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BEDSIDE
TECHNIQUES
Methods of Clinical Examination
Fourth Edition
A book for medical students and doctors
Muhammad Inayatullah
FRCP (Lond)
Professor of Medicine
Nishtar Medical College, Multan
Shabbir Ahmed Nasir

FRCPE
Principal
Multan Medical and Dental College, Multan
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©Paramount Books (Pvt) Ltd.
Bedside Techniques
Methods of clinical Examination
by
Muhammad Inayatullah
Shabbir Ahmed Nasir
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system,
or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or
otherwise, without the prior permission of the Copyright holders.
This book is sold subject to the condition that it shall not, by way of trade or otherwise, be lent, resold,
hired out or otherwise circulated without the publisher’s prior consent in any form of binding or cover
other than that in which it is published and without a similar condition including this condition being
imposed on the subsequent purchaser.
Medical knowledge is constantly changing. As new information become available, changes in
treatment, procedures, equipment and the use of drugs become necessary. The editors, contributors
and the publishers have, as far as it is possible, taken care to ensure that the information given in this
text is accurate and up-to-date. However, readers are strongly advised to confirm that the information,
especially with regard to drug usage, complies with the latest legislation and standards of practice.
Copyright ©2013
All Rights Reserved

Fourth Edition........... 2013
Reprint........................2014
Reprint........................2015
.Paramount Books (Pvt.) Ltd.

152/0, Block-2, P.E.C.H.S., Karachi-75400. Tel: 34310030
Fax: 34553772, E-mail: paramount(a)cyber.net.pk
Website: www.paramountbooks.com.pk
ISBN: 978-969-494-920-8
Printed in Pakistan
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old,
Dver
iing
>rs
his
ion,
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Dedicated to our teachers
PDFelement
CONTENTS
Introduction................................ 1 Summary of Examination... 80

1. History Taking and Physical Peripheral Arterial System.........81
Examination................................2 Peripheral Venous System.......... 82
Routine Questions
Writing Out Routine
About Cardinal Symptoms......... 6
Examination............................ 82
Writing Out the Examination.....14
3. Respiratory System.................. 83
General Physical Examination...14
Anatomical Considerations......... 83
Summary of General
Surface Anatomy....................83
Physical Examination.......... 29
Symptoms........................................83
Writing Out Routine
Examination........................... 32 Cough........................................ 83
2. Cardiovascular System.............. 33 Sputum......................................84
Symptoms........................................ 33 Hemoptysis.............................. 84
Dyspnea.................................... 33 Chest Pain................................ 84
Chest Pain.................................34 Dyspnea.................................... 85
Palpitation................................ 34 Wheeze...................................... 85
Examination................................... 34 Stridor........................................ 85
Examination of Pulse.............34 Symptoms of Upper
Measurement of Blood Respiratory Tract Disease.... 85
Pressure.....................................43 History...................................... 85
Neck Veins............................... 45 Examination................................... 86
Examination of Precordium........ 49 Position of the Patient............86
Inspection.................................49 Inspection................................. 87
Palpation...................................53 Palpation................................... 90
Percussion.................................53 Percussion................................. 93
Auscultation............................ 53 Auscultation............................ 96
Signs of Rheumatic and Summary of Examination... 103
Congenital Heart Diseases.... 65
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Writing Out Routine 6. Pediatric Clinical Examination.. 216

Examination............................104
History............................................. 216
4. Alimentary and Genito
Presenting Complaints/Chief
urinary System...........................107
Complaints............................... 216
Symptoms...................................... *.‘107
History of Present Illness...... 217
Alimentary System................ 107
History of Birth....................... 220
Genitourinary System........... 110
Feeding History....................... 220
Examination................................... Ill
Immunization..........................220
Oral Cavity............................... Ill
Developmental History......... 220
Examination of Abdomen.... 113
Past History............................. 221
Writing Out Routine
Family History........................ 221
Examination......................... ....133
Social History........................... 221
5. Nervous System.......................... 135
Personal History......................221
History............................................. 135
Environmental History......... 221
Symptoms.................................135
Examination................................... 221
Applied Anatomy and
Physiology.......................... 136 General Physical
Examination............................ 223
Examination................................... 143
Cardiovascular System.......... 229
Higher Mental Functions..... 143
Respiratory System.................231
Speech........................................145
Abdomen................................. 233
Cranial Nerves......................... 152
Nervous System...................... 235
Motor System........................... 177
Neonatal Examination........... 238
Localization of Motor
Lesion........................................ 197 Developmental
Examination............................ 241
Sensory System........................201
The Acutely Ill Infant........... 242
Localization of Sensory
Lesion........................................ 206 7. How To Present A Case? ..j........ 243
Miscellaneous Tests............... 208 History NO. 1: Dyspnea........... 243
Writing Out Routine History NO. 2: Pain Epigastrium... 245
Examination............................ 214
History NO. 3: Fever................ 246
Lumbar Puncture................... 214
8. INDEX ........................................... 248
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FOREWORD
I have great pleasure in writing a foreword for BEDSIDE TECHNIQUES: Methods
of Clinical Examination. There is no dearth of books on clinical examination but what
distinguishes this book is the stress on explaining the relevant symptoms and the correct
methods of eliciting physical signs; this is the real justification for this book.
All the chapters in this book are clearly written without going into unnecessary details and
deserve close study by undergraduate students, postgraduate students and medical practitioners.
Two chapters, on cardiology and neurology, deserve special praise.
Cardiology is a difficult subject to grasp but the method of clinical examination has been
clearly explained by the authors. Detailed description of important cardiac conditions has been
given alongwith the approach to history and physical examination. It must be remembered,
however, that physical signs should be interpreted with the help of relevant investigations like
chest x-ray, ECG and where possible, echocardiography.
The chapter on clinical neurology deserves special praise for its simplicity and the confidence
which it gives to the undergraduate student not only to carry out clinical examination but also
to arrive at a diagnosis. The subject of neurology has been traditionally painted as something
very difficult to grasp and only meant for specialists; this myth has been broken in this book.
The study of clinical neurology requires a basic understanding of anatomy and physiology,
more so than any other specialty of medicine, and these facets have been clearly explained
in this book. After studying the chapter on neurology, I am sure that both undergraduate and
postgraduate student will find that clinical neurology is not such a bug bear as traditionally
described. The fact of the matter is that this is one speciality which most commonly allows
the correct diagnosis to be made on the basis of clinical examination alone. One of my great
teachers used to say that the knowledge of neurology distinguishes between a good physician
and a good quack.
I should like to remind the student of an old dictum ‘clinical medicine can be only learnt at
the bedside and not by books’ but it is equally important that books be consulted to really
understand medicine. I hope the students make full use of the knowledge contained in this
book and practices the routines as described to arrive at the correct diagnosis.
I strongly recommend this book to anybody who is interested in clinical medicine. I feel that
this is a significant addition and a breakthrough in the study of clinical methods written by
local authors. I wish and pray for the unqualified success of this book.
Dr. Abdul Rauf Ahmad (late)

MD; FRCP (EDIN & LOND); FCPS (PAK)
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PREFACE TO THE FIRST EDITION

The question most frequently asked of us was why we ever wanted to write about clinical
methods when there were so many other books already in the market. This is probably the
right place to answer this question. As teachers and examiners in Medicine, we had been aware
for a long time of the unenviable position* of the brilliant medical student who has learnt the
method of examination, the differential diagnosis, the significance of probabilities in their
proper order, and the preferred investigations from foreign books, only to face the wrath of
the examiner who is more realistically aware of the different local disease prevalence and
diagnostic medical facilities. We have been aware too of the plight of the average medical
student for whom English remains a relatively difficult foreign language whose nuances are
completely lost upon him and who needs to struggle not only with already difficult concepts
of clinical Medicine but also has to decipher (subtle but significant) shades of meaning which
are obvious only to the native speaker of the English language; and a problem common to all
students - the sequence of narration of information given in books is very different from what
is taught and expected of them.
When faced with these problems the students resort to ‘notes’ prepared by other students and
full of conceptual and factual errors, or booklets which are little better. They learn with great
diligence all that is contained within, the truth, half truth and the gross untruth. They can go
through life without ever realizing the myths and fallacies they have imbibed. We thought it
was time to address this problem, prompting us to write this book.
We have tried to make this book easily readable for our students. We have tried to do away
with concepts and material not relevant to local conditions and to put things in the proper
perspective, keeping in mind the constraints operating here. But we have also tried to retain
all material that the aspiring postgraduate might need. We have included a large number of
line drawings to illustrate concepts; what they lack in artistic quality we hope they make up in
content and clarity, and should make learning relatively easier.
The initial interview with the patient and the results (history taking and presentation) is usually
a particularly weak skill with our students and we have attempted to address this problem.
We already have a publication which lists relevant questions to be asked from the patient
according to the main presenting feature and a synopsis of differential diagnosis in tabulated
forms (Aids to Diagnostic Process); this would be an excellent companion book to strengthen
what we call “The Art of Relevance”.
There is a section on Pediatrics, not found in many current books. We think this is very timely
considering that Pediatrics will soon be a separate subject in the final professional MBBS
examination.
Departing from the usual format, we do not have sections on X-rays and ECG interpretation.
Students consult these sections infrequently and very selectively, usually relying on the
ward instructions. We have also not included examination of ENT, Eye and Gyneacology as
examination in these specialties too is usually learnt from single subject texts. This has helped
in cutting the size and price, and improving ‘portability’ of this book.
During the whole process of writing of this book we have relied on feedback from our students
and young resident staff and we should like to continue this process so that subsequent editions
can be responsive of reader preferences. We would appreciate any comment or suggestion that
the reader might make.
Muhammad Inayatullah MRCP (UK)

Multan 1995 Shabbir Ahmad Nasir FRCPE
PDFelement
PREFACE TO THE FOURTH EDITION
Art of history taking and methods of physical examination don’t change frequently but style of
presentation, composing, printing, illustrations and photographs can be modified to improve
the readability, understanding, interpretation and reproducibility of the contents. This edition
is a new look book with significant improvement in all categories of contents and printing
quality. Authors hope that this new look of “Bedside Techniques” will be of great help in
learning of clinical skills for current and future medical graduates.
Muhammad Inayatullah FRCP (LONDON)

Multan 2013 Shabbir Ahmad Nasir FRCPE
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I
ACKNOWLEDGEMENTS
of Writing a book is arduous. It would be almost impossible if every author didn’t have a circle of
ve friends and colleagues who support and encourage him. Many books would remain unwritten
)n but for these individuals and acknowledging their help is one of the more pleasant tasks of
ig writing books.
m Dr. Durr-e-Sabih. Our most ruthless critic, and self-appointed guardian of quality (readability),
who went over each line asking for its justification, any more effort on his part and we would
have to give him credit as another author.
Dr. Imran Iqbal. For reviewing the chapter on Pediatircs.
Drs. Altaf Baqir Naqvi, Muhammad Bilal Ahsan and Muhammad Javed Rana. Registrars
(Naqvi is a senior registrar now) who have been involved in proof processing and sharing our
burden of the ward while we were busy with our writing.
Dr. Rafique - ur - Rehman. For arranging access to a laser printer where the final manuscript
was printed.
Mohammed Wamiq. Ever cheerful and full of energy, who has drawn all the illustrations.
Dr. Zahida Sabih. For logistic support.
Mr. Zain-ul-Abedin Iqbal, Director Paramount Publishing Enterprise for his valuable
suggestions in pictographic work of this book.
Mr. Dilshad Alam graphic designer, Paramount Publishing Enterprise for taking all the trouble
to bring the book in current shape.
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■
4
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INTRODUCTION
Remember: far from the truth. Laboratory tests are

I hear and I forget just data, not knowledge and undirected
I see and I remember investigations without proper
understanding of the patient's problem
I do and I understand
usually yield useless information which
The mastery of the art of clinical
does nothing to help the patient. This
examination separates the good from
the mediocre physician. This is the basic doesn't mean that investigations should
foundation on which the whole structure not be used, just that the decision to
of medical diagnosis and management undertake any test should be made
rests. With a proper clinical examination after a thorough understanding of the
you are almost within reach of the patient's problem and presentation. This
correct diagnosis. The abundance of can only be achieved by a good history
Hi-tech investigations now available and clinical examination.
might suggest to some that listening to
the patient and examining him with The diagnostic process has three parts:
care might not be very important, that 1. History taking
laboratory tests can substitute and
2. Physical examination
improve the knowledge gained by the
history and examination, but this is 3. Investigations
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Chapter
1 I HISTORY TAKING
■ I AND PHYSICAL
EXAMINATION
This is an interview with the patient First listen to the patient, then ask
aimed at understanding the nature of necessary questions to complete
his illness. It can be defined as to know
the history, and then write.
about the patient's illness as he knows.
The process of history taking cannot be
+ If interruption is necessary, it should
restricted to a predefined pattern and has
be timed and planned depending
to be modified according to the patient's
upon patient's personality.
symptoms, attitude, age and level of
literacy. Following guidelines are helpful + Try to avoid asking leading
in learning the art of history taking. questions, ie, a question that can be
answered in 'yes' or 'no', eg, "have you
GUIDELINES FOR HISTORY got pain in the chest or diarrhea"?
TAKING Instead, ask "have you got any pain
anywhere? How are your bowels"?
+ Your approach to the patient should
be sympathetic, gentle, friendly and + Encourage the patient to give details
confident but not frivolous, sarcastic of his symptoms and discourage
or belittling. the use of pseudo medical terms
like 'rheumatism' 'acidity' etc. Don't
+ Introduce yourself to the patient
accept a diagnosis except if it has
first.
been made by somebody competent
+ Try to communicate in the language and has been based on definite
which the patient can fully external tests as required; otherwise
understand. ask details of the illness as it occurred.
+ Be courteous; in the hospital, For example, somebody being told
don't interrupt patient's personal to be a case of peptic ulcer without
activities like eating etc. You should, barium meal x-rays or gastroscopy is
either wait for the patient to finish not acceptable.
or come some other time. + Avoid writing when the patient is
+ Allow the patient to give his own talking. This will give an impression
account of current illness and then as if you are not attentive. Brief
ask questions about aspects that notes can be scribbled if necessary:
remain deficient. Write down the history soon after
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CH I HISTORY TAKING AND PHYSICAL EXAMINATION 3
the interview is over and before Sex

physical examination, so that you Apart from identification value and
don't forget the details. specific diseases of genital organs,
+ Record the history in the pattern certain disorders are more common in
described below. Patient's narration one particular sex, eg, ischemic heart
doesn't follow that pattern. disease is more common in males
while systemic lupus erythematosis
HISTORY RECORD and primary biliary cirrhosis are more
Write down the history under the common in females.
following headings:
Occupation
1. Name, age, sex, marital status,
It not only gives clue about patient's
occupation, address
socio-economic and educational status
2. Presenting complaints but also tells about possible risk to his
3. History of present illness health. It is further discussed under
4. Systemic inquiry occupational history.
5. Past history Address
6. Menstrual history Complete postal address is vital for
7. Treatment history future communication. In addition,
8. Family history some problems like iodine deficiency,
parasitic infestations are more prevalent
9. Personal and social history
in certain regions; knowledge of patient's
10. Occupational history address may help in the diagnosis.
Name Presenting Complaints
This is the identity of the patient. These are the symptoms which made
Record the father's or husbands name the patient to come to the doctor. Record
as well in order to differentiate between them in chronological order, ie, write
individuals with the same name. the symptom which developed first at
the top followed by other complaints in
Age sequence of occurrence. Enter duration
Some patients are not sure about their of each complaint in front of it. For
age. An approximate age can be assessed example:
by the look of the patient. Information
Pain epigastrium: 12 days
like age at the time of marriage and age
of eldest child also can help. Vomiting: 10 days
Some diseases are more common in Loose motions: 7 days
certain age groups, eg, communicable If a symptom has been occurring again
diseases like polio, chicken pox, measles and again, and is present this time as well,
etc. are common in childhood while include this information in presenting
malignancies, ischemic heart disease, complaint. For example:
strokes are more common in older age Recurrent pain
group. left lumbar region 6 months
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4 BEDSIDE TECHNIQUES
or. unimportant/unrelated to present

