reabsorbed by 18 month of age. * Foreign body are often inserted by child into vagina and cause irritation and infection which lead to purulent vaginal discharge. Ask child to push down to relax sphincter. Flex the leg to right angle at the hip and knee with baby supine. abduct both hip simultaneously until the lateral aspect of each knee touches the examining table. pubic and axillary hair.Adductus Deformity. the clunk or click of the ortolanic sign is less obtainable. * For rectal examination assure the child with knee. press your thumb backward and out ward feel the movement of the head of femur laterally out of acetabulum (normally no 53 NOT FOR COMMERCIAL USE OR SALE . * Fusion of labia minora is seen occasionally in girl under 4 yr of age. hirsutism. It may be partial or complete. development abnormality. if ambiguous genetalia is present it is essential that the sex of the child should be determined before sex assignment is made. somatic growth and muscle mass. * When fore foot is adducted and the foot is inverted suggest Talipes varus. This finding is know as Ortalanic Sign. * When fore foot adduction and inversion with planter flexion of entire foot occur suggest Talipes Equinovarus (Club foot).Prepared by Dr. (use index finger for rectal examination regardless of the size of your finger slight bleeding may occur on its removal). bacterial infection. the Abduction of the flexed leg becomes a significant sign in congenital dislocation of the hip. irritant vulvovaginitis. * Cryptoorchidism or undecided testicals may persist uni or bilaterally with testes remain in abdomen or with in inguinal canal. * When the fore foot is twisted inward on its longitudinal axis (inverted) it suggest Metatarsus Varus. It is characterize by pronation of entire foot. * Perianal skin tab in childhood are of no significance. Hydrocele may be differentiated easily with hernia in that. The labia will also separate if the estrogen containing crème is applied to labia once or twice daily for several days. it is common and spontaneous correction occur with in 2 yrs. A thin mem that join the labial edges is easily lysed with cotton swab or a probe. labia majora and minora are prominent due to the effect of maternal estrogen. due to an excess circulating androgen of adrenal or testicular origin due to tumor of an organ or pituitary gland. testicular size. * Enlargement of penis may occur in precocious puberty. * Bimanual recto abdominal palpation in female reveal a small mid line mass which is cervix any other mass than that should be consider abnormal. * Hold the feet together and flex the knee and hip on the abdomen with one hand and with other hand observe the rectum. * When congenitally dislocated hip is present you will see and feel the Clunk or click at the femoral head. this prominence decrease in 1 or 2 month. * In new born female the mon pubis. eversion of the fore foot and pain on walking.Knee Pattern ( Genu Valgum) persist from 2 yrs until 6 . In young boys prostate gland is not palpable. * Use child’s own hand to open the genitalia for more comfort for her and your self. Ask child to breath rapid to mouth like puppy. which in this condition lies posterior to the acetabulum and enters the acetabulum at same point in the 90 degree abduction arc. * In fore foot in infant adducted at metatarsal . place your index finger over the greater trochanter of each femur and your thumb over the lesser trichinae . * The absence of central Hymen orifice (imperforate hymen) is rare and of no clinical significance. * Spastic flat foot is very rare in children and not exist during infancy. a chromosomal defect. or STD. Other signs are Virilization. * Enlargement of the Clitoris and posterior fusion of the labia majora are the sign of ambiguous genitalia due to inborn error of testosterone biosynthesis. don’t misdiagnosed as being flat footed. * Physiologic Leucorrhea (a thin whitish vaginal discharge) is common in adolescents where as purulent discharge may be due to foreign body. * Overcome the Cremasteric reflex by having the child sit crossed legged on table exanimate testicle in this position.tarsal line is called Metatarsus . IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE * Generalized scrotal edema may be present for several days due to the effect of maternal estrogen and of breech delivery when bruising is also present. * The examination of inguinal hernia is same as in adult. * Bowlegged Growth Pattern (Genu Varum) usually disappear at 18 month of age. * Testes may move upward when medial aspect of each thigh is scratched lightly ( Cremasteric Reflex ). deepening voice usually accompany the penile enlargment. Where as Knock . * Examination of vagina and cervix is indicated when sexual abuse is suspected. former Transilluminate and are not reducible. * Beyond the new born period as the muscle surrounding the hip increases strength. Some time there is bloody vaginal discharge during first week which may be replaced by serosanguineous discharge for several more week. * Examine the female genitalia in supine frog leg position. * Hip of all infant should be examine for dislocation. * The appearance of pubic hair or breast enlargement before 8 yrs of age in girls may be due to precocious puberty and must be thoroughly evaluated. teratogenic agent. * Hydrocele overlying the testes and spermatic cord are common in infancy and often associated with potential inguinal hernia. hip flexed and leg abducted. * Examine the female genitalia by separating the labia majora at their mid point with thumb of each hand apply traction laterally and posteriorly for full view.