Recurrent bouts of cough: 2 years illness or he might even forget some
of the less severe symptoms. In order to
Avoid writing mini history, ie,
make sure that no aspect of the patient's
description of symptoms under
illness is missed, it is recommended that
this heading. If patient had certain
you should ask about all the cardinal
symptoms before presenting com
symptoms of each system as a routine
plaints but this time he has not come for
under the heading of systemic inquiry.
those symptoms, record them under the
Some symptoms occur due to disease of
past history.
more than one system; inquire about such
History of Present Illness symptoms only once. Similarly, don't
Describe the presenting complaints in repeat questions about those symptoms
detail one by one; in the sequence they which already have been described
developed. Relevant questions to be under the history of present illness. If a
asked about various symptoms are learnt symptom is present, find out its details as
only with experience and increasing you did in history of present illness. A list
knowledge of Medicine. A list of such of common symptoms due to diseases of
questions about important symptoms is various systems is given below.
given on page 6.’
Quickly ask about cardinal
Describe each presenting
symptoms of diseases of each
complaint in detail at one
system.
place and follow sequence of
occurrence of complaints. General
Appetite, weight gain or weight loss,
If symptoms have been occurring sleep, energy.
in bouts, describe the latest episode
in detail and then record duration, Cardiovascular System
frequency and progress of these episodes Breathlessness, palpitation, chest pain,
from the beginning. Record the history edema feet.
in patient's words and don't substitute
medical terms for patient's description, Respiratory System
eg, paroxysmal nocturnal dyspnea for Cough, sputum, hemoptysis, breath
breathlessness during the night and lessness, wheezing, chest pain.
angina for chest pain on exertion
Alimentary System
Systemic Inquiry Nausea, vomiting, abdominal pain,
The patient generally tends to tell heartburn, dysphagia, diarrhea,
only those symptoms which he thinks constipation, hematemesis, melena,
are important and need immediate jaundice.
attention of the doctor. Either he ignores
other symptoms, considering them
Urinary System
* Significance of various questions has been Pain in the flanks, dysuria, hematuria,
discussed in our other book "Aids to Differential frequency of micturition, polyuria,
Diagnosis".
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CH I HISTORY TAKING AND PHYSICAL EXAMINATION ' '
5
oliguria, nocturia, passage of gravel in + History of admission to hospital,

the urine, nausea, vomiting. accident or operation; ask more
Nervous System details if the answer is yes.
Weakness, numbness, tingling, headache, 4 Any chronic illness like
vomiting, giddiness, blackouts, fits, hypertension, diabetes mellitus,
visual loss, diplopia. ischemic heart disease, arthritis,
tuberculosis. If someone has one of
Skin these illnesses, ask how and when it
Rash, itch, colored spots. was diagnosed, what treatment he
has been taking and how effectively
Locomotor System it has been controlled.
Joint pain, stiffness, swelling, restriction 4 Residence or travel abroad. It is
of movements. becoming more relevant due to
Endocrine frequent travel and emergence of
diseases like AIDS.
Polyuria, polyphagia, polydypsia, .heat
or cold intolerance, weight gain or loss, Menstrual History
sweating, palpitation. Note down the following:
Information from Another Person 4 Age of menarche (onset of
menstruation).
In certain situations patient himself
cannot give the details of history. Seek 4 Duration of each period.
the information from another person, 4 Length of cycle (from the 1st day
particularly an eye witness. These of one period to the 1st day of next
situations include: period).
+ Childhood. 4 Regularity of cycle.
4 Senility or mental retardation. 4 Any pain associated with periods:
4 Unconscious/aphasic patient. site, duration, relationship to the
onset of periods.
+ Convulsions with loss of
consciousness. 4 Any intermenstrual or postcoital
bleeding.
Past History 4 Menopause; age, postmenopausal
Inquire about the following: bleeding or discharge.
+ Nature of delivery (spontaneous, Treatment History
assisted or Cesarean section; at home
Patients usually don't remember names
or in hospital). It is more relevant in of drugs. Ask about any left over drugs,
children.
labels or prescription. Note down
+ Congenital anomalies. names of drugs, dosage and duration of
therapy. Also ask about effect of these
4 Communicable diseases in childhood.
drugs on patient's illness. If patient has
4 Any significant illness (ask a prescription, find out whether he is
description of illness if diagnosis is taking all the drugs in the prescribed
not known). doses. If patient was not taking
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drugs regularly, find, out the cause of 4 Any special worries, sleep
non-compliance. disturbance.
4 Knowledge of drugs taken might 4 Dietary details if there is doubt of
give a clue to the nature of patient's nutritional abnormality.
past or even existing disease. 4 Home surroundings.
4 Side effects of drugs are sometimes
responsible for patient's symptoms. Occupational History
+ Some patients are sensitive to drugs
Seek the following information:
like sulfonamides, penicillin etc. and 4 Exact nature of the present job.
this information helps to avoid any 4 Details of jobs in the past.
catastrophes. 4 Any possibility of exposure to
4 It helps to avoid any possible drug chemicals or radiations? If yes, what
interaction with newly prescribed is their nature and quantity?
drugs, eg, anticoagulant may interact
with oral contraceptives which ROUTINE QUESTIONS ABOUT
patient is already taking. CARDINAL SYMPTOMS
(Significance of various symptoms, signs
Family History and investigations has been discussed
Inquire about health of parents, in our book ''Aids to Differential
siblings (brother and sister) and Diagnosis". It will be worth to look at.)
children, and ask questions about
individual member. Find out whether Pain
any one of them is suffering from a
similar illness or a chronic illness like Site of Pain
hypertension, diabetes mellitus, Ask the patient to indicate where exactly
ischemic heart disease, asthma, he feels the pain. Pain of duodenal ulcer
arthritis or tuberculosis? If any one of is in the epigastrium, pain of ischemic
them is dead, ask about possible cause of heart disease is across the sternum and
death. If there is suspicion of inherited not over the precordium while pain of
disorder, ask about health of uncles and reflux esophagitis is along the sternum.
aunts as well.
Intensity
Personal and Social History Although the threshold of pain varies in
Seek the following information: different people, make a rough estimate
of intensity. Pain can be mild, moderate
+ Patient's economic status. It is or severe. Pain which keeps the, patient
important to decide how much awake at night, or makes him toss in
patient will be able to afford the cost the bed, is severe. Pains of myocardial
of investigations and treatment. ischemia, pancreatitis, and colicky pains
4 Nature of family relations. are very severe.
4 Any habit or addiction, now or in the Radiation
past like smoking, drug dependence, It means the pain spreads to some other
alcohol intake. site while maintaining its continuity
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CH I HISTORY TAKING AND PHYSICAL EXAMINATION
(KMMMMMM
7
with the main site, eg, pain of cholecystitis 7. Dull

radiates from right hypochondrium 8. Gripping
along right costal margin to the back.
Similarly, pain of cardiac ischemia 9. Pricking
radiates to the left arm and jaw. 10. Colicky
In colic periods of sudden severe pain
Shift of Pain
alternate with, either pain free intervals
It means, at first pain occurs at one site, (intestinal colic) or pain of lesser
is relieved from there and then is felt intensity (ureteric colic).
at another site. For example, pain of
appendicitis starts around the umbilicus Frequency and Periodicity of Pain
and then moves to right iliac fossa due to Ask the patient about duration of
involvement of parietal peritoneum. pain free intervals and whether this is
increasing or decreasing.
Referred Pain
Periodicity means patient gets bouts
It means pain is felt at a remote site of pain for few weeks and then becomes
away from the main site due to common completely symptom free without
nerve supply, eg, pain of cholecystitis is treatment for few weeks. This cycle is
felt at the tip of right shoulder. repeated again. This occurs in duodenal
ulcer.
Duration
Estimating duration of pain without Special Times of Occurrence
actual measurement is usually Pain of duodenal ulcer may waken the
inaccurate, but it is at times helpful in patient after midnight, but it is never
making a diagnosis, eg, pain of angina present at usual hours of rising. Pain of
usually lasts for less than 30 minutes sinusitis is maximum few hours after
while that of myocardial infarction lasts rising. Headache of migraine may occur
for more than 30 minutes. Similarly, during menses.
persistent chest pain is less likely to be
Aggravating Factors
due to ischemic heart disease.
Ask the patient if any particular factor
Character aggravates the pain. Movements worsen
the pain of joint and muscle disease. Pain
Following terms are commonly used to
of angina is precipitated by exertion.
describe the character of pain. Different
Pain of peptic ulcer may be worse after
patients can use different terms to tea or spicy food. Pleuritic pain is worse
describe the same pain. on deep breathing and coughing,
1. Heaviness
Relieving Factors
2. Burning
Pain of angina is relieved by rest and
3. Aching sublingual nitrates. Pain of duodenal
4. Stabbing or cutting ulcer is relieved by food and antacids.
5. Throbbing Associated Phenomenon
6. Jolt like Depending upon underlying disease
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other symptoms may be present, like Pattern of Fever

vomiting in abdominal pain due to Continuous fever. Temperature does
cholecystitis and headache due to not touch the baseline and variation
meningitis, palpitation and sweating between maximum and minimum
in chest pain of ischemic heart disease, temperature in a day is of less than 1°C
hematuria in ureteric colic, distension of (1.5°F). Fever in typhoid is continuous.
abdomen and constipation in intestinal Remittent fever. Temperature does not
colic due to intestinal obstruction. touch the baseline and daily variation is
Fever more than 2°C (3°F). Fever due to most of
infections is remittent.
It means rise in the body temperature**
Intermittent fever. Fever is present
above upper limit of normal. Average
for several hours followed by fever free
normal body temperature is 98.4°F (37°C),
interval. In tuberculosis usually there
range is 97 - 99°F (36.6 - 37.2°C). There is a is evening rise of temperature followed
variation of about one degree Fahrenheit by night sweats. In malaria fever is
between morning and evening (diurnal typically intermittent. Following are the
variation), being less in the morning. subtypes of intermittent fever.
Fever is a common symptom. Ask the Quotidian fever. Bout of fever occurs
following questions from all the patients daily for few hours.
presenting with fever.
Tertian fever. Fever occurs on alternate
Mode of Onset days.
Fever due to acute infections (eg, Quartan fever Fever occurs after an
malaria, pneumonia) is of acute onset interval of two days.
while fever due to chronic infections Relapsi ng fever. Fever occurs for several
(eg, tuberculosis) and malignancies is of days followed by fever free interval of
gradual onset. similar duration; this cycle is repeated.
Relapsing fever due to Hodgkin's disease
Rigors or Chills is called Pel Ebstein fever.
These indicate sudden rise in the body
temperature. Malaria is a common Associated Symptoms
cause but these can occur in any acute Headache and vomiting are nonspecific
infection like pneumonia, urinary tract symptoms and accompany fever of any
infection. etiology, but if persistent, meningitis
must be excluded. Certain symptoms
Grade of Fever
point towards possible site of infection
Fever of acute infections is of high in a feverish patient. These are:
grade while fever of chronic infections
is usually of low grade.*** + Ear discharge.
* * Celsius (centigrade) scale is commonly used all Usually fever of more than 102’F (39*C) is considered
over the world, but we in Pakistan are more familiar as high grade and fever of less than 101’F (38.5‘C) is
with the Fahrenheit scale. Formula to convert one considered as low grade. If temperature rises above
scale into the other is Celsius = Fahrenheit - 32 X 5/g 107’F (41.6*C) it is called hyperpyrexia; if it falls below
** * There is no precise definition of grades of fever. 95*F (35’C) it is called hypothermia.
PDFelement
1
CH I
DIFFERENTIAL DIAGNOSIS OF ABDOMINAL PAIN
Peptic Cholecy-stitis Pancrea Renal Ureteric colic Appendi Worm Intestinal Hepatitis
HISTORY TAKING AND PHYSICAL EXAMINATION

ulcer titis pain citis infestation obstruc
tion
Site epigas right hypo- epigas lumbar lumbar region umbilicus, upper generalized right hypo
trium chon-drium trium region right iliac abdomen chondrium
fossa
Radiation localized back, right back localized groin localized whole -
shoulder -
abdomen
Character gnawing colicky gnawing dull colicky - aching or colicky aching
or aching or cutting colicky
Severity mild to moderate to severe mild to moderate to mild to mild to moderate to mild to
severe severe moderate severe moderate moderate severe moderate
Perio present absent absent absent absent absent absent absent absent
dicity i
------------- !---
Special after none none none none none none none none
time of midnight
occurr
ence
Aggrava empty fatty meal none move move-ments none none none none
ting stomach ments
factors
Relieving food and none bending none none none none none none
factors antacids forwards
Associ vomiting, vomiting, fever vomiting urinary vomiting, vomiting, - vomiting, anorexia,
ated herniate-. symptoms urinary fever distension nausea,
pheno mesis symptoms of abdomen, vomiting
mena melena obstipation
Signs tender tenderness mild tenderness kidney may tender anemia borborygmi jaundice,
ness in in right tenderness in lumbar be palpable ness, mass audible tender
epigast hypochon in epigas region, if there is in right hepato
rium drium, trium, kidney hydronephrosis iliac fossa megaly
Murphy's sign hypoten may be
is positive sion palpable NO
PDFelement
4 Sore throat. 4 Pressure symptoms (eg, dyspnea or

4 Cough, expectoration (respiratory dysphagia if mass is in the neck).
infection). Edema
4 Pain right hypochondrium 4 Site - it may be generalized (eg,
(cholecystitis, amebic liver abscess). nephrotic syndrome) or localized
+ Diarrhea with blood and mucus (eg,CCF):
(dysentery). 4 Where did it start first - around the
+ Pain in flank (pyelonephritis). eyes (renal disease) or feet (CCF)?
+ Dysuria, burning micturition + Ask about breathlessness (CCF);
(urinary tract infection). anorexia, vomiting, oliguria (renal
> Night sweats (tuberculosis). failure); indigestion, diarrhea
(malabsorption); distension of
Weight Loss abdomen (cirrhosis of liver).
4 If previous weight is known,
weigh the patient to find the Dyspnea (Breathlessness)
difference; otherwise ask the patient It is of two types: exertional dyspnea
approximately how much he has (dyspnea precipitated or made worse by
lost. exertion) and dyspnea at rest (dyspnea
which comes in attacks without any
4 How is appetite: weight loss may be
relation to exertion).
associated with poor or good appetite.
4 If appetite is decreased, ask about Exertional Dyspnea
fever, night sweats, cough and 4 Duration.
expectoration. (Weight loss with
+ How much exertion precipitates
poor appetite may be due to chronic
dyspnea, eg, does it come on
infection or malignancy.)
climbing stairs, running or walking
4 If appetite is normal or increased, at a normal pace, and how much
ask about polyuria, polydypsia, distance can the patient walk
palpitation, heat intolerance or without becoming dyspneic?
chronic diarrhea. (Weight loss
4 Has it been progressive, ie, has the
with good appetite may be due to
amount of exertion precipitating
diabetes mellitus, thyrotoxicosis or
dyspnea been decreasing since the
malabsorption.)
dyspnea started?
Mass 4 History of sudden wakening at night
It may occur anywhere in the body. Ask due to breathlessness (paroxysmal
about: nocturnal dyspnea).
4 Duration. 4 History of such exacerbation that
dyspnea is present at rest or becomes
4 Site.
worse on lying flat (orthopnea).
4 Recent change in size.
4 Associated symptoms (cough,
4 Pain. sputum, palpitation, sweating, chest
4 Fever. pain).
PDFelement
+ Past history of chest pain, + What is the quantity, color and smell
hypertension or fever with joint of the sputum?
pain (rheumatic fever). + Is sputum more early in the
morning?
Dyspnea at Rest (Unrelated to
Exertion) + History of hemoptysis (blood in
Dyspnea occurs in episodes due to sputum). Is blood mixed with
bronchospasm (bronchial asthma). sputum or pure (frank hemoptysis)?
What is frequency of hemoptysis
+ Age of onset. and quantity of blood?
+ Wheeze (whistling sound).
Vomiting
+ Frequency, severity and duration of
attacks. + Duration.
+ Frequency.
+ Change in frequency, severity
and duration of attacks since first + Relation with food intake.
episode. 4- Any special timing.
■+ History of skin or nasal allergy. + Loss of weight, if vomiting is long
+ Family history of similar illness or standing.
allergy. + Quantity, color, smell and contents
+ Does patient require regular of vomitus.
treatment to remain symptom free? + Blood in the vomitus (hematemesis);
if yes its color, quantity and
Palpitation frequency, and associated melena
It means the awareness of heart beat. (black colored, foul smelling stools).
Find out following information. 4- Other symptoms like pain abdomen,
+ Does it come in attacks at rest constipation and distension of
(paroxysmal tachycardia) or occurs abdomen (intestinal obstruction);
on exertion? anorexia (carcinoma stomach,
renal failure) oliguria (renal
+ Duration of an attack.
failure); headache (migraine, raised
4- Does it start and terminate suddenly intracranial pressure, meningitis).
or gradually?
+ Associated symptoms Diarrhea
(breathlessness, chest pain, sweating, 4 Duration.
loss of weight despite good appetite, 4- Frequency of stools.
heat intolerance). 4- Quantity of stools - small or bulky and
difficult to flush (malabsorption).
Cough
+ Consistency (watery stools with
+ Duration.
specks of fecal matter are typical
+ Frequency and severity. of cholera and are called rice water
+ Is it more at night or during the day? stools).
+ Is it dry or productive? 4 Blood or mucus in the stool.
PDFelement
BEDSIDE TECHNIQUES
+ Tenesmus (sense of incomplete Jaundice

evacuation). 4 Pain right hypochondrium
4 If diarrhea is acute, any relation (moderate, localized and continuous
with food intake and history of pain may be due to hepatitis;
diarrhea in other individuals who recurrent, severe, colicky pain
took the same food (food poisoning); radiating to the back is due to
if so, interval between food intake gallstones).
and onset of diarrhea.
+ Loss of appetite.
4 Does it occur at night (nocturnal
+ Distaste for smoking, if patient is
diarrhea is always due to organic
smoker (hepatitis).
disease of the gut)?
4 Color of stools and urine.
4 Other symptoms (fever, abdominal
pain, vomiting, weight loss). 4 Itching (cholestasis).
+ Loss of weight (malignancy).
Constipation
4 Past history of injections, blood
+ Usual bowel habits (how many
transfusion (hepatitis B or C).
stools per week).
4 Contact with jaundiced patient
4 Duration (recent change in bowel
(hepatitis A or E).
habits is important).
4 Family history of jaundice
4 Blood in feces.
(inherited disorders).
4 History of alternating diarrhea.
4 Drug history. Polyuria
4 Duration.
4 Change in eating habits.
4 It should be differentiated from
+ Other symptoms (abdominal pain,
frequency of micturition. In polyuria
distension and vomiting, loss of
quantity of urine passed each time is
weight).
large while in frequency it is small.
Dysphagia 4 Excessive thirst (polydypsia).
+ Duration. 4 Appetite: normal, increased or
decreased.
+ Is it more to solids or liquids?
4 History of diuretic intake.
4 Is it progressive?
4 Is it more at night (nocturia)?
+ Is there a feeling of food sticking
somewhere? What site? Hematuria
4 Is swallowing painful? 4 Duration.
4 Loss of weight. 4 Exact color of urine.
4 Vomiting; does vomitus contain food 4 Any difference in the color of urine
eaten 48 - 72 hours earlier (achalasia)? in the beginning, in the middle or at
4 Past history of retrosternal burning the end of micturition?
(reflux esophagitis). 4 Associated symptoms (fever,
PDFelement
burning micturition; pain in the + Onset: sudden or gradual.

hypogastrium, lumbar region or loin 4 Is it static or progressive?
to groin).
4 Premonitory symptoms like
Fits (Convulsions) headache, vomiting.
4 What was the age at the time of the 4 Loss of consciousness.
first attack? 4 Fits.
4 Gather the following information 4 Is speech affected?
about an attack from the patient 4 Sensory symptoms (numbness,
and an eye witness: tingling, pain) or visual symptoms.
• Aura (any special feeling or 4 History of hypertension, ischemic
symptoms before the fit). heart disease, diabetes mellitus,
• Loss of consciousness. valvular heart disease or smoking.
• Rigidity. 4 Past history of similar episode; if yes
• Tonic, clonic contractions. what was the outcome.
• Are the fits generalized or 4 Family history of vascular disease.
localized?
Headache
• Tongue bite, urinary/fecal
incontinence. 4 Site (psychogenic headache is
over the vertex while headache
• Fall, trauma. due to organic disease is frontal or
• Duration of attack. occipital).
• After symptoms, eg, sleep, 4 Severity.
headache, paralysis.
4 Duration.
• Do the attacks occur during sleep
4 Continuous or intermittent
or not?
(duration of each episode and
4 What has been the shortest and the frequency of episodes).
longest interval between the attacks?
4 Character.
4 History of headache, vomiting,
4 Special time of occurrence (cluster
sensory or motor symptoms or fever
headache usually occurs at night
(febrile fits are common in children).
while headache of sinusitis is
+ Past history of ear discharge, head maximum few hours after sunrise).
injury or birth trauma.
4 Aggravating and relieving factors.
Weakness or Paralysis Attack of migraine may be
precipitated by menses and certain
4 Which part is involved: one limb
foods like cheese. Headache of
(monoplegia), both limbs on one
sinusitis is worse on stooping.
side (hemiplegia) or both legs
(paraplegia)? 4 Associated phenomena like
vomiting, visual halos, rhinorrhea.
4 Is weakness complete (paralysis) or
partial (pareses)? 4 Insomnia.
PDFelement
BEDSIDE TECHNIQUES
+ Any cause for anxiety or depression. rather than systemic. This routine can
4- Effect of analgesics (psychogenic vary with the individual doctor, and
headache is not relieved by should be modified according to the
analgesics although these are taken circumstances and patients condition. It
very frequently). will be different in a patient who walks
into a clinic than in an unconscious
Joint Pain patient admitted to a hospital. In a
+ Age of onset. seriously ill patient, examination should
+ Which joint was involved first? be restricted to a minimum necessary to
+ What was the sequence of make a provisional diagnosis. Initiation
of treatment should not be delayed
involvement of other joints?
just for the sake of completion of
+ Did the pain in the previously routine examination. A chaperone
involved joint persist or disappear (female attendant, nurse or female
when other joints were affected? student) should be present when a male
+ Swelling of joints. doctor/student is examining a female
+ Relation of pain with movements of patient.
joints.
WRITING OUT THE
+ Morning stiffness. EXAMINATION
+ Past history of trauma to the joints. While the examination is done on regional
+ Any systemic symptoms? basis, the findings are recorded under
+ History of urinary, bowel or eye systems with headings. This needs a little
practice at first, but then proficiency
problems.
develops very quickly. In this book
PHYSICAL EXAMINATION methods are described under systemic
The examination should begin the headings and at the end a regional
moment you see the patient. Observe the sequence of examination is given.
general look of the patient, and his gait
if he walks in. Make an assessment about GENERAL PHYSICAL
his behavior, mental state and level of EXAMINATION
education during history taking. The following scheme is useful for a
speedy and thorough GPE (General
Practice a sequence of exami Physical Examination). A physical sign
nation and then adhere to this may be seen at more than one sites, but
sequence. this should be recorded and described at
one place.
A routine of examination should be A sequence of recording general physical
developed so that no important step examination is given at the end of this
chapter (page 32).
is omitted. Sequence of examination
should be such that one can perform General Appearance
speedy but thorough examination Make a quick assessment of degree of
with minimum necessary disturbance patient's illness whether he looks well,
to the patient. It should be regional mildly ill or severely ill.
PDFelement
Posture and Attitude

The patient's posture and attitude Normally sitting height
sometimes give information about his (height of the person while
illness. For example: sitting on his buttocks) is
half the total height or arm
+ A patient of severe heart failure
span (measured from the tip
prefers to sit propped up because his of middle finger of one hand
dyspnea worsens on lying flat. to the tip of middle finger of
+ A Patient with severe airways other hand when arms are
obstruction sits up, bending forwards fully extended).
and supporting himself with his
In Marfan's syndrome and
arms, so that shoulder girdle is fixed
hypogonadism arm span is
and he can use extra respiratory
more than double the sitting
muscles.
height.
+ A patient of peritonitis lies still
while the patient with severe colic is In achondroplasia arms and
restless. legs are short while trunk is
normal, so sitting height is
4- In meningitis the neck may be bent
more than length of legs as
backwards (neck retraction).
measured from pubis to feet.
Consciousness In congenital hypopituitarism
Note whetherpatientlooksalert,confused (pituitary dwarf) total height
and drowsy or deeply unconscious is less than normal, but limbs
(assess level of unconsciousness using and trunk are proportionate.
Glasgow coma scale given on page 144).
Hand
Physique
Examine nails, fingers and palm in
Although, generally a visual impression detail, but at first have a general look at
is made about patient's height and the hand and note the following:
weight, preferably both should be
Shape: Hands adopt special shape
measured and compared with tables of
in tetany due to carpal- spasm (see
ideal height and weight, particularly
under nervous system examination).
if patient looks obese, undernourished,
Short 4th metacarpal (which becomes
abnormally tall or short. Dosage of
evident on making a fist) in a female
drugs is also calculated according to the is seen in Turner's syndrome. Short
patient's weight or surface area (which is 4th/5th metacarpal is also seen in
determined using a nomogram). Regular pseudohypoparathyroidism.
measurement of weight is useful to
monitor the response in patients with Size: Hands are large and broad in
edema or ascites. In unduly tall and acromegaly.
short patients sitting height should Tremor, grip, muscle wasting:
be compared with arm span and total Discussed under nervous system
height. examination.
PDFelement
BEDSIDE TECHNIQUES
proximal part of the nail which is

Common signs in hand
absent if angle is obliterated 4) by
Nails
Schamroth's sign. When two fingers
Pallor are approximated, normally there is
Cyanosis a space between two nails. It is absent
Koilonychia in clubbing; fig 1.7).
- Clubbing
Fingers
Heberden's nodes
Swelling of joints
Palm
Fig 1.1: Koilonychia (spoon-shaped nail)
Pallor
Sweating
Nails
Pallor: There is marked variation in the
color of the nails in normal individuals.
It becomes pale in anemia. Fig 1.2: Normal angle
Cyanosis: It means bluish discoloration

(see page 26).
Koilonychia: Nails become thin, brittle
and concave (spoon-shaped) (fig 1.1). It
is seen in long standing iron deficiency
anemia.
Clubbing**: It consists of following
changes:
+ There is loss of angle between
nail and nail base (fig 1.2, 1.3, 1.4). It
can be assessed by 1) examining the
fingers from the side in profile 2) by
palpating the nail from distal end Fig 1.4: Late clubbing
towards base of the nail 3) by placing
a piece of paper across the nail and + Fluctuations are present at
nail base, normally their remain an nail base; method to elicit these
opening between the paper and the
fluctuations is shown in fig 1.8.
* * Hypertrophic osteoarthropathy. Clubbing + The curvature of the nail is increased,
is associated with swelling and tenderness above
the wrist and ankle due to subperiosteal new bone
both, in transverse and longitudinal
formation. Although it can occur in any pathology axis, and nail becomes convex. Normal
causing clubbing, it is more commonly associated people can have curved nail but angle
with respiratory diseases and is then called
pulmonary hypertrophic osteoarthropathy. is normal (fig 1.5).
PDFelement
+ Finally, due to overall swelling,

terminal phalanx becomes bulbous
and resembles the end of a drumstick Fig 1.8: Method of eliciting fluctuations in clubbing
(fig 1.6}
Causes of clubbing
Respiratory disease
1. Chronic suppurative conditions
(bronchiectasis, lung abscess,
empyema)
2. Carcinoma lung
3. Fibrosing alveolitis
Cardiovascular disease
1. Cyanotic heart disease (Fallot's
tetralogy, transposition of great
arteries)
2. Infective endocarditis
+ Schamroth's sign is present. (When two Gastrointestinal tract disease

fingers are approximated, normally 1. Malabsorption syndrome
there is a space between two nails. It is 2. Crohn's disease
absent is clubbing; fig 1.7.)
3. Ulcerative colitis
4. Primary biliary cirrhosis
Miscellaneous
1. Familial
2. Pseudoclubbing (it is seen in
hyperparathyroidism; there is
resorption of terminal phalanx
which gives impression of
clubbing)
Splinter hemorrhages: These are

vertical hemorrhagic streaks under the
nails and are commonly seen in manual
workers (fig 1.9). These can also occur in
infective endocarditis.
PDFelement
BEDSIDE TECHNIQUES
Fig 1.9: Splinter hemorrhages
Leuco nychia: These are white patches

in nail plates often present in normal
persons and are also sometimes seen in
hypoalbuminemia.
Pitting of nails: There are a large
number of small pits in the nails (fig
1.10). This occurs in psoriasis.
Fig 1.11: Nodes in the fingers (A) Heberden’s (B)

Bouchard’s
4 Anterior of the
subluxation
Fig 1.10: Pitting of nails metacarpophalangeal joints with
ulnar deviation (fig 1.14B).
Fingers 4 Swan neck deformity
Osier's nodes: These are pea size painful (hyperextension at proximal
swellings in the pulps of terminal interphalangeal joint and fixed
phalanges. These are seen in infective flexion at the distal interphalangeal
endocarditis and are due to vasculitis. joint - fig 1.14A).
Heberden's nodes**: These are bony 4 Button-hole deformity (fixed
swellings on the side of terminal flexion at proximal interphalangeal
interphalangeal joints, and are joint and extension at terminal
osteophytes seen in osteoarthritis (fig interphalangeal joint - fig 1.14A).
1.UA, 1.12). 4 'Z' deformity of thumb.
Joint swelling/deformity: In Arachnodactyly: It means fingers are
rheumatoid arthritis proximal thin and long, and are seen in ’Marfan's
interphalangeal joints are swollen and syndrome.
fingers become spindle shaped (fig 1.13).
In long standing rheumatoid arthritis
Palm
following deformities can occur. Pallor: Color of palmar skin becomes
pale in anemia.
* * Bouc ha rd's nodes: These are similar to Heberden's Palmar erythema: Redness of the
nodes and occur at proximal interphalangeal joints
(fig 1.11B, 1.12).
thenar and hypothenar eminences
PDFelement
is seen in some normal subjects. It

is also a feature of hepatic failure,
pregnancy, rheumatoid arthritis and
oral contraceptive therapy.
A
Swan neck deformity
Fig 1.14: Rheumatoid arthritis (A) button-hole and

swan neck deformities (B) ulnar deviation
Sweating: Excessive sweating on the

palm may be idiopathic but is also
seen in anxiety (palm is cold) and
thyrotoxicosis (palm is warm).
Dupuytren's contracture: There is
thickening of the palmar fascia felt as
thickened plaque or cord between palm
and ring and little fingers. Later, flexion
contracture of the fingers, particularly
ring and little fingers may develop. It is
a feature of alcoholic cirrhosis.
Pulse
Detailed examination of pulse is
discussed under cardiovascular system.
Fig 1.13: Rheumatoid arthritis; swollen proximal In GPE its rate and regularity should be
interphalangeal joints noted.
PDFelement
BEDSIDE TECHNIQUES
Blood Pressure General appearance: There are certain

You must measure the blood pressure characteristic facies, eg, moonlike
in every patient. Some doctors prefer face of Cushing's syndrome, masklike
to measure it during general physical (expressionless) face of Parkinsonism.
examination while others do so at the Puffiness: This is due to periorbital
end of examination. It doesn't make edema and is seen in renal failure,
any difference as long as measuring the nephrotic syndrome and acute
blood pressure isn't forgotten. Technique glomerulonephritis. It may also be due
is discussed under cardiovascular system to angioedema and myxedema. In right
examination (page 43). heart failure puffiness of the face is
uncommon and only occurs if patient
Face can lie flat.
Common physical signs which must Proptosis (exophthalmos): It means
be looked for on the face are puffiness,
protrusion of the eyeball. If eyes look
pallor of the lower conjunctiva for
unusally prominent, inspect them from
anemia, yellow discoloration of the
above. Stand behind the seated patient,
sclera for jaundice, bluish discoloration
draw the upper lids gently upward, and
of the tip of the nose and ear lobules
for cyanosis, bluish discoloration of note the relationship of the corneas to the
the inner surface of the lower lip for lower lids. If cornea is protruded beyond
cyanosis, dryness, pallor and cyanosis of the lower lid exophthalmos is present. In
dorsum of the tongue and yellowness of Grave's disease exophthalmos is usually
the undersurface of the tongue. bilateral, although it may be unilateral
initially. Orbital tumor is another cause
Facies of Cushing syndrome,
of unilateral exophthalmos. Other
xanthelasmas, exophthalmos, butterfly
eye signs of Grave's disease are lid
rash, and hirsutism are comparatively
retraction and lid lag *.
uncommon.
Xanthelasmas: These are yellow
plaques on eyelids due to deposition of
Common signs to be looked for
lipids. These may be associated with
on the face
hyperlipidemia, but are also seen in
Puffiness elderly with normal lipids.
Pallor of the lower conjunctiva Color of the conjunctiva: Ask the
patient to look upwards, pull the
Yellow discoloration of the
lower eyelid downwards to expose
sclera
the conjunctiva (fig 1.15) and look for
Bluish discoloration of the tip pallor. Subconjunctival hemorrhages
of the nose and ear lobules
* * Lid retraction: Ask the patient to look straight.
Bluish discoloration of the Normally sclera above and below the cornea is not
inner surface of the lower lip visible. In thyrotoxicosis sclera above the cornea
may be visible due to lid retraction while in marked
Dryness, pallor and cyanosis of proptosis sclera, both, above and below the cornea is
the dorsum of the tongue visible.
Yellowness of undersurface of Lid lag: Ask the patient to look straight at your
finger and then follow it downwards. Normally both
the tongue eyeball and upper eyelid move together while in
thyrotoxicosis upper eyelid may lag behind.
PDFelement
are seen as bright patches on the eyeball Color of skin: Bluish discoloration of
and occur without any cause but may be tip of the nose and ear lobules occurs in
due to trauma or bleeding disorders. cyanosis. Redness on the cheeks (malar
flush) may be due to mitral stenosis, but
may be seen in normal individuals too.
Hirsutism: There is excessive growth of
hair on face (moustache and beard area),
limbs and trunk in a female.
Parotid glands: Swelling of parotid
glands may be due to mumps (usually
bilateral) or tumor (unilateral).
Lips: Pull the lower lip and look for
bluish discoloration of its inner surface
due to cyanosis.
Tongue: Look for dryness (which is seen
in dehydration and mouth breathers),
pallor and cyanosis on the dorsum of
the tongue.
Fig 1.15 Exposure of the lower conjunctiva for pallor
Look for jaundice on the undersurface
Color of sclera: Ask the patient to look of the tongue.
downwards and pull the upper eyelid Look for size of the tongue (tongue
upwards (fig 1.16). Normal sclera is white. is enlarged in amyloidosis and
In jaundice it becomes yellow. acromegaly).
Neck
Examine the neck for:
4- Thyroid.
4- Neck veins.
4- Lymph nodes.
Thyroid
It consists of two lobes lying on either
side of the trachea and connected to each
other by the isthmus. Enlargement of
the thyroid is called goiter.
Inspection
Ask the patient to extend the neck and
look for obvious swelling on either side
of the trachea or in front of it. Ask the
Rash: In systemic lupus erythematosis, patient to swallow. Any swelling that
there is rash over the cheek and bridge moves up with laryngeal cartilage
of the nose (butter fly rash). on deglutition (swallowing) is
PDFelement
BEDSIDE TECHNIQUES
enlarged thyroid. Note its size, whether is hyperfunctioning. Ask the patient to
it is unilateral or bilateral, diffuse or hold his breath while auscultating for
nodular. t
thyroid bruit with the bell. It should
not be confused with murmur radiating
Palpation
from heart, carotid bruit or venous hum
It can be carried out, both, from front
(page 65).
and back (fig 1.17). Put both your hands
over the swelling and palpate. Ask the Neck Veins
patient to swallow and note various Examination of pulsations in the jugular
characteristics as swelling moves under veins gives a nearly accurate estimation
your fingers. Note: of the right atrial pressure (which is also
+ Size. called jugular venous pressure or central
venous pressure). Examine the patient
+ Diffuse, single nodule or multiple
from right side while head of the bed
nodules.
is elevated about 45 degrees. Look
+ Consistency. for venous pulsations in the internal
+ Tenderness. jugular vein along the anterior border of
the sternomastoid and measure vertical
distance from the highest point of
venous pulsations to the sternal angle. If
it is more than 3 cm it is abnormal. More
details are given on page 45.
Lymph Nodes
Lymph nodes of the neck are divided
into following groups (fig 1.18):
+ Submental (under the chin).
+ Submandibular (under the jaw).
k________________________________ J
Fig 1.17: Palpation of thyroid from behind
Retrosternal thyroid. Thyroid can

be partially or totally retrosternal and
in this case its lower limit cannot be
reached. When patient is asked to raise
the arms above his head, there is stridor,
face is congested and neck veins become
distended; this is called Pemberton's sign.
Auscultation
A bruit (a sound resembling murmur,
see page 64) may be audible if thyroid Fig 1.18: Lymph nodes groups in the neck
PDFelement
+ Pre and postauricular. + Size.