If movement is present it constitutes Barlow’s sign. From behind watch for asymmetry of scapula. orientation to visual and auditory stimuli and habituation of various stimuli. * Acoustic Blink reflex (Cochleopalpabral) present at birth both eyes blink in response to sharp loud noise. * With baby supine raise the lower leg stroke the perianal area with a paper clip and observe the external anal sphincter contraction. * Test for pain sensation by flicking he infant palm or sole with your finger. * One can also illicit ankle clonus by pressing your thumb over the ball of the infant foot and abruptly dorsiflexing the foot. & flaccidity. Note that baby normally clench their hand during the first month of life. In 12th CN paresis the tongue tip deviate toward the effected site. * Postural indicator of severe Intracranial disease. Absent reflex suggest generalized or CNS dis. * Infantile Automatism are reflex phenomenon have prognostic value for CNS integrity. * Assess mental status by observing the ease of transition b/w the state of alertness and drowsiness. plasticity. * Babinski Response to planter extension stimulation can be illicit in some normal infant until 2 yrs of age. * Test for severe hip dis with its associated weakness of gluteous medius muscle by observing the child from behind as the wt is shifted from one leg to another pelvis tilt toward the affected hip when wt is borne on affected side (+ Trendelenburg Sign). * Trunk Incurvation (Galants) Reflex disappear at 2 months. pigmented spot. Pinch the nostril of the infant this produce reflex opening of mouth and raising of the tip of tongue. persistence of the clench hand beyond 2 months suggest CNS damage particularly when finger overlap the thumb. and extension of arm and legs (Opisthotones) Indicate severe meningeal or brain stem irritation seen in IC infection or hemorrhage. this sign is not diagnostic of congenital dislocated hip. * A sinus tract provide potential entry to organism into spinal cord cause meningitis. ease of consolability. It is a eye lid close in response of bright light absence of reflex may indicate Blindness. * Palmar Grasp Reflex disappear at three to four month this reflex enhance by offering a baby bottle since suckling facilitate grasping. the extremities withdraw reflex with pain but baby’s facial expression or cry will not change. * Tricep reflex is usually not present until after 6 month of age where as rapid rhythmic planter flexion of foot in response to ankle reflex (ankle clonus) is common in new born as many as 8 . There exaggerated presence or absence has very little diagnostic significance. skin. When the contraction are continuous (sustained ankle clonus) severe CNS dis should be suspected. * Absence of withdrawal when a painful stimuli is applied to an extremity indicate anesthesia or paralysis. tumor or injury. * 12th CN is easily tested.10 such contraction occur normally (unsustained ankle clonus). or deep pit that might over lie the external opening of the sinus tract that extend to spinal canal. * Spinabifida Occulta (a vertebral defect) may be associated with underlying defect of spinal cord (Diastomatomyelia) that can cause mal function of the bladder and rectum also weakness and paralysis of lower extremities. How ever planter flexion response is illicit in 90% of normal infants. marked extension of head. * With baby head position in the mid line and the hand held against the ant chest stroke with your finger the perioral skin at the corner of the baby’s mouth and on upper and lower lip in response mouth will open and turn to the stimulated side. Absence may indicate noise or impaired or absent hearing.Prepared by Dr. Absence of reflex suggest loss of innervation due to spinal cord lesion at the level of lower sacral segment (or higher) Such as spin bifida. * The absence of infantile automatism (reflex activity) in neonate or persistence of some beyond there expected time of disappearance may indicate severe CNS dysfunction. * Rooting Reflex disappear at 3 . stiffness of neck. hairy patches. * The technique for eliciting these reflexes is similar to that in adult except you used semi flexed index finger can substitute for neurologic hammer. Hold the baby horizontally and prone in one of your hands. include persistent asymmetries. * Abdominal reflex is absent in new born but appear in 6 months of life. Stimulate one side of the baby’s back approx 1 cm from the midline along the paravertebral line extending from shoulder to buttock. * Ask child to bend forward when you suspect scoliosis. rib cage. * Because the corticospinal tract is not fully developed in infant. but it indicate the need to observe baby for this possibility. observe for withdrawal or arousal and change in facial expression( do not use pin to test pain sensation). * Use Denver Developmental screening Test for gross and fine motor coordination testing. and hipmark spinous process with ink and look for curve. * Test for motor function by putting each major joint through its range of motion to determine muscle tone. predominant extension of extremities and constant turning of head to one side. the spinal reflex mechanism (deep tendon reflex and planter response) during infancy are variable. Persistence of Grasp reflex beyond 4 months suggest cerebral Dysfunction. * Palpate spine carefully specially lumbosacral area. * Blinking (Dazzle) reflex present at birth disappear after 1st year. * CN are tested in infancy as in adult. If a facial expression or a cry changes in the absence of withdrawal suggest paralysis. * In childhood the thoracic convexity is and lumbar concavity is . This produce curving of the trunk toward the stimulated 54 NOT FOR COMMERCIAL USE OR SALE . IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE movement is felt). Lordosis is common and rarely cause symptom. Than with your index finger press greater trichinae forward and inward feel for sudden movement (normally there is non).4 months may be present longer during sleep. Where as with spinal cord lesion or dis.