+ Occipital. + Number.
4- Lymph nodes of posterior triangle + Consistency.
behind the sternomastoid. + Mobility with reference to each other
+ Lymph nodes of anterior triangle.in (matted or discrete), to overlying
front of the sternomastoid. skin and to underlying structures.
Method of Palpation + Tenderness.
Stand behind the patient, flex his neck + Discharge or sinuses.
and push middle and ring fingers of both Lymph nodes are tender in acute
hands under the chin. Move the fingers infection, matted together in
backwards to palpate submental and tuberculosis (sinuses may also be
submandibular groups. Then palpate present), discrete and of rubbery
in front and behind the auricle and consistency in Hodgkin's disease and
over the occiput. Move your fingers hard in consistency in metastases.
downwards behind the sternomastoid
towards clavicle for lymph nodes of Axillary Lymph Nodes
posterior triangle. For palpation of There are six groups: anterior, posterior,
supraclavicular fossa, push your lateral, medial, central and apical.
fingers behind the clavicle (fig 1.19).
Right Axilla
Finally, move the fingers upwards
between trachea and sternomastoid for Elevate patient's arm above his head
lymph nodes of anterior triangle. and push fingers of the left hand up in
the axilla, palm facing patient's chest.
Bring back patient's arm alongside his
chest. Move your fingers downwards
along the chest wall. If lymph nodes are
enlarged, they will slip between your
fingers and patient's chest (fig 1.20).
Elevation of patient's arm is necessary to
reach the apex of the axilla. In this way
apical, central and medial groups are
palpated.
Fig 1.19: palpation of supraclavicular lymph nodes
Note the following features if lymph

nodes are palpable:
+ Site. Fig 1.20: Palpation of right axillary lymph nodes
PDFelement
For palpation of anterior group, hold Lymph Nodes of Groin

anterior axillary fold between thumb These are easily palpable over the
and fingers of your left hand. For lateral inguinal ligament, if enlarged. Isolated
group, place palmar aspect of fingers of enlargement of this group is less
your right hand along the medial side of significant compared with other groups.
the humerus.
Note
When a group of lymph node is

Lymph nodes are commonly enlarged
palpable, examine its drainage
due to disease of the drainage area,
eg, infection or malignancy. So when
area.
you detect an enlarged lymph node,
For posterior groups of both sides, hold examine the drainage area of that
posterior axillary folds between thumb lymph node to exclude any pathology.
and fingers of your corresponding hand Examine scalp, face and oral cavity in
from behind the patient. case of cervical lymph nodes, upper limb
in case of axillary lymph nodes and
Left Axilla lower limb in case of inguinal lymph
Same process is repeated but apical, nodes.
central and medial groups are palpated
with the right hand (fig 1.21) while Causes of enlarged lymph nodes
lateral group is palpated with the left 1. Infection or malignancy in
hand. drainage area
2. Tuberculosis
3. Lymphomas
4. Leukemias
Feet
Look for clubbing, koilonychia and
cyanosis in the feet as well. Feet are
commonly affected by ischemia due to
peripheral vascular disease; early signs
Epitrochlear Lymph Nodes are loss of hair and shiny skin.
These are palpated by the method shown Edema
in fig 1.22.
Look for edema over the dorsum of the
foot, behind medial malleolus and over
the shin. In a bedfast patient also
check over the sacrum. Compare
two sides. Press the thumb for at least
5 seconds. If edema is present, a pit is
formed which refills gradually. In
cardiovascular conditions, edema is
more prominent in lower half of the
body. In hypoproteinemia, there is
PDFelement
generalized anasarca.and pitting can be State of Hydration

demonstrated over the upper half of the
In dehydration (loss of fluid from the
body as well.
t body):
Causes of Edema + Eyes are sunken.
Pitting edema + There is dryness of tongue.
Gcneralized/bilateral + Skin elasticity is decreased. (It is
A. Cardiovascular (only in the lower demonstrated by pinching a fold of
half of the body) skin between thumb and fingers; it
1. Right heart failure will subside abnormally slowly. In
2. Constrictive pericarditis elderly, this sign is less reliable.)
3. Pericardial effusion
+ Pulse is rapid and blood pressure
4. Inferior vena cava obstruction
is low.
B. Renal (generalized, but more on
the face) + Urine output is decreased.
1. Renal failure
2. Nephrotic syndrome
Respiratory Rate
C. Hypoproteinemia; other It should be counted for full minute
than nephrotic syndrome counting abdominothoracic movements.
(generalized) Normal rate is 14 - 16/minute.
1. Cirrhosis of liver (decreased
synthesis of albumin) Temperature
2. Malnutrition Thermometer can be placed at various
3. Malabsorption sites for recording the body temperature,
Localized (only in the affected part) eg, under the tongue, in the axilla, groin
1. V enous obstruction or rectum. Mouth or axilla is the usual
2. Immobile, bedridden patient, eg, sites. The rectal temperature is 1.0°F
paralysis higher than the oral temperature which
3. Inflammation (eg, cellulitis) in turn is 1.0°F higher than the axillary
Non-pitting edema* temperature. Rectal readings are more
1. Lymphatic obstruction reliable than oral or axillary readings.
a. Filariasis Normal average oral temperature is
b. Milroy's syndrome 98.4°F (98°F - 99°F) with a variation of
c. Surgical removal/irradiation of 1.0T between morning and evening
lymph nodes (diurnal variation).
2. Angioedema
Patient should not have taken
3. Myxedema
hot or cold drink immediately
before recording oral temperature.
* * A part of the body looks swollen (veins, tendons
and bones are obscured) but there is no pitting on Thermometer should be shaken well
pressure. It should be differentiated from obesity in below 98.4°F and left in place for
which skin is normal and foot (hand in case of upper
limb) is spared while in non-pitting edema skin is
1/2- minutes (a little longer than the
thickened and foot (or hand) is swollen too. manufacturer instructions).
PDFelement
Pallor Peripheral cyanosis

Anemia (reduced hemoglobin If only nails, nose and ear lobules
concentration) is the most are cyanosed while the color of
common cause of pallor.
the lips and tongue is normal, it is
Vasoconstriction (as a result of
called peripheral cyanosis. It is due
shock, heart failure and exposure
to, either reduced blood supply or
to cold or Raynaud's phenomenon)
and hypopituitarism are other defective venous drainage. The
causes. It should be looked for at hands are usually cold in this
following sites: condition.
Nails
Palmar skin Causes
Lower conjunctiva
1. Exposure to cold
Dorsum of the tongue
Vasodilatation may deceptively 2. Severe hypotension
produce pink color in the presence
of anemia. 3. Raynaud's, phenomenon
4. Venous obstruction
Cyanosis*
Central cyanosis
If the concentration of reduced
hemoglobin in blood rises above 5 If lips and tongue are also cyanosed,
gm%, a bluish tinge is seen in the it is called central cyanosis. It
skin and mucous membrane; this may be due to the inability of
is called cyanosis. Sites to look for the lungs to oxygenate the blood,
cyanosis are:
or the mixture of venous blood
Nails with arterial blood in the heart
- Tip of the nose or outside. Patient is usually
dyspneic.
Ear lobule
Inner surface of the lip
Tongue Causes
1. Respiratory failure (page 106)

Bluish discoloration also occurs due to 2. Cyanotic heart diseases (Fallot's
sulfhemoglobin and methemoglobin which
are abnormal pigments formed as a result
tetralogy, transposition of
of exposure to certain drugs or toxins. The great arteries, Eisenmenger's
patient is not breathless. Oxygen saturation
of hemoglobin is normal. Diagnosis is made
syndrome)
by spectroscopic examination of blood.
PDFelement
In cirrhosis, the pubic hair distribution

Jaundice
becomes female type in male patients,
Bilirubin is the end product of and there is loss of axillary hair. In
hemoglobin metabolism. When its certain endocrinal disorders, there is
concentration in the serum rises hirsutism (hair growth on face, trunk
above 2 mg%, it becomes clinically *
and limb of a female).
detectable as a yellow discoloration
of various tissues and is called Pigmentation
jaundice. It should be looked for in
In Addison's disease (decreased
bright day light as mild jaundice
may be missed in artificial light.
production of cortisol by adrenal glands),
Sites to look for jaundice are: there is dark brown pigmentation of
exposed parts, axillae, palmar creases and
Skin recent scars. A bluish black pigmentation
Sclera (most reliable site) is also seen in buccal mucosa but it may
Undersurface of the tongue be normal in Negroes.
Generalized greyish-bronze color
Jaundice should be differentiated pigmentation is a feature of
from an uncommon condition hemochromatosis.
called hypercarotenemia which
Mask-like pigmentation (also called
occurs in people who eat excessive
chloasma) occurs in pregnancy (it
quantities of carrots. Skin is yellow
may occur in women taking estrogen
but sclera is white.
containing contraceptive pills).
Cafe au lait spots: These are brown
Subcutaneous Emphysema patches of pigmentation seen in patients
Crackling sensations are felt when the of neurofibromatosis.
affected skin is palpated. It is due to Albinism: There is congenital absence
leakage of air from the chest as a result of melanin pigment which is generalized.
of penetrating chest injury, accidental
Vitiligo: There are patches of white and
injury to the lung during thoracic
paracentesis, escape of air during darkly pigmented skin. It is associated
intubation of chest for pneumothorax with autoimmune disorders.
or rupture of esophagus. It is also present
Abnormal Sounds and Odors
in gas gangrene.
Stridor is an inspiratory whistling
Hair Distribution sound heard in upper respiratory tract
There is characteristic distribution of obstruction. Wheeze is similar sound but
hair in male and female. In female pubic occurs in expiration and is due to spasm
hair are limited to the pubic area with of smaller airways.
horizontal upper border while in male In hepatic failure there is a sickly odor
they spread further up the abdomen in the breath of the patient and is called
towards the umbilicus in a triangular fetor hepaticus. In ketoacidosis there is a
pattern. sweat smell of acetone in breath.
PDFelement
BEDSIDE TECHNIQUES
BagaS&ammaMaMMMaMMaaNMMMMMMWMMMMMMM
Definitions of Skin Lesions Ecchymosis: These are large reddish

blue lesions due to bleeding into
Macules: TheseV are areas of skin
subcutaneous tissue and are also called
discoloration which are neither raised
bruises.
nor depressed.
Hematoma: It is palpable fluctuant
Papules: These are elevations of“S*kin
collection of blood.
which are palpable and diameter is less
Telangiectases: These are groups of
than 5 mm.
abnormally dilated small blood vessels.
Nodules: These are similar to papules
Spider nevi: These consist of a central
but diameter is more than 5 mm.
arteriole from which several branches
Vesicles: These are cystic swellings radiate. When the central arteriole is
containing serous fluid and diameter is obliterated by pressure with a needle, all
up to 5 mm. the branches are blanched and refilling
Pustules: These are similar to vesicles starts from the center when needle is
but fluid is opaque and yellow. removed.
Bullae: These are cystic lesions of more Campbell de Morgan spots: These are
than 5 mm diameter and are filled with red swellings, 1 - 2 mm in diameter which
serous, seropurulent or hemorrhagic don't fade on pressure and commonly
fluid. develop on chest and abdomen with
Wheals: These are swellings of skin due
advancing age.
to acute localized edema. Erythema nodosum: There are red,
painful, tender, indurated swellings
Scales: These are formed by abnormal
of variable size (from few millimeters
desequamation of superficial layer of
to several centimeters) mainly on the
skin.
shin. Common causes are primary
Crusts: These are formed by dried tuberculosis, streptococcal infection,
secretions. sarcoidosis and drugs.
Purpura: It means bleeding into the Erythema marginatum: These are
skin. transient pink patches mainly on the
Petechiae: These are red lesions 1-3 trunk which join to form large areas
mm diameter due to bleeding and don't with pale center, and are one of the
blanch on pressure. major criteria of rheumatic fever.
PDFelement
CH I HISTORY TAKING AND PHYSICAL EXAMINATION \
29
SUMMARY OF GENERAL PHYSICAL EXAMINATION
Young or old
General appearance
Healthy or ill
Normal
Unusually tall or short
Physique
Obese, thin or wasted
Puffy
Alert and oriented
Confused
Consciousness Drowsy
Unconscious (test conscious
level using Glasgow coma
scale)
Posture and attitude Comfortable
Lying in the bed
Dyspneic Lying propped up
Sitting up and bending
forward
Lying still
In pain
Writhing in the bed
Shape Short metacarpals
Hand
Carpal spasm
Size Normal or broad
Pallor
Cyanosis
Koilonychia
Nails Clubbing
Splinter hemorrhages
Leuconychia
Pitting of nails
Osier's nodes
Heberden's nodes
Bouchard's nodes
Fingers
Joint swelling
Deformity of fingers
Arachnodactyly
PDFelement
BEDSIDE TECHNIQUES
Pallor
Palmar erythema
Palm Sweating
Dupuytren's contracture
Pulse Rate and rhythm

Palpatory method
Blood pressure
Auscultatory method
Moonlike face
Face General appearance
Expressionless face
Puffiness
Proptosis
Xanthelasmas
Color of lower conjunctiva
Color of sclera
Rash
Color of skin
Hirsutism
Parotid glands
Lips
Dryness (dorsum of
tongue)
Pallor or cyanosis
Tongue (dorsum of tongue)
Yellowness
(undersurface)
Size
Inspection
Palpation
Neck Thyroid
Auscultation
Pemberton's sign
Venous pulsations
Neck veins Level of jugular venous
pressure
PDFelement
Submental
Submandibular
Pre and postauricular
Lymph nodes
Occipital
Posterior triangle
Anterior triangle
Anterior
Posterior
Lymph nodes
Lateral
Axilla (note characteristics if
Medial
palpable)
Central
Apical
Groin Lymph nodes
Clubbing
Koilonychia
Feet Cyanosis
Loss of hair
Edema
Dorsum of foot
Behind medial malleolus
Pitting
Edema Shin
Non pittingv
Sacrum (bedfast patient
only)
Respiratory rate Count for full minute
Keep the thermometer in the
mouth, axilla or groin longer
Temperature
than recommended by the
manufacturer
PDFelement
£9 BEDSIDE TECHNIQUES
WRITING OUT ROUTINE EXAMINATION

An ill looking old man lying in the bed. He is of normal height and built and fully
conscious. *
Pulse: 80/minute
BP: 160/95
Respiration: 24/minute
Temperature: 100°F
Pallor: absent
Cyanosis: absent
Jaundice: absent
Clubbing: absent
Koilonychia: absent
Splinter hemorrhage: absent
Leuconychia: absent
Osier's node: absent
Heberden's nodes: absent
Bouchard's nodes: absent
Interphalangeal joints: normal
Hand deformity: absent
Hand size and shape: normal
Palmar sweating: absent
Palmar erythema: absent
Dupuytren's contracture: absent
Periorbital edema: absent
Proptosis: absent
Skin rash: absent
Parotid gland: not enlarged
Thyroid: diffusely enlarged, nontender, no bruit audible
Neck veins: not engorged
Lymph nodes:
Cervical; two postauricular lymph nodes palpable, 1 cm diameter, discrete, mobile,
nontender, no discharge or sinus.
Axillary; not palpable
Inguinal; not palpable
Ankle edema: present, pitting
Dehydration: absent
PDFelement
Chapter
O 1 CARDIOVASCULAR
SYSTEM
Clinical examination of the CVS Dyspnea
(Cardio Vascular System) is particularly Dyspnea or breathlessness means
rewarding as it usually leads to an difficulty in breathing. It may occur
accurate diagnosis. Investigations are on exertion or at rest.
carried out, either to confirm the clinical
impression or to differentiate between
Exertional Dyspnea
various possibilities. It is an early symptom of heart
failure. Initially, it may occur after
unaccustomed or strenuous exertion,
SYMPTOMS but as disease progresses, patient may
Early diagnosis of important cardiac become breathless even on walking a
diseases like ischemic heart disease and few steps.
heart failure is based on careful history
Paroxysmal Nocturnal Dyspnea
taking.
The patient wakes up at night due to
There are two cardinal symptoms of severe breathlessness which improves
cardiovascular disease - dyspnea and on sitting upright for several minutes,
chest pain. and is usually accompanied by cough
and frothy sputum. This is called
Major symptoms of paroxysmal nocturnal dyspnea. This
cardiovascular disease is due to transient pulmonary edema,
Dyspnea Exertional precipitated by increased venous return
dyspnea to the heart in recumbent position. It
is a feature of left heart failure; causes
Paroxysmal
include left ventricular pressure/
nocturnal volume overload (hypertension, mitral/
dyspnea aortic valve disease) and severe left
Orthopnea ventricular disease (ischemic heart
Chest Ischemic Angina disease, cardiomyopathy).
pain heart disease Infarction Orthopnea
Pericarditis In patients of severe heart failure
Dissection of breathlessness worsens on lying flat;
the aorta this is called orthopnea.
33
PDFelement
leaning forward and may get worse on