Fixed extension and adduction of the leg (scissoring) indicate spastic paraplegia.Hold the baby in supine position. advanced ant horn cell dis or severe myopathy. diplegia. Reflexes and muscle tone is normal.(it may be useful to collect urine specimen from neonate). at arms length facing you and turn baby in one direction and than other. Now allow the dorsal surface of one foot to touch the under surface of table (take care not to planter flexed the foot). It can be illicit by turning the head of baby at supine position with holding a jaw over baby’s shoulder. Which push up on the thigh until the upright position is gained. the leg are than flexed at knees while the arm are extended to the side of the body to push off from the floor in smooth motion. place the thumb of your other hand on baby’s sacrum and move it firmly toward the head and spine. bringing the legs to flex position under the trunk the leg are extended with the help of hand and forearm. injury to the brachial plexus. * Combination of finding in infancy with Hx of hemolytic anemia or hemolytic dis or neonatal jaundice are presence of the Setting of Sun Sign. * Asymmetric arm movement in walking and running may indicate hemi paresis may show unequal wear of sole of the shoes. IRFAN MIR ONLY FOR EDUCATIONAL PURPOSE side with shoulder and pelvic moving in that direction. Flexing of knee. when this fencing response occur at any age indicating major CNS damage. * In certain form of muscular dystrophy with pelvic girdle weakness. * Perez Reflex and Moro Reflex (startle Reflex) :. Other way is to produce loud noise (eg strike the table with palm of your hand). * Bilateral cerebral injury produce hypotonic with normal or brisk deep tendon reflex. lower spinal cord injury. This fencing posture response does not occur normally when each time this maneuver is performed. cry and empty of bladder are the usual responses. * Rotation Reflex present at birth hold the baby under the axillae. Opisthotones. Hold the baby upright from behind by placing your hand under the baby arms with your thumb supporting the back of the head. Strabismus may be detected early in this maneuver. fracture of the clavicle or humerus. * Moro Reflex (Startle Reflex) :.Suspend the baby prone in one of your hand. These response are absent when paresis is present and in babies born by breech delivery. Repeat this maneuver on other side too. * persistence of Moro reflex beyond 4 month may indicate neurologic dis and the persistence of response beyond 6 month is almost exclusively suggest neurologic dis. the head turn the direction you turn baby. from a supine position. It produces a response in which arm briskly abduct and extend with hand open and finger extended. Absence of the reflex suggest transverse spinal cord injury or lesion. * Placing response best illicit after first 4 days disappearing time is variable. unilaterally absent or diminish movement of the extremity along with abnormal posturing is seen. than arm return forward over the body and baby cries. and absence of Moro Reflex suggest Kernicterus. rising from supine to standing position is different (Gower’s Sign) because weakness of the hip extensor muscle. * Tonic Neck Reflex may be present at birth but usually appear at 2 months of age and disappears at 6 months. The head and eye do not move if there is vestibular dysfunction. Followed by hypotonic early in infancy and persistent clenched fist coupled with scissoring after the first few month. Absence of either reflex during first 3 months of life indicates severe cerebral insult. congenital dislocation of hip may produce absence of response in one or both legs. The arm and leg on the side to which the head is turned extend while opposite arm and leg flexed. injury to upper cervical cord. delay in reaching motor milestone and persistence of the tonic neck reflex. the child roll over to prone position and pushes of the floor with the arms. The sudden lower the entire body about two feet and stop abruptly.They are present at birth and disappear by 3rd month. It may also caused by orthopedic condition. * Vertical Suspension Positioning disappears after 4 month. If you restrain the head with your thumb the baby eyes will turn in the direction you turn baby. * Perez Reflex :. supporting the head back and leg. * Observe the children rising from the floor . Note baby respond by flexing the hip and knee and placing the stimulated foot on the table the opposite leg step forward and a series of alternate stepping movement occur as you move the baby forward. * The Spastic Diplegia Produce variable dystonic spasm. An asymmetrical response in upper exteremities suggest hemi paresis. It illicit while you support the baby upright with your hand under the axila the head is normally maintained in the midline and the leg are flexed at the hip and knee. Normally sitting position is first assumed.Prepared by Dr. ---------------------------------------------------------------------------------------------------- 55 NOT FOR COMMERCIAL USE OR SALE . * In congenital Hemiplegia.
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