Pulmonary edema deep breathing and coughing.
There is transudation of fluid
Dissection of the Aorta
into the alveoli due to left heart
dysfunction. Symptoms are Pain is severe in intensify and is felt in
the back between the scapulae.
persistent severe breathlessness,
orthopnea and cough productive Precordial Gatch
of copious, frothy, watery, blood It is a transient, sharp pain at the site
stained sputum. of the cardiac apex, commonly felt by
normal subjects. It has no significance.
Note: Persistent precordial pain
CHEST PAIN unrelated to the exertion, is not due to
It is an important symptom of heart cardiac disease.
disease. Its characteristics vary with the
underlying pathology. PALPITATION
It is awareness of the heart beat and
Ischemic Heart Disease is a common feature of anxiety. It also
It means the coronary arteries cannot occurs in tachycardia and heart failure.
maintain adequate blood supply to the
myocardium. It may present as angina
Examination
or infarction. When you are asked to examine a
particular system of a patient, always
Angina Pectoris start from the general physical
There is transient myocardial ischemia. examination except when examiner
The patient develops chest pain on asks you to omit it.
exertion which is relieved by rest Examination of the cardiovascular
and sublingual nitroglycerin. Pain is system consists of:
retrosternal, across the chest and radiates 1. Examination of pulse
to the jaw and left arm. Patient describes 2. Measurement of blood pressure
it as a tight band around the chest or 3. Examination of neck veins
heaviness. It may be associated with
4. Examination of precordium by:
dyspnea, palpitation and sweating. Total
duration of pain is less than 30 minutes. a. Inspection
b. Palpation
Myocardial Infarction c. Percussion
There is total occlusion of one or more d. Auscultation
branches of the coronary artery and
the dependent myocardium dies. Pain Examination of Pulse
is similar to that of angina pectoris but The pulse is a wave imparted by the
duration is more than 30 minutes and it contraction of the left ventricle to the
is not relieved by sublingual nitrates blood column and travels 10 times faster
or rest. than the blood itself. Pulse is felt where
an accessible artery can be pressed
Pericarditis against an underlying bone.
Features are similar to the pain of Commonly felt pulses are radial, brachial,
ischemic heart disease. There is no carotid, femoral, popliteal, posterior
effect of rest or nitrates. It is relieved by tibial and dorsalis pedis. Pulse becomes
PDFelement
CH 2 CARDIOVASCULAR SYSTEM 35
impalpable when systolic pressure falls Palpate the right carotid from the right
below 50 mmHg in adults. side and the left from the left side.
Radial pulse: It is the most easily
accessible and the most commonly felt
pulse. The patient's hand should be
slightly flexed and pronated. Pressr the
radial artery against the head of the
radius (fig 2.1 A).
Fig 2,2: Palpation of carotid pulse
Femoral pulse: Press with the thumb/

finger halfway between the anterior
superior iliac spine and the pubic tubercle
along inguinal ligament (fig 2.3A).
Fig 2.1: Palpation of (A) radial pulse (B) brachial

pulse
Brachial pulse: Flex the patient's arm

and feel for the tendon of the biceps;
press on its medial side with the thumb
of your opposite hand (fig 2.1B).
Carotid pulse: Place the thumb or
fingers of your opposite hand along the
anterior border of the sternomastoid, at
the level of laryngeal cartilage and press
backwards (fig 2.2). Keep in mind that
carotid sinus (present at the bifurcation
of common carotid artery) may be
stimulated and can result in bradycardia
or syncopy. Don't palpate both carotids
simultaneously because blood supply
Fig 2.3: Palpation of (A) femoral pulse (B) popliteal pulse
to the brain may be critically reduced
PDFelement
BEDSIDE TECHNIQUES
Popliteal pulse: Popliteal artery lies except in certain arrhythmias like atrial
deep in the popliteal fossa and is difficult fibrillation.
to palpate. Flex the knee at an angle of 1. Tachycardia: It means pulse rate is
120° and push finge’rs of both hands into more than 100 per minute.
the popliteal fossa (fig 2.3B). 2. Bradycardia: It means pulse rate is
Dorsalis pedis pulse: Palpate in the less than 50 per minute.
proximal part of the first intermetatarsal
3. Relative bradycardia: Normally
space (fig 2.4A). pulse rises 10 beats per minute for
Posterior tibial pulse: Palpate behind each degree F (or 0.5°C) rise in the
body temperature. If pulse rate is
slower than expected for the body
temperature, it is called relative
bradycardia.
Rhythm
Normally interval between the beats is
constant and rhythm is regular (fig 2.5).
If it is dis turbed, pulse becomes irregular.
1. Sinus arrhythmia: Pulse rate is
faster during inspiration and slower
during expiration (fig 2.6). This is a
normal phenomenon and is more
pronounced in certain individuals.
It disappears in heart failure and
autonomic neuropathy.
2. Occasional irregularity: It is due
to premature beats. Premature beat
occurs earlier than expected normal
beat, is weak and is followed by a
longer pause (fig 2.7). Occasional
premature beats are common in
healthy individuals and are not
significant. Frequent premature
During examination of pulse note beats in a patient with underlying
the following features. heart disease should- be taken
seriously.
1. Rate
2. Rhythm 3. Regularly irregular: Premature
beats occur at a fixed interval
3. Volume (fig 2.8), eg, after one normal beat
4. Character (bigeminy) or two normal beats
5. Comparison with other pulses (trigeminy). Digoxin toxicity is
6. Condition of the vessel wall the most common cause of such
arrhythmias.
Rate 4. Irregularly irregular:There is no
Count the pulse for full one minute. pattern and beats occur irregularly
Normal average pulse rate is 72 beats (fig 2.9). It is easier to detect if rate
per minute. It is equal to the heart rate is fast.
PDFelement
CH 2 - CARDIOVASCULAR SYSTEM
Causes of abnormal heart rate

Relative
Tachycardia Bradycardia
bradycardia
1. Exercise
2. Anxiety 1. Athletes 1. Enteric fever
3. Fever 2. Complete heart 2. Viral
4. Anemia block infections
5. Heart failure 3. Drugs like digoxin, 3. Meningitis
6. Hypotension beta blockers with raised
7. Thyrotoxicosis 4. Raised intracranial intracranial
pressure pressure.
8. Tachyarrhythmias
(eg, supraventricular 5. Hypothyroidism
tachycardia)
Causes
1. Atrial fibrillation
2. Frequent multiple premature
beats
a 3. Atrial flutter with varying block
Inspiration Expiration
Pulse deficit: In atrial fibrillation some
of the left ventricular contractions are
weak and are not conducted to the arteries;
Fig 2.6: Sinus arrhythmia the pulse rate is slower than the heart rate
counted by auscultation. The resulting
difference between pulse rate and
heart rate is called pulse deficit.
Causes of atrial fibrillation

1. Mitral stenosis
2. Thyrotoxicosis
3. Ischemic heart disease
v________________________________________ y Volume of Pulse

Fig 2.8: Regularly irregular pulse
This is the amplitude of the pulse wave
and is determined by the amount of
displacement of the palpating fingers.
Pulse could be of normal volume
(learned by experience), high volume (eg,
fever, aortic regurgitation) or low volume
(heart failure, hypovolemic shock).
PDFelement
In younger people it reflects stroke cause, but it can also occur in

volume. In old age vessel wall becomes ventricular septal defect, persistent
rigid and pulse volume is higher than ductus arteriosus and severe anemia.
expected for the stroke volume. 3. Pulsus bisferiens: Two systolic
peaks are palpable in one pulse.
Character of Pulse (In dicrotic pulse 2nd peak is in
In certain diseases the pulse wave has a diastole. It is not palpable and is
specific wave form or character. A major only seen on direct recording of
pulse close to the heart (brachial, carotid, the pulse) (fig 2.12). It is sometimes
femoral) should be palpated for this seen in combined aortic stenosis and
purpose. regurgitation.
1. Slow rising pulse (pulsus
plateau): It is a low volume pulse,
rises slowly and stays longer with
the palpating finger (fig 2.10).
pressure is narrow. It occurs in
Fig 2.12: Pulsus bisferiens
aortic stenosis.
4. Jerky pulse: In hypertrophic
obstructive cardiomyopathy ejection
of blood is normal initially. It is
then suddenly obstructed by the
Fig 2.10: Slow rising pulse
contraction of a band of muscle in
the aortic outflow tract. It gives a
2. Collapsing pulse (water hammer
pulse): It is a high volume pulse
jerky character to the pulse (fig 2.13).
with normal upstroke but rapid
downstroke (fig 2.11).
Fig 2.13: Jerky pulse
Fig 2.11: Collapsing pulse

5. Pulsus paradoxus: Pulse either,
becomes weak or impalpable during
Grasp the patient's wrist with inspiration. This is an exaggeration
your right palm in such a way of a normal phenomenon (2.14).
that radial pulse is felt along
metacarpophalangeal prominences.
Lift the patient's arm suddenly by
grasping his fingers with your left
hand (not with the right hand).
There is increased run-off of blood
towards heart due to effect of the
gravity and collapsing character of
the pulse becomes more obvious.
The collapsing pulse reflects wide
pulse pressure (>60 mmHg). Aortic
regurgitation is the most important
PDFelement
CH 2 - CARDIOVASCULAR SYSTEM 39
Normally, during inspiration there is palpatory method. Lower the pressure

a fall in the systolic pressure, about in the cuff gradually; at first Krotokoff
5 mmHg or less; in pulsus paradoxus this sounds for strong beats will appear. Note
fall is more than 10 mmHg. It occurs the number of these Krotokoff sounds
in massive pericardial effusion (cardiac per minute. Further lower the pressure
tamponade), constrictive pericarditis and in the cuff. When level of systolic
acute severe bronchial asthma. pressure for weak beats is reached, the
Pulsus paradoxus** * can be confirmed rate of Krotokoff sounds will suddenly
by checking the blood pressure during become double. This phenomenon will
inspiration and expiration. Ask the confirm presence of pulsus alternans.
patient to breath quietly. Inflate the
7. Pulsus bigeminus: It is similar
cuff above systolic level and then deflate
it gradually. Note the level at which to pulsus alternans, but interval
Krotokoff sounds first appear. These between beats is variable. A strong
will be audible during expiration only. beat and a weak beat occur close
Continue deflating the cuff till the sounds to each other followed by a long
remain audible throughout respiratory pause (strong and weak beats are
cycle and note this level as well. In pulsus coupled), and this cycle is repeated
paradoxus difference between these two (fig 2.16). Strong beat is a normal
levels is more than 10 mm Hg. beat. Weak beat is a premature
6. Pulsus alternans: A strong beat beat which occurs earlier than its
alternates with a weak beat, but the expected time, and is followed by
interval between beats is constant a compensatory pause. Diagnosis
and rhythm is regular (fig 2.15). It is is confirmed on ECG which shows
seen in left ventricular failure and ventricular bigeminy. Digoxin
supraventricular tachycardia. toxicity is the most important cause.
Fig 2.15: Pulsus alternans

Fig 2.16: Pulsus bigeminus
Level of systolic pressure is high for

strong beats and low for weak beats; Comparison with other Pulses
this helps in confirming the presence of Palpate corresponding pulses of both
pulsus alternans by using BP apparatus. sides simultaneously and compare their
Inflate the cuff above systolic blood volume except carotids. Don't palpate
pressure level as determined by the
both carotids simultaneously (see
* In cardiac tamponade only systolic pressure page 35). Compare radial and femoral
decreases; diastolic remains unchanged and pulse pulses; in coarctation of the aorta, femoral
pressure is reduced. In bronchial asthma both
systolic and diastolic pressures fall during inspiration pulse is weak and delayed as compared
and pulse pressure remains unchanged (fig 2.14). to radial pulse (radiofemoral delay)
This is due to marked changes in the intrathoracic
pressure which are transmitted to the vessels. (fig 2.17).
PDFelement
BEDSIDE TECHNIQUES
Radiofemoral delay is the most Condition of the Vessel Wall

important clinical feature of Feel the radial pulse with three fingers.
the coarctation of the aorta.
Press with the proximal finger so that the
pulse is occluded and feel the vessel wall
with the middle finger. Normally it is
not palpable. In advanced atherosclerosis
it can be felt as a cord between finger
and underlying bone.
CHARACTERISTICS OF PULSE
Characteristics Example Description Causes

Rate 4 Tachycardia 4 Pulse rate 4 Exercise
more than 4 Anxiety
100/minute 4 Fever
4 Anemia
4 Heart failure
4 Hypotension
4 Thyrotoxicosis
4 Tachyarrhythmias
+ Bradycardia 4 Pulse rate 4 Athletes

less than 50/ 4 Complete heart
minute block
4 Drugs (digoxin, beta
blockers)
4 Raised intracranial
pressure
4 Relative 4 Pulse rate 4 Enteric fever
bradycardia is less than 4 Viral infections
expected
for body
temperature
Rhythm 4 Regular 4 Interval
between
the beats is
constant
PDFelement
4 Sinus 4 Pulse rate is + It is a normal

arrhythmia faster during phenomenon and is
inspiration absent in:
and slower 4 Heart failure
during
4 Autonomic
expiration
neuropathy
+ Occasional + It is due to 4 Common in
irregularity occasional healthy persons
in pulse premature 4 Any myocardial
beats disease
4 Regularly 4 Irregularity 4 Digoxin toxicity
irregular comes at
pulse regular
intervals
+ Irregularly + No regularity 4 Atrial fibrillation
irregular at all 4 Multiple ectopics
pulse
4 Atrial flutter with
varying blocks
+ Pulsus 4 Heart rate is 4 Atrial fibrillation
deficit faster than Causes
pulse rate
4 Mitral stenosis
and it is the
difference 4 Thyrotoxicosis
between the 4 Ischemic heart
two disease
Volume 4 Normal 4 It is learnt by
practice
4 Low volume + Pulse is weak 4 Heart failure
pulse 4 Hypovolemic shock
+ High + Pulse is 4 Fever
volume bounding 4 Severe anemia
pulse
4 Aortic regurgitation
Character + Slow rising + Low volume 4 Aortic stenosis
pulse pulse, rises
slowly and
stays longer
. with the
finger
PDFelement
■+ Collapsing 4 High volume 4 Aortic regurgitation

pulse pulse with + Persistent ductus
normal arteriosus
upstroke
4 AV fistula
but rapid
downstroke
4 Pulsus + Two upstrokes 4 Combined aortic
bisferiens in one beat stenosis and
regurgitation
+ Pulsus 4 Pulse becomes 4 Cardiac tamponade
paradoxus weak or + Acute severe
impalpable asthma
during
inspiration
4 Pulsus 4 A strong beat + Left ventricular
alternans alternates failure
with a weak 4 Supraventricular
beat and tachycardia
the interval
between them
is constant
4 Pulsus 4 Strong and 4 Digoxin toxicity
bigeminus weak beats are (ventricular
coupled and bigeminy)
are followed
by a longer
pause
Comparison + Radio 4 Femoral pulse 4 Coarctation of aorta
with other femoral is delayed
pulses delay compared
with radial
pulse
PDFelement
MEASUREMENT OF BLOOD Method

PRESSURE Patient should be resting and relaxed,
sitting or lying. Place the manometer at
The Blood Pressure (BP) is the product the same level as cuff on the patient's
of the heart rate, stroke volume and arm (this is not necessary if aneroid
peripheral resistance. There are two type of sphygmomanometer is used).
levels - systolic and diastolic. The cuff should be wide enough to cover
There are two types of blood pressure about two thirds of the arm length.
apparatuses (sphygmomanometers) Higher reading is obtained if a small cuff
in common use. In Mercury is used. The length of the cuff should be
Sphygmomanometer a column of about 80% of the circumference of the
mercury moves up and down in a limb and width should be 40% of the
calibrated vertical glass tube as the cuff circumference of the limb (fig 2.20) A
is inflated and deflated (fig 2.18). In standard adult cuff is 12.5 cm wide. In
Aneroid Sphygmomanometer a spring is children smaller cuffs are used.
connected to a needle; when the pressure
in the cuff changes, this needle moves
on a dial and indicates pressure (fig
2.19). This is less reliable and should be
frequently compared with a mercury
sphygmomanometer.
Fig 2.20: Blood pressure apparatus cuff; length is

equal to 80% of the limb’s circumference, width is
equal to 40% of the limb’s circumference
Remove all the clothing from the upper arm.

Apply the cuff closely to the upper arm in
such a way that its lower border is not less
than 2.5 cm (1") above the cubital fossa and
tubing is on the medial side (fig 2.21)
Fig 2.18: Blood pressure apparatus; Mercury type |
Fig 2.21: Application of cuff to the arm; distance

from the cubital fossa should be at least 1 inch
PDFelement
Palpatory Method level at which fainting of sounds (phase

Feel the radial pulse (fig 2.22). Inflate the IV) occurs is taken as the diastolic level.
cuff to a pressure above the level at which
the radial pulse becomes impalpable and
then gradually deflate it. The level at
which the radial pulse becomes palpable
again is taken as the systolic pressure.
It is a few mmHg less than the systolic
pressure measured by the auscultatory
method. Deflate the cuff completely.
Fig 2.23: Measuring BP: auscultatory method
9999995 190
160
140
120
Fig-2.22: Measuring BP: palpatory method

112-
Auscultatory Method
Palpate the brachial artery which lies
on the medial side of the tendon of the
biceps.
Place the stethoscope lightly over it
(fig 2.23) and inflate the cuff above A
the systolic level determined by the J
palpatory method. Lower the pressure in Fig 2.24: (A) normal Krotokoff sounds (B) silent gap
the cuff by 5 mmHg at a time. The level
at which the Krotokoff sounds are heard
for the first time is the systolic pressure. Normal Blood Pressure
The Krotokoff sounds become louder as It varies with age. In adults’<130/85 is
the pressure is lowered further; suddenly normal, 130-139/85-89 is high normal and
they become faint (phase IV) and then 140/90 or above is hypertension. Blood
disappear (phase V). The level at which pressure is lower in children and women
sounds disappear is the diastolic pressure and higher in elderly.
(fig 2.24A). In certain high cardiac Pulse pressure: It is the difference
output states the sounds remain audible between the systolic and the diastolic
at a very low level. In these situations the pressure. Normal range is 30 - 60 mmHg.
PDFelement
Silent Gap angle of 45°, the transition point is just

Normally Krotokoff sounds once behind the clavicle. If patient is inclined
becoming audible a;t the systolic pressure, further or there is increase in the right
only disappear at the diastolic pressure. atrial pressure, the transition point
In some hypertensive patients these will become visible in the neck above
sounds disappear for sometime between the clavicle as upper limit of venous
systolic and diastolic pressures. This pulsations (fig 2.25).
is called the silent gap (fig 2.24B). Its
significance is not known, but there is a
risk of, either recording a low systolic level
if systolic pressure is not measured with
palpatory method before auscultatory
method or a high diastolic level if one
does not continue auscultation till below
normal diastolic level.
NECK VEINS
Fig 2.25: Jugular venous pressure in a normal
The central venous pressure (which is
subject; (A) in supine position veins are distended
the same as the right atrial pressure) is
but transition point between distended and collapsed
an important guide to the cardiovascular vein is not visible (B) at the angle of 45 degrees
function. It is measured by inserting a transition point between distended and collapsed
catheter into the right atrium through vein is just below the clavicle (C) in upright position
the internal jugular or subclavian vein. transition point between distended and collapsed
A nearly accurate estimation of the right vein is hidden behind the sternum
atrial pressure can be made clinically
by observing the upper limit of venous As guessing the position of the center of
pulsations in the neck and measuring the right atrium might create confusion,
its distance from the sternal angle (see it has become traditional to use the
below). It is then called JVP (Jugular manubriosternal angle (the angle of
Venous Pressure). Louis) as reference point for measuring
the venous pressure. It is 5 cm above
Neck veins are in continuity with the the center of the right atrium and its
right atrium. They become distended position doesn't vary much with the
when filled with the blood, otherwise change in the posture. As normal mean
are collapsed. Normal mean right atrial pressure of the right atrium is 7 to 8 cm
pressure is 5 mmHg, equivalent to 7 cm of blood, JVP more than (7 - 5) 2 to 3 cm
high column of blood. In the upright above the sternal angle is abnormal.
position the proximal 7 - 8 cm of veins,
as measured from the center of the right Jugular Venous Pulse
atrium, remain distended. The transition + There are two waves - a' and 'v', and
point between distended and collapsed two descents - 'x' and 'y* (fig 2.26).
veins is hidden behind the clavicle and + The 'a' wave coincides with the right
sternum. If patient is inclined at the atrial contraction.
PDFelement
MNNMMMMMI
+ The 'x' descent .is due to the right the superior vena cava, so it can't
atrial relaxation. truly reflect right atrial pressure.
+ A small wave (called 'c' wave) which b. It is superficial and is easily affected
is seen on ’x’ descent during recording by changes in the local pressure.
of venous pulsations is thought to be
an artefact due to carotid pulsations. Head end of the patient should
+ The 'v' wave represents filling of the be elevated to an angle of 45
right atrium as a result of venous for examination of neck veins.
return.
4- The ’y' descent is due to emptying + The right side is preferred because
of the right atrium into the right the right internal jugular is more
ventricle during ventricular diastole. in line with the superior vena cava
than the left.
+ The internal jugular vein lies deep
with the carotid artery and is not
visible. But if venous pulsations are
present, they can be seen along the
anterior border of the sternomastoid.
They are more easily visible from
the side (in profile) than from the
front (en face).
Difference between arterial and
venous pulsations in the neck
Arterial pulsations are commonly visible
in the neck and venous pulsations have
Method to be differentiated from them. The
following points will help:
+ The patient should be propped up
at an angle of 45°. If there is slight 1. Venous pulsations have a definite
increase in the right atrial pressure, upper limit which represents the
venous pulsations will become transition point between distended
visible in the neck at this angle. and collapsed part of the vein. It is
+ The head should be well supported affected by:
and slightly tilted towards left and + Change in posture; moves up in
be in line with the trunk. recumbent position and < down in
+ There should be enough light. upright position.
+ The internal jugular vein is + Respiration; falls during
preferred over the external jugular inspiration.
vein because, although external + Change in the intraabdominal
jugular vein is easily visible, it is not pressure; if abdomen is suddenly
reliable for two reasons: pressed, it will move up (abdomino
a. There is a valve at its junction with jugular reflux).
PDFelement
Arterial pulsations, don't have any of Note:

these properties. Sometimes venous pressure is so high
2. In venous pulsations inward that venous pulsations only become
movement is more prominent visible when patient is upright or veins
while in arterial pulsations outward of the hand remain distended until it is
movement is more prominent.
raised well above the head.
3. There are for each arterial
pulsation. Palpate left carotid Measurement of JVP
artery from left side of the patient Once upper limit of venous pulsations
and compare with the pulsations has been determined, JVP is measured
visible on the right side (fig 2.27).,
by two pencils method. Place one pencil
4. If gentle pressure is applied at the at the sternal angle vertical to the
base of the neck, venous pulsations ground and other pencil at upper limit
disappear while arterial don't.
of venous pulsations (transition point
5. Venous pulsations are not palpable of distended and collapsed vein) in the
(except in tricuspid regurgitation)
neck, horizontal to the ground. Measure
while arterial pulsations are easily
palpable.
length of the vertical pencil (in cm)
between the sternal angle and where it
6. Venous pulsations are wavy.
is crossed by the horizontal pencil. It is
7. If venous pressure is very high, it
JVP (fig 2.28); upto 3 cm is normal.
may cause pulsatile displacement
of ear lobule; it doesn't occur due
to arterial pulsations.
Fig 2.27: While standing on the left side of the

Fig 2.28: Measuring jugular venous pressure (A)
patient and palpating his left carotid, the examiner
transition point of distended and collapsed vein (B)
is looking for venous pulsations on the right side
sternal angle (C) vertical pencil (D) horizontal pencil
of the patient
PDFelement
BEDSIDE TECHNIQUES
Ventricular ization of venous pulse:

Causes of raised JVP
In tricuspid regurgitation a prominent
1. Right ventricular failure early systolic wave is produced. It
2. Constrictive pericarditis occurs earlier than usual 'v' wave and is
3. Pericardial effusion palpable (fig 2.30B).
4. Tricuspid valve disease Rapid 'if descent: In constrictive
Note pericarditis 'y' descent is rapid but halt
If neck veins are distended but non- is sudden.
pulsatile, cause is obstruction of the
superior vena cava.
Abnormal Wave Form

Venous waves 'a' and 'v' can be’
differentiated by comparing the venous
pulsations with the carotid pulsations
which represent systole; 'a' wave is
presystolic (comes just before the carotid
pulsation) while V' wave is late systolic
(comes close to the end of the carotid
pulsation) (fig 2.29). Normally 'x' descent
Fig 2.29: Relationship of the venous pulsations with

the carotid pulsations: ‘a’ comes before the carotid
pulsation, ‘v’ comes close to the end of the carotid
pulsation
Fig 2.30: (A) prominent ‘a’ wave
Prominent 'a' waves: These are seen (B) abnormal ‘v’ wave
in right atrial and right ventricular
hypertrophy (eg, due to pulmonary Kussmaul sign
hypertension or pulmonary stenosis} Inconstrictivepericarditis(lesscommonly
and tricuspid stenosis (fig 2.30A). in tamponade)the JVP, instead of falling,
Cannon waves: These are strikingly rises during inspiration. The downwards
large 'a' waves which are produced when movement of the diaphragm during
right atrium contracts against closed inspiration compresses the congested
tricuspid valve. These are seen in complete liver; the venous return is increased, but
heart block and ventricular pacing with right atrium cannot expand due to the
intact retrograde conduction. rigid pericardium and the JVP rises.
PDFelement
EXAMINATION OF 4- Prominent veins due to superior

vena cava obstruction.
PRECORDIUM
Palpation
Precordium is that part of the chest wall Palpate the precordium with the flat of
which overlies the heart. Examination of the palm starting from the lower part
the precordium consists of following-steps: of the left side of the chest, then along
4- Inspection. the left parasternal border and finally
4- Palpation. upper part of the right side of the chest.
4- Percussion. Note the following physical signs:
+ Auscultation. + Apex beat (site and character).
+ Left parasternal heave (also called
Inspection right ventricular heave).
Look for the following physical signs: + Palpable heart sounds.
+ Chest deformity (discussed under 4 Thrill (palpable murmur).
respiratory system). 4 Palpable pericardial rub.
+ Bulging of precordium.
+ Scars, particularly along the Apex Beat
It is defined as the lowermost and
sternum or intercostal spaces (these
outermost part of the precordium where
indicate past cardiac surgery).
a definite cardiac impulse is felt.
+ Pulsations: Apex beat is normally formed by the
• Apex beat. left ventricle.
• Pulsations along the Method
parasternal border, eg, due to The patient should be lying supine.
right ventricular hypertrophy. Place flat of the palm over the left side of
• Pulsations in the left 2nd the chest in a way that it covers 4th to 7th
intercostal space, eg, due to intercostal spaces and tips of the fingers
dilatation ofpulmonary artery. extend upto, lateral side of the chest wall
• Pulsations in the right 2nd (fig 2.31). Once pulsations are felt, locate
intercostal space, eg, due to their lowermost and outermost part
aneurysm of the aorta. with the tip of a finger (fig 2.32).
• Pulsations in the suprasternal
notch, eg, due to aortic
regurgitation.
• Pulsations in the epigastrium.
These are normally present in
thin individuals due to aorta.
They could also be due to
right ventricular hypertrophy,
pulsatile liver (tricuspid
regurgitation) or aneurysm of
the abdominal aorta.
• Whole of the precordium moves
with each cardiac beat if the
heart is greatly enlarged.
PDFelement
BEDSIDE TECHNIQUES
C '■ h while midaxillary line is drawn from

center of the axilla (fig 2.34).
»
W
W*
Fig 2.33: Palpation of apex beat in left lateral

position
If apex beat is not palpable in supine

position, turn the patient towards
left side or ask him to sit up and lean
forward and palpate again (fig 2.33). The
apex beat is slightly shifted with change
in the position of the patient. When apex
beat is palpable, determine its site and
character.
Localization
Move your finger from the suprasternal
notch downward along middle of the
sternum; first prominence felt is the
manubriosternal angle or angle of
Louis. At this site is attached the 2nd
costal cartilage and the space below
is the 2nd intercostal space. From here
count intercostal spaces, find out in
which space apex beat is palpable. Spaces
are more easily palpable away from the
sternum.
Distance of the apex beat from midline Fig 2.34: Reference lines on the chest (A) ipidsternal
is, either measured in cm or is described line (B) midclavicular line (C) anterior axillary line (D)
with reference to various imaginary midaxillary line (E) posterior axillary line
vertical lines. The midclavicular line is a
vertical line from a point on the clavicle + Normal apex beat is in the 4th or 5th
midway between its medial and lateral intercostal space, about 1 cm medial
ends. Anterior and posterior axillary to the midclavicular line.
lines are drawn along the anterior and + Shift of apex beat occurs if left
posterior axillary folds respectively ventricle is enlarged.
PDFelement
Causes of Shift of Apex Beat Left Parasternal Heave

Cardiac causes It is also called right ventricular
heave and is due to right ventricular
1. Mitral regurgitation
enlargement. Place the hand vertically
2. Aortic regurgitation
along the left parasternal border; if it
3. Aortic stenosis
moves with each cardiac contraction,
4. Ventricular septal defect
left parasternal heave is present (fig
5. Hypertension
2.35). Right venricular heave can also be
6. Ischemic heart disease felt in the epigastrium (fig 2.36).
7. Cardiomyopathy (dilated)
8. Occasionally a grossly dilated
right ventricle may cause shift of
apex beat
Non cardiac causes
1. Left lateral or sitting forward
position of the patient
2. Deformities of the chest (page 88)
3. Pulmonary diseases causing shift
of the mediastinum (page 91)
Causes of impalpable apex beat
1. Thick chest wall
2. Emphysema
3. Pericardial effusion
4. Dextrocardia (apex beat will be
palpable on the right side)
Fig 2.35: Palpation of left parasternal heave
Character of apex beat
Normal apex beat is neither forceful
nor does it lift the palpating finger (it is
neither tapping nor heaving).
Tapping apex beat: Apex beat is
forceful, but palpating finger is not
displaced. Feeling resembles hard knock
on the other side of a closed door. It is due
to palpable loud 1st heart sound in mitral
stenosis.
Heaving apex beat: Palpating f inger is
lifted.
Ill sustained heave: Finger is lifted for
a short period. It occurs when the left
ventricle has to eject excessive blood
volume, eg, mitral and aortic regurgitation.
Well sustained heave: Finger is lifted
for longer period. It occurs when the left
Fig 2.36: Palpation of right ventricular heave in the
ventricle has to contract against high
epigastrium
resistance, eg, aortic stenosis, hypertension.
PDFelement
+ Aortic component of the 2nd heart

Causes
sound (A2) my be palpable at the
1. Pulmonary hypertension: aortic area in systemic hypertension.
a. Mitral stenosis/regurgitation + Third and 4th heart sounds may also
b. Chronic lung disease be palpable.
c. Long standing atrial septal
Thrill
defect, ventricular septal defect,
persistent ductus arteriosus A loud murmur becomes palpable and
is called thrill. It is best exemplified by
d. Primary pulmonary
purring of a cat. Once experienced it is
hypertension
easily remembered.
2. Pulmonary stenosis
Thrills and sounds are timed by
3. Fallot's tetralogy comparing them with the carotid
pulsations. Those which come with
Palpable Heart Sounds the carotid pulsations are systolic and
First and second heart sounds, when those which alternate with the carotid
loud, become palpable. pulsations are diastolic.
+ First heart sound is palpable at the Thrills are best appreciated when the
apex in mitral stenosis and is called patient leans forwards, holding his
tapping apex beat. breath in expiration, except thrill of
mitral stenosis which is best palpable
+ Pulmonary component of the 2nd in the left lateral position. If a thrill
heart sound (P2) may be palpable at is palpable note its site and timings
the pulmonary area in pulmonary (systolic or diastolic). . Examples are:
hypertension. Pulsations due to diastolic thrill of mitral stenosis and
dilated pulmonary artery are also systolic thrill of mitral regurgitation,
felt at the same site. both are palpable at apex.*
Timing of thrill Site Cause

Mid diastolic thrill Apex Mitral stenosis
Systolic thrill Apex Mitral regurgitation
Left parasternal Ventricular septal
border defect
Pulmonary area Pulmonary stenosis
Aortic area Aortic stenosisl*
Early diastolic thrill is rare and
occurs if there is acute rupture Aortic area Aortic regurgitation
of aortic valve
Left 2nd intercostal Persistent ductus
Continuous thrill
space arteriosus
* Thrill of aortic stenosis is also palpable in the neck
and is called carotid shudder.
PDFelement
Percussion
As chest radiograph is a routine
investigation and shows the exact size
and shape of the heart, percussion of
the precordium for cardiac dullness
is not performed routinely nowadays.
Increased cardiac dullness due to a large
pericardial effusion may still be detected
on percussion.
For the right border percuss in the
2nd to 4th or 5th intercostal spaces,
laterally to medially, starting from
the midclavicular line. Normal cardiac
dullness is lateral to the right lateral
edge of the sternum in the 4th intercostal
space. For the left border percuss in the
3rd to 5th intercostal spaces (or below if
necessary), laterally to medially, starting
in the axilla. Normal cardiac dullness is
medial to the midclavicular line in the Fig 2.38: Chest piece of a stethoscope
4th intercostal space.
Auscultation Stethoscope (fig 2.37 and 2.38)

It consists of:
This is the most important step in the
examination of the cardiovascular 1. Chest piece
system. 2. Tubing
3. Ear piece
Bell Chest piece

It consists of a diaphragm and
a bell. The diaphragm filters
the low pitched sounds so that
the high pitched sounds become
more clearly audible. It should be
applied firmly to the chest wall.
The bell is used for the low pitched
sounds. It should be applied lightly
so that skin underneath is not
stretched, otherwise it will become
a diaphragm. The common low
Diphragm pitched sounds are 3rd and 4th heart
<__________ _________ y sounds, and mid diastolic murmur
of mitral stenosis.
Fig 2.37: Stethoscope
PDFelement
MM
Tubing
It should be thick and of uniform
caliber. An average length of 25
cm is appropriate.
Ear piece
Its knobs should comfortably fit
into the ears and spring should
have enough strength to hold
them in place. The stethoscope is
worn with the ear pieces pointed
slightly forward so that they are
in line with the external auditory
canal.
Method of Auscultation
Areas of Auscultation (fig 2.39) Auscultate whole of the

precordium, not just the areas
It has been found with experience described.
that sounds produced at a
particular valve are more clearly The areas mentioned above are useful
audible at a particular part of the for the description of clinical findings
precordium (although there are and drawing conclusions; otherwise
some exceptions). For each valve auscultation should not be restricted
there is a different such site and to these areas. Auscultate whole of the
is named after that valve as that precordium, either starting from the apex,
area. These areas don't represent moving up along the left parasternal
anatomical surface projections of border to the pulmonary area and then
the valves. to the Aj area or starting from the A1 area
The mitral area corresponds to and moving towards the apex (fig 2.40).
the apex.
The tricuspid area is close to the
lower part of the sternum on the
left side.
The pulmonary area is in the
left 2nd intercostal space close to
the sternum.
There are two aortic areas;
the Aj (aortic 1) is in the right
2nd intercostal space close to the
sternum, the A2 (aortic 2) is in the
left 3rd intercostal space close to
the sternum. In further discussion
aortic area will mean A, unless
mentioned otherwise.
PDFelement
MMMM
55
MMMMMMMI
+ Auscultate in supine position, at first and ventricles are called atrioventricular

with the diaphragm and then with valves; the valves between ventricles
the bell. and major vessels are called semilunar
+ Turn the patient to the left lateral valves.
position and auscultate at apex with
the bell for mid diastolic murmur of Mitral valve lies between left
mitral stenosis. atrium and left ventricle. It has
+ Ask the patient to sit up and two cusps (or leaflets); anterior
lean forward, and auscultate the and posterior.
pulmonary and A2 areas with the Tricuspid valve lies between
diaphragm. Patient should hold his right atrium and right
breath on inspiration for murmur ventricle and has three cusps.
of pulmonary regurgitation and
Aortic valve lies between left
on expiration for murmur of aortic
ventricle and aorta and has
regurgitation.
three cusps.
Pulmonary valve lies
Auscultatory notation between right ventricle and
On phonocardiographic recording pulmonary artery and has
heart sounds appear as vertical three cusps.
blips, the height representing
loudness and width duration. First and Second Heart Sounds
Murmurs resemble shading.
The first heart sound is produced
Similar graphic notations are used
to describe auscultatory findings. by closure of the mitral and tricuspid
Interval between ST (first heart valves. It marks the beginning of systole.
sound) and S2 (2nd heart sound) is The mitral is the major component; the
systole and interval between S2 tricuspid component is comparatively
and Sj is diastole (fig 2.42B). quiet. Its maximum intensity is at the
apex.
During auscultation note the following: The second heart sound is produced
1. Heart sounds (first, second, third by closure of the aortic and pulmonary
and fourth) valves. It denotes the end of systole
2. Other sounds (opening snap, and the beginning of diastole. The
ejection systolic click, mid systolic pulmonary component is localized to the
click, prosthetic valve sounds) pulmonary area while aortic component
3. Murmurs is audible all over the precordium with
maximum intensity at the A} area.
4. Pericardial rub
Heart Sounds How to differentiate between first

and second heart sound?
There are four valves in the heart. Their
closure produces sound while opening is 1. Palpate the carotid artery while
normally quiet. The valves between atria auscultating (fig 2.41). The sound
PDFelement
which comes just before the carotid

pulsations is S} and the sound which
comes after the carotid pulsations is
S2. Similar relation exists with the
apex beat (fig 2.42A).
2. At normal heart rate the systolic
interval is shorter than the diastolic
interval. This difference can be
recognized with experience. The
sound which comes at the beginning
of the shorter interval (systole) is Sj
and the sound which comes at the
end is S2 (fig 2.42B). This requires
practice.
3. First and second heart sounds can
also be recognized by their character;
this requires lot of experience.
Characteristics of heart sounds

The sound which comes just
before the carotid pulsations Note the following two characteristics of
is SL heart sounds:
The sound which comes 1. Intensity
after the carotid pulsations 2. Splitting
isS2. Intensity
Normal intensity of heart sounds is
learned with practice.
First heart sound. It is best audible at
the apex and you should comment about
its intensity with reference to the apex
only.
Second heart sound. It is usually
possible to find out the intensity of its
both components.
+ If S2 is single and its intensity is loud
at the pulmonary area while normal
at the aortic area, P2 is loud.
+ If S2 is loud, both at the pulmonary
area and aortic area, A2 is loud.
+ If S2 is of normal intensity at the
Fig 2.41: Palpation of carotid while auscultating
pulmonary area and soft at the
PDFelement
aortic area, A2is soft. for the splitting of S2at the pulmonary
+ Soft P2 is difficult to appreciate. Single area because P2 is audible only at that
S2 of normal intensity is an indirect area. Splitting of S2 is of three types; usual
evidence of soft or inaudible P2. splitting, fixed splitting and reverse
splitting.
+ If S2 is splitted, both components
can be easily appreciated and their Usual splitting. It means interval
intensity can be commented upon. between A2 and P2 is more during
inspiration than expiration (splitting
is more prominent during inspiration
Concentrate on S2 while
and sound becomes single or splitting
auscultating at apex and is narrower during expiration), it is
tricuspid area. explained below.
- Concentrate on S2 while
auscultating aortic and
Right sided cardiac output
pulmonary areas.
increases during inspiration
and left sided cardiac output
increases during expiration.
Causes
Soft both 1. Pericardial effusion Normally the aortic valve closes earlier
heart than the pulmonary valve. During
2. Emphysema inspiration as negative intrathoracic
sounds
3. Thick chest wall pressure increases, venous return to the
Loud Sj 1. Mitral stenosis right atrium is increased which leads to
2. Tachycardia increase in the right ventricular stroke
volume. The right ventricle takes longer
Soft S, 1. Mitral regurgitation to empty itself, closure of the pulmonary
2. Heart failure valve is delayed and so is P2.
3. Rheumatic carditis As lung expands during inspiration,
Variable 1. Atrial fibrillation blood containing capacity of pulmonary
intensity vasculature is increased; more blood is
2. Complete heart block
of SI retained in the lungs, venous return to
Loud P2 Pulmonary hypertension the left atrium is decreased and so is the
left ventricular stroke volume. The left
Soft P2 Pulmonary valvular ventricle empties itself in shorter time,
stenosis closure of the aortic valve and A2 so
Loud A2 Systemic hypertension produced are early (fig 2.43).
Soft A2 Aortic stenosis Hence during inspiration P2 is delayed
Aortic regurgitation and A2 is early, resulting in splitting of S2.
Splitting During expiration reverse occurs. Venous
return to the right atrium and the stroke
First heart sound: Its splitting is volume of the right ventricle are decreased
uncommon and insignificant. and P2 is early. More blood goes to the left
Second heart sound: Its splitting is atrium, stroke volume of the left ventricle
very common and significant. Search is increased and A2 is delayed. As a result
PDFelement
S2 is, either single during expiration or the closure of the aortic valve occurs after
split is narrow (fig 2.43). the closure of the pulmonary valve, the
An important point to be remembered effect of respiration on splitting of S2 is
from above discussion is that during reversed, ie, it is more during expiration
inspiration right sided cardiac and less during inspiration. This is called
output increases while left sided reverse splitting (fig 2.43).
cardiac output falls; during
expiration reverse occurs.
Causes
1. Normal in children and
young adults. It is also called
physiological splitting.
2. Right bundle branch block
3. Dilated right ventricle
4. Pulmonary hypertension (split is
narrow)
Fixed splitting: In atrial septal defect

blood flows from the left atrium
to the right atrium. The right sided
stroke volume is increased three times
normal and P2 is delayed, resulting in
wide splitting of S2. As both atria are
communicating with each other, the
differential effect of respiration on
stroke volume of two sides of the heart
is lost and the interval between A2 and
P2 remains constant during inspiration Causes
and expiration. This is called fixed 1. Left bundle branch block
splitting (fig 2.43). This is the most
2. Hypertrophic obstructive
important sign of atrial septal defect.
cardiomyopathy
Reverse splitting: If left ventricular
3. Severe aortic stenosis
emptying is delayed to the extent that
PDFelement
Splitting of the second heart sound

Type of Description Causes
splitting
Usual splitting Interval between A2 1. Children and young adults
and P2 is more during (physiological splitting)
inspiration and less 2. Dilated right ventricle
during expiration
3. Right bundle branch block
4. Pulmonary stenosis if P2 is
audible
5. Pulmonary hypertension
(split is narrow)
Fixed splitting Split is wide and interval Atrial septal defect
between A2 and P7 is the
same during inspiration
and expiration
Reverse Interval between A2 1. Left bundle branch block
splitting and P2 is less during 2. Hypertrophic obstructive
inspiration and more cardiomyopathy
during expiration
3. Severe aortic stenosis
Third Heart Sound ventricles are stiff or non complaint due

This is a low pitched sound and occurs to disease (fig 2.45).
in early diastole at the time of rapid
ventricular filling (fig 2.44).
< r—
1 1 1
SI S2 S3
1
si ) Fig 2.45: Fourth heart sound
Fig 2.44: Third heart sound

Causes
Causes 1. Hypertension
2. Ischemic heart disease
1. Children and healthy young
adults Note:
2. Pregnancy 4-Both S3 and S4 are low pitched sounds
3. Heart failure and are more clearly audible with
4. Mitral regurgitation the bell.
4 Both heart sounds may originate
Fourth Heart Sound from right or left ventricle. Left
This is a low pitched sound and occurs in sided sounds are best audible at
late diastole due to atrial contraction if the apex while right sided sounds
PDFelement
are best audible at left parasternal S2 and maximum intensity is medial to

border. the apex (fig 2.47). Presence of opening
snap means valve cusps are stenosed but
mobile.
Both S3 and S4 are best audible
with the bell, at apex if left
sided and at left parasternal
border if right sided.
Gallop rhythm or triple rhythm:

Presence of 3rd or 4th heart sound (S3 Fig 2.47: Opening snap
or S4) gives an auditory impression of
the galloping of a horse and is called Ejection systolic clicks
gallop rhythm or triple rhythm (three These are sharp systolic sounds produced
sounds). due to the opening of the abnormal
Summation gallop: Both S3 and S4 aortic and pulmonary valves and are
may be audible in the same patient. At heard soon after Sz (fig 2.48). The aortic
slow heart rate both are appreciated click is best heard at the area and
separately. If heart rate increases, S3 apex. It is not affected by respiration.
and S4 come very close to each other The pulmonary click is best heard
and are inseparable. This is called at the pulmonary area and increases
summation gallop (fig 2.46). in intensity during expiration. If click
Presystolic gallop: It means S4 is is audible along with other signs of
present. stenosis, it means stenosis is valvular
rather than supra or subvalvular.
Pericardial Knock
This is loud but distant diastolic sound
audible in constrictive pericarditis due
to abrupt halt to early diastolic filling
of the ventricle. This can be described as
distant 3rd heart sound.
Fig 2.48: Ejection systolic click
Causes
Aortic 1. Aortic valvular
click stenosis
2. Bicuspid aortic
Fig 2.46: Summation gallop valve
Other Sounds Pulmonary 3. Pulmonary

These include opening snap, ejection click valvular stenosis
clicks and sounds of prosthetic valves. 4. Dilatation of
pulmonary artery
Opening snap (idiopathic or due
In mitral stenosis a sharp high pitched to pulmonary
sound is produced due to the opening of hypertension)
the mitral valve. It is audible soon after
PDFelement
Mid systolic click pregnancy. Such murmurs are also

In mitral valve prolapse (a condition in called functional or flow murmurs.
which a cusp of mitral valve prolapses 2. Flow of normal amount of blood
into the left atrium during systole) a across a narrowed valve, eg, mitral
click is produced in the mid systole stenosis or aortic stenosis.
which may be followed by a late systolic 3. Flow of blood in abnormal direction:
murmur (fig 2.49). a. Normally a valve allows only
unidirectional flow. If it is
abnormal, leakage may occur,
eg, mitral regurgitation or aortic
regurgitation.
b. Abnormal communication
within the heart, eg, atrial septal
Fig 2.49: Mid systolic click defect, ventricular septal defect
or outside the heart, eg, persistent
ductus arteriosus.
Characteristics of a Murmur
If a murmur is audible, note the
following characteristics:
1. Timing
Fig 2.50: Added sounds; ejection systolic click,
opening snap, third and fourth heart sounds
2. Intensity
3. Site of maximum intensity
Prosthetic Valve Sounds 4. Radiation
Prosthetic valves are of two major 5. Character
varieties: 6. Pitch
Biological valves: These are of animal 7. Effect of respiration
tissue and produce sounds similar to the 8. Effect of posture
normal heart sounds.
Mechanical valves: These valves Timing
produce sounds both at the time of For a beginner it will be sufficient if
closure and opening; there are four he can differentiate between a systolic
sounds rather than two. The intensity murmur and a diastolic murmur.
of these sounds is loud and character is Palpate the carotid artery while
different. auscultating. The murmur which
comes with the carotid pulsation
Murmurs is systolic and the murmur which
These are abnormal sounds and are of alternates with it is diastolic.
longer duration as compared to heart
sounds. These are produced due to the Systolic murmurs
turbulence of blood flow and one of There are two major types of systolic
three mechanisms is involved. murmur.
1. Excessive flow of blood across a Pansystolic murmur: It starts with ST
normal valve, eg, severe anemia or and goes upto or beyond S2(fig 2.51).
PDFelement
MMHMH
Fig 2.53: Mid diastolic murmur

Fig 2.51: Pansystolic murmur
Causes
Causes
1. Mitral stenosis
1. Mitral regurgitation
2. Tricuspid stenosis
2. Tricuspid regurgitation
3. Atrial septal defect (a flow
3. Ventricular septal defect murmur at the tricuspid area)
Ejection systolic murmur: It starts
slightly after the first heart sound '
and ends before the second heart
sound. There is a gap between the
heart sounds and the murmur on
either side. It is soft initially, intensity
is maximum in the middle and then
decreases (it is diamond shaped on
phonocardiography) (fig 2.52).
Fig 2.54B1: Auscultating in left lateral position with

the bell for mid diastolic murmur
Early diastolic murmur: This occurs

soon after S2 (fig 2.54A).
Causes
1. Aortic stenosis
2. Pulmonary stenosis
Fig 2.54A: Early diastolic murmur
Diastolic murmurs
These are of two major types:
Causes
Mid diastolic murmur: As is obvious
1. Aortic regurgitation
from the name it is audible in the middle
2. Pulmonary regurgitation
of diastole (fig 2.53).
PDFelement
Gr<ides of Murmurs I
Grade Description
Grade I: Murmur audible with great
difficulty in a quiet room
Grade II: Murmur easily audible
but not loud
Grade III: Loud murmur without
thrill
Grade IV: Loud murmur with a thrill
Grade V: Very loud murmur,
audible even outside the
precordium
Grade VI: Murmur audible without
stethoscope
Causes of murmurs
Timing Finer timing Causes
Systolic Pansystolic Mitral regurgitation
Tricuspid regurgitation
Ventricular septal defect
Ejection systolic Aortic stenosis
Pulmonary stenosis
Diastolic Mid diastolic* Mitral stenosis
Tricuspid stenosis
Early diastolic Aortic regurgitation
Pulmonary regurgitation
Site of maximum intensity

Intensity
A murmur may be audible all over the
precordium depending upon its loudness
A murmur may be audible with great but its intensity is maximum where it is
difficulty in a quiet room (grade I) or being produced (with few exceptions),
it may be audible without stethoscope eg, murmur of mitral regurgitation is
(grade VI). A loud murmur without a loudest at the apex while murmur of
thrill is grade III and similar murmur tricuspid regurgitation is of maximum
with a thrill is grade IV (see below) intensity at the tricuspid area.
Radiation
* In atrial septal defect a mid diastolic flow murmur A murmur may be better audible
may be audible at the tricuspid area; in persistent in one particular direction outside
ductus arteriosus similar murmur may be audible at the precordium, depending upon the
the mitral area. Austin flint murmur is a mid diastolic
murmur heard at the apex in aortic regurgitation direction of flow of blood. This is
(page 69). called radiation, eg, murmur of mitral
PDFelement
regurgitation radiates towards the axilla, leans forward or when the stethoscope is
murmur of pulmonary stenosis radiates pressed. Rub usually disappears with the
to the left shoulder and the murmur of development of pericardial effusion.
aortic stenosis radiates to the neck.
Character To learn auscultation you
should practice to concentrate
Murmurs of stenosis are usually rough on a part of cardiac cycle at a
or harsh and murmurs of regurgitation
time.
are blowing in character.
Pitch If pleura close to the heart is inflamed,
pleural rub is produced which is also
Murmur of mitral stenosis is low pitched
audible along the left parasternal
and is best audible with the bell while
border. Sometimes both rubs are present,
other murmurs are high pitched.
then it is called pleuropericardial rub.
Effect of respiration The pericardial component is not due to
As it was described on page 58 right pericarditis; it is caused by the movement
sided stroke volume increases during of roughened pleural surfaces by cardiac
inspiration and left sided stroke volume pulsation These three types of rubs are
increases during expiration. differentiated by asking the patient to
hold the breath:
Murmurs of right heart (eg, murmur
of tricuspid regurgitation, pulmonary + If rub disappears, it is pleural.
stenosis) increase in intensity during 4- If rub persists without any change
inspiration while murmurs of left heart of character, it is pericardial.
(eg, murmur of mitral regurgitation, + If rub persists, but character changes,
aortic stenosis, ventricular septal defect) it is pleuropericardial.
increase in intensity during expiration.
Bruit
Effect of respiration is more pronounced
This is a sound similar to a murmur
on the right sided murmurs as compared
produced outside the heart (murmur of
to the left sided murmurs.
persistent ductus arteriosus technically
Effect of posture should be called bruit). This may be,
Murmur of mitral stenosis is best either due to excessive blood flow to an
heard in the left lateral position while organ or narrowing of a vessel. Thyroid
murmurs of pulmonary and aortic bruit in hyperthyroidism and hepatic
regurgitation are best audible when the bruit in hepatocellular carcinoma are
patient sits up and leans forwards. examples of excessive blood flow. Carotid
bruit in atherosclerosis and renal bruit
Pericardial Rub are examples of narrowing of vessel.
This is a superficial scratchy sound For carotid hruit place the bell of the
audible both in systole and diastole due to stethoscope along the anterior border of
rubbing of two surfaces of pericardium the sternomastoid and ask the patient
as a result of pericarditis. It is best to hold the breath. For thyroid bruit
audible at the left lower sternum and place the bell of the stethoscope over the
increases in intensity when the patient thyroid swelling while patient is holding
PDFelement
his breath. Carotid bruit radiates along + Right ventricular heave is present
the anterior border of the sternomastoid if pulmonary hypertension has
and may be audible over the orbit as well developed.
while thyroid bruit is localized to the + Diastolic thrill may be palpable at
thyroid swelling (thyroid bruit may also the apex.
have a diastolic component). In order, to
+ First heart sound is loud.
differentiate carotid bruit from murmur
radiating from the heart, gradually + Loud P2 indicates pulmonary
move the stethoscope towards clavicle: a hypertension.
murmur will increase in intensity and + The opening snap may be audible
will also be audible below the clavicle after S2. it is high pitched and its
while bruit will decrease in intensity. maximum intensity is medial to the
apex (it indicates that valve cusps
Venous Hum are mobile).
This is a continuous murmur-like sound + There is a mid diastolic murmur
audible in the neck when the patient best heard with the bell in the left
is standing, sitting or reclining against lateral position. It is low pitched,
pillows. It is due to kinking of larger rough, rumbling in character and
neck veins or hyperkinetic jugular localized to the apex. It may be loud
venous flow. It disappears by pressing during expiration. A Presystolic
the neck above the stethoscope or accentuation may be audible which
patient assuming a horizontal or head occurs due to atrial contraction at
down position. It is common in children. the end of diastole and is usually
It should not be confused with murmur absent in atrial fibrillation (fig 2.55).
of persistent ductus arteriosus.
SIGNS OF RHEUMATIC
AND CONGENITAL HEART
DISEASES
Signs of common diseases are briefly
discussed below.
Mitral Stenosis
Tapping apex beat

Diastolic thrill at apex
Loud Sj
Opening snap
Mid diastolic murmur at
apex
+ Pulse is normal or low volume. It

could be irregularly irregular if
atrial fibrillation supervenes.
+ Blood pressure is normal. Fig 2.55: Signs of mitral stenosis and site of
maximum intensity of its murmur
+ Apex beat is tapping in character.
PDFelement
Severity of Mitral Stenosis Mitral Regurgitation

+ Lesser the interval between the
second heart sound and opening Heaving apex beat
snap, the more severe the stenosis.
- Systolic thrill at apex
+ Longer the duration of mid diastolic;
- Soft S1
murmur, the more severe the stenosis.
- Pansystolic murmur at
Tricuspid Stenosis apex, radiating to the axilla
+ Pulse is normal.
+ Diastolic thrill may be palpable at + Pulse is normal or high volume.
the tricuspid area. + Pulse pressure is wide.
+ Tricuspid component of S, (TJ is 4-There may be a downward and
loud. outward shift of the apex beat. There
+ The opening snap may be audible. is an ill sustained heave.
+ A systolic thrill may be palpable at
+ There is a mid diastolic murmur the apex.
at the tricuspid area. It is harsher + Left parasternal heave is present
and higher pitched than murmur if pulmonary hypertension has
of mitral stenosis. It is loud during developed.
inspiration (fig 2.56). + First heart sound is soft.
4- Neck veins show prominent 'a' + Loud P2 indicates pulmonary
wave. hypertension.
Fig 2.57: Signs of mitral regurgitation and site of

maximum intensity and radiation of its murmur
PDFelement
■■MM
67
+ There is a pansystolic murmur

with maximum intensity at the
apex. It is blowing in character,
high pitched, becomes loud during
expiration and radiates to the
axilla (fig 2.57).
+ S3 may be audible.
Tricuspid Regurgitation
Left parasternal heave

Systolic thrill at tricuspid
area
Sj normal
Pansystolic murmur at
tricuspid area, loud on
inspiration
Systolic wave in neck veins,
pulsatile liver Fig 2.58: Signs of tricuspid regurgitation and site of
maximum intensity of its murmur
+ Apex beat may be shifted outward if
right ventricle is grossly dilated. Aortic Stenosis
4- Right ventricular heave is
present. Slow rising pulse
+ A systolic thrill may be palpable at Heaving apex beat
the tricuspid area. Systolic thrill at aortic area
4- First heart sound is usually normal. Soft A2
4 P2 is loud if pulmonary hypertension Ejection systolic murmur
is the cause of functional tricuspid at aortic area, radiating to
regurgitation. the neck
4 There is a pansystolic murmur
with maximum intensity at the + Pulse is low volume and slow rising.
tricuspid area. It is blowing in 4 Pulse pressure is narrow. '
character, high pitched and loud 4 Apex beat is usually not shifted
during inspiration (fig 2.58). and there is well sustained heave.
4 S3 may be audible. + A systolic thrill may be palpable at
+ Other features are a prominent the aortic area which radiates to the
systolic wave in the neck veins just neck (carotid shudder).
before actual V wave which may be + A2 is soft.
palpable, and pulsatile liver. 4 There is an ejection systolic
PDFelement
. 68 BEDSIDE TECHNIQUES
murmur with maximum intensity high pitched, loud during inspiration

at aortic area. It is best heard when and radiates to the left shoulder.
patient sits up-and leans forward. It + An ejection systolic click may
is harsh, high pitched, loud during be audible at the pulmonary area
expiration and radiates to the neck. which is loud during expiration
+ An ejection systolic click may be (it indicates that the stenosis is
audible with maximum intensity at valvular) (fig 2.60).
the aortic area and apex. It does not
vary with respiration. It indicates
that the stenosis is valvular (fig 2.59).
Fig 2.60: Signs of pulmonary stenosis and site of

maximum intensity and radiation of its murmur
Fig 2.59: Signs of aortic stenosis and site of + Prominent 'a' wave may be seen in
maximum intensity and radiation of its murmur the neck veins.
Aortic Regurgitation
Pulmonary Stenosis
4- Right ventricular heave is Collapsing pulse
present.
Heaving apex beat
+ A systolic thrill may be palpable at
Soft A9
the pulmonary area.
Early diastolic murmur at A2
+ P2 is soft; if P2 is audible there is
area
usual splitting of S2
+ There is an ejection systolic + Pulse is collapsing.
murmur with maximum intensity + Pulse pressure is wide.
at the pulmonary area. It is harsh, + Apex beat is shifted downward and
PDFelement
outward and there is an ill sustained is the most common cause of

heave. pulmonary regurgitation.
+ A2 is soft. + There is an early diastolic murmur
+ There is an early diastolic murmur at the pulmonary area. It is high
with maximum intensity at the pitched, resembling breath sounds,
A2 area. It is audible along the* left loud during inspiration and localized.
parasternal border. It is high pitched, It is best heard when patient sits up
resembling breath sounds and is and leans forward, holding his breath
loud during expiration. During
auscultation ask the patient to sit up,
lean forward and hold his breath on
expiration (fig 2.61).
+ A mid diastolic murmur may be Wide, fixed splitting of S2 is the

heard at the apex (Austin Flint most important physical sign.
murmur).
+ Pistol shot sounds are heard over + Right ventricular heave is present
peripheral arteries. A to and fro when pulmonary hypertension
murmur may be audible over develops.
femorals (Duroziez's murmur) when + Wide, fixed splitting of S2 is the
stethoscope is pressed. most important physical sign on
which diagnosis of atrial septal
Pulmonary Regurgitation defect is based.
+ Right ventricular heave is present. + An ejection systolic murmur
+ P2 is loud as pulmonary hypertension is heard at the pulmonary area. It
PDFelement
is soft, high pitched and is due to 4 Pulse is normal or high volume; it

excessive flow of blood across the may be collapsing.
pulmonary valve (fig 2.63). 4 Pulse pressure may be wide.
7 A 4 Apex beat is shifted downward and
Inspiration III I 4
outward and there is ill sustained
heave.
Right ventricular heave indicates
SI ESM A2 P2 SI pulmonary hypertension.
4 A systolic thrill may be palpable at
B...11
SI ESM A2 P2
B SI.
+
the left parasternal border in 3rd/4th
Intercostal Spaces (ICS).
Loud P2 indicates pulmonary
hypertension.
Fig 2.63A: Signs of atrial septal defect 4 There is a pansystolic murmur
with maximum intensity at the
left parasternal border in 3rd/4th ICS,
also audible across the sternum. It is
blowing in character, high pitched
and loud during expiration. S3 may
be audible (fig 2.64).
4 A mid diastolic murmur may be heard

at the tricuspid area. It is harsh, high
pitched and is due to excessive flow of
blood across the tricuspid valve.
Ventricular Septal Defect
- Heaving apex beat

Systolic thrill in left 3rd/4th
ICS
Normal S}
- Pansystolic murmur at
left 3rd/4th ICS, loud on Persistent Ductus Arteriosus
expiration
4 Pulse is normal or high volume; it
PDFelement
may be collapsing. Hypertrophic Obstructive

+ Pulse pressure is normal or wide. Cardiomyopathy
+ Apex beat may be shifted. This is an autosomal dominantly inherited
+ Right ventricular heave is present disorder. There is disproportionate
if pulmonary hypertension has hypertrophy of interventricular septum.
developed. During ventricular contraction there is
+ A continuous thrill may be functional subvalvular aortic obstruction.
palpable in the left 2nd/3rd ICS. + Pulse is jerky.
+ Loud P2 indicates pulmonary + Apex beat is double.
hypertension. + Murmur is either typical ejection
+ There is a continuous murmur systolic or mid to late systolic
with maximum intensity in the with maximum intensity at the
left 2nd/3rd ICS. It is blowing in aortic area.
character, high pitched and loud + Intensity of A2 is normal. There may
during expiration. It is also called be reverse splitting of S2.
machinery murmur. + S4 may be present.
+ S3 may be audible.
Eisenmenger's Syndrome: In
atrial septal defect, ventricular
septal defect and persistent ductus
arteriosus the direction of blood
flow is from the left heart to the
right heart. With passage of time
pulmonary hypertension develops,
direction of blood flow is reversed
(it flows from right to left) and
there is cyanosis (in persistent
ductus arteriosus cyanosis is
present only in the lower limbs and
is called differential cyanosis). This
is called Eisenmenger's syndrome.
Graham Steel murmur: This
is an early diastolic murmur
of functional pulmonary
regurgitation due to pulmonary
hypertension.
Austin Flint murmur: This is a
mid diastolic murmur audible at
the apex in aortic regurgitation.
It occurs due to movement of
anterior mitral leaflet between
Fallot’s Tetralogy two streams of blood (one from
This is a congenital cyanotic heart
the left atrium and other from
the aorta). It resembles murmur
disease and consists of four components:
of mitral stenosis but is not loud
1. Ventricular septal defect and opening snap is not present.
2. Pulmonary stenosis Carry-Coomb's murmur: This is
3. Overriding of the aorta a diastolic murmur audible at the
4. Right ventricular hypertrophy apex in acute rheumatic carditis.
PDFelement
Differential diagnosis of a pansystolic murmur

Features Mitral Tricuspid Ventricular septal
regurgitation regurgitation defect
Pulse Normal or high Normal Normal or high
volume volume
Blood pressure Normal or wide Normal Normal or wide
pulse pressure pulse pressure
Neck veins Normal Prominent Normal
systolic wave
Apex beat Shifted, ill Normal Shifted, ill sustained
sustained heave heave
Right ventricular Present Present Present
heavel*
Thrill Systolic thrill at Systolic thrill at Systolic thrill at left
apex tricuspid area parasternal border
in 3rd/4th ICS
First heart sound Diminished in Normal Normal
intensity
Second heart Loud P7 Loud P2 Loud P2
sound!**
Murmur
Timing Pansystolic Pansystolic Pansystolic
Site of maximum Mitral area Tricuspid area 3rd/4th ICS/ left
intensity parasternal border
Radiation Towards axilla Localized Across the sternum
Character Blowing, high Blowing, high Blowing, high
pitched pitched pitched
Effect of Loud during Loud during Loud during
respiration expiration inspiration expiration
Other features S3 may be audible Liver is pulsatile S3 may be audible
* Right ventricular heave is a sign of right ventricular enlargement and pulmonary hypertension, a complication
of mitral regurgitation and VSD (Ventricular Septal Defect), is its important cause. Tricuspid regurgitation is
usually functional which occurs when right ventricle dilates due to long standing pulmonary hy pertension. Hence
pulmonary hypertension is a complication of mitral regurgitation and VSD and a cause of tricuspid regurgitation.
** Loud P2 is a feature of pulmonary hypertension.
PDFelement
Differential diagnosis of an ejection systolic murmur

Features Aortic steno Aortic Hypertrophic Pulmonary
sis , sclerosis3* obstructive car stenosis
diomyopathy
Pulse Slow rising High vol Jerky Normal
pulse ume
Blood pres Narrow pulse Wide pulse Normal Normal
sure pressure pressure
Neck veins Normal Normal Normal Prominent 'a'
wave
Apex beat Well sustained Normal Double apex Normal
heave beat
Right ventric Absent Absent Absent Present
ular heave
Thrill Systolic thrill None None Systolic thrill at
at A! area pulmonary area
First heart Normal Normal Normal Normal
sound
Second A2 is soft Normal or Intensity of A2 P2 is soft
heart sound loud A2 is normal. There
may be reverse
splitting of S2
Murmur
Timing Ejection sys Ejection Ejection, mid or Ejection systolic
tolic systolic late systolic
Site of Aortic area Aortic area Aortic area Pulmonary area
maximum
intensity
Radiation Towards neck Towards Towards neck Towards left
neck shoulder
Character Harsh Harsh Harsh Harsh
Effect of res Loud during Loud during Loud during Loud during
piration expiration expiration expiration " inspiration
Effect of Best audible on - - Best audible on
posture leaning for leaning forward
ward
Other fea Ejection systol — S. may be audi Ejection systolic
tures ic click, at Aj ble click, at pulmo
area and apex, nary area, loud
not affected during expira
by respiration tion
* Aortic sclerosis means thickening of the cusps of aortic valve which occurs in old age. There is a murmur
resembling that of aortic stenosis but pulse is of high volume and A2 is loud.
PDFelement
Differential diagnosis of an early diastolic murmur

Features Aortic regurgitation Pulmonary regurgitation
Pulse Collapsing pulse Normal
Blood pressure Wide pulse pressure Normal
Neck veins Normal Normal or prominent 'a'
wave
Apex beat Ill sustained heave Normal
Right ventricular Absent Present
heave
Thrill Rare Rare
First heart sound Normal Normal
Second heart sound A2 is soft P2 may be loud
Murmur
Timing Early diastolic murmur Early diastolic murmur
Site of maximum A2 area Pulmonary area
intensity
Radiation Along left parasternal border Localized
Character High pitched resembling High pitched resembling
breath sounds breath sounds
Effect of respiration Loud during expiration Loud during inspiration
Effect of posture Best audible when patient Best audible when patient
leans forward leans forward
Other features Pistol shot sounds and Duro
ziez's murmur may be audi
ble over femorals
A mid diastolic murmur may -
be audible at apex (Austin-
Flint murmur)
PDFelement
CH 2
Differential diagnosis of various cardiac lesions
- CARDIOVASCULAR
Disease Pulse Blood Apex beat Right, Thrill4* Cs,) s2
pressure ventricu
lar heave
Mitral steno Normal or Normal Taping Present5# Diastolic at Loud P2 is loud#
sis low volume apex
SYSTEM
Tricuspid Normal Normal Normal - Diastolic at Loud Normal
stenosis TA6@ CT,)
Mitral regur Normal or Wide pulse Shifted: ill sus Present# Systolic at Soft P2 is loud#
gitation high volume pressure tained heave apex
Tricuspid , Normal Normal Normal or Present Systolic at Nor P, is loud if PH® is
regurgitation shifted TA® mal the underlying cause
Aortic steno Low volume, Narrow Well sustained Absent Systolic at Nor A2 is soft
sis slow rising pulse pres heave AA1®, radiates mal
sure to the neck
Pulmonary Normal Normal Normal Present S^s^olic at Nor P9 is soft: if P2is
stenosis mal audible there is usual
splitting of S2
Aortic Collapsing Wide pulse Shifted: ill sus Absent - Nor A7 is soft
regurgitation pressure tained heave mal
Pulmonary Normal Normal Normal Present - Nor P7 is loud as PH® is
regurgitation mal the commonest cause
Atrial septal Normal Normal Normal Present8# - Nor Fixed splitting of S2
defect mal
Ventricular Normal or Normal or Shifted: ill sus Present# Systolic at Nor P2 is loud#
septal defect high volume wide pulse tained heave LPB9@ in mal
pressure 3rd/4th ICS
Persistent Normal or Normal or May be shifted Present# Continuous in Nor P9 is loud#
ductus arte high volume wide pulse left 2nd/3rd ICS mal
riosus pressure
Thrill is present when murmur is loud.
# Present if stenosis pulmonary hypertension has developed.
@ TA: tricuspid area; PA: pulmonary area; AA1: aortic 1 area; AA2: aortic 2 area; LPB: left parasternal border; PH: pulmonary hypertension; OS: opening snap;
ESC: ejection systolic click
PDFelement
Murmur Ch
Disease Timing Site of Radiation Character Effect of Best Other Other

maximum and pitch respiration posture sounds features
intensity
Mitral Mid Apex Localized Rough, Loud during Left osio@,
stenosis diastolic rumbling; expiration lateral medial
with low pitched position, to apex
presystolic with the
accen bell
tuation
Tricuspid Mid TA© Localized Harsh; high Loud during Flat os© Prominent
stenosis diastolic pitched inspiration 'a' wave in
neck veins
Mitral reg Pansystolic Apex Axilla Blowing; Loud during Flat S3 may
urgitation high expiration be
pitched audible
Tricuspid Pansystolic TA@ Blowing; Loud during Flat S3 may Systolic
regurgita high inspiration be wave in
tion pitched audible neck veins;
pulsatile
liver
Aortic Ejection AA1@ Neck Harsh; high Loud during Sitting ESC@, at
stenosis systolic pitched expiration up and AA1@
leaning and
forward apex
Pulmonary Ejection PA@ Left Harsh; high Loud during Flat ESC© at Prominent
BEDSIDE TECHNIQUES
stenosis systolic shoulder pitched inspiration PA@ 'a' wave in
neck veins
@ TA: tricuspid area; PA: pulmonary area; A Al: aortic 1 area; AA2: aortic 2 area; LPB: left parasternal border; PH:
pulmonary hypertension; OS: opening snap; ESC: ejection systolic click
1
PDFelement
1
CH 2
Disease Timing Site of Radiation Character Effect of Best Other Other
- CARDIOVASCULAR
maximum and pitch respiration posture sounds features
intensity
Aortic Early AA211@ Audible High Loud during Sitting up Mid Pistol
SYSTEM
regurgita diastolic along LPB® pitched, expiration & leaning diastolic shot
tion resembling forward, murmur sounds; to
breath breath at apex and fro
sounds held in murmur
expiration over
femorals
Pulmonary Early PA@ Localized High Loud during Sitting up -
regurgita diastolic pitched inspiration & leaning
tion forward
Atrial i. Ejection i. PA@ i. Soft, high
septal systolic ii. TA@ pitched
defect ii. Mid ii. Harsh,
diastolic ( high
both flow pitched
murmurs)
Ventricu Pansystolic 3rd/4th ICS Audible Blowing; Loud during Flat S3 may ■
lar septal at LPB@ across the high expiration be
defect sternum pitched audible
Persistent Continuous 2nd/3rd ICS Blowing; Loud during Flat S3 may -
ductus on left side high expiration be
arteriosus pitched audible
@ TA: tricuspid area; PA: pulmonary area; A Al: aortic 1 area; AA2: aortic 2 area; LPB: left parasternal border; PH: pulmonary hypertension; OS: opening snap;
ESC: ejection systolic click
PDFelement
Disease Notation (height represent intensity and width

duration)
Mitral stenosis
Tricuspid stenosis
Mitral regurgitation
SI
Tricuspid regurgitation
Aortic stenosis
Pulmonary stenosis
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CH 2 - CARDIOVASCULAR SYSTEM. 79
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■I
Aortic regurgitation
Pulmonary regurgitation
SI S2 EDM
i
SI
0
Inspiration
Atrial septal defect
L
Expiration
Ventricular septal defect

□
Patent ductus arteriosus
SI Continuous (S2) Murmur

□
PDFelement
SUMMARY OF EXAMINATION
PULSE 5. Rate
6. Rhythm
7. Volume
8. Character
9. Comparison with
other pulses
10. Condition of the
vessel wall
BLOOD PRESSURE
NECK VEINS
EXAMINATION OF
PRECORDIUM
INSPECTION Chest deformity
Bulging of precordium
Scar
Pulsations 1. Apex beat
2. Pulsations along
the left parasternal
border
3. Pulsations in the
pulmonary area
suprasternal notch
epigastrium
Prominent veins
PALPATION Apex beat 1. Site
2. Character
Left parasternal heave
Palpable heart sounds
Thrill 1. Site
2. Timing
Palpable pericardial rub
PERCUSSION Extent of cardiac dull
ness
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AUSCULTATION Heart sounds 1. Intensity of first and

second heart sound
2. Splitting of second
heart sound
3. Third and fourth
heart sounds
Other sounds 1. Opening snap

2. Ejection clicks
3. Mid systolic click
4. Prosthetic valve
sounds
Murmurs 1. Timing
2. Intensity
3. Site of maximum
intensity
4. Radiation
5. Character
6. Pitch
7. Effect of respiration
8. Effect of posture
Pericardial rub
PERIPHERAL ARTERIAL + Nails become brittle.

SYSTEM + Dry gangrene may develop. Digits
The most important effect of arterial become black and there is clear
disease is ischemia. demarcation between gangrenous
part and healthy tissue.
Intermittent Claudication
This is a symptom of chronic vascular
+ Peripheral pulses are weak or
insufficiency. Patient gets pain mainly impalpable.
in the legs after walking certain distance 4- Reactive ischemia: Ask the patient
which is relieved by rest. to lie down and elevate the leg for
Signs of Chronic Ischemia several minutes. Then ask him to
sit up and hang the same leg over
+ Skin is atrophic and shiny.
the edge of the bed. Normally leg
+ Hair are lost.
PDFelement
becomes pink in 10 seconds. If don't collapse when leg is elevated.

perfusion is inadequate, it is delayed. + Forceful dorsiflexion of foot causes
pain in the calf (Homan's sign).
Acute Ischemia This test is usually avoided because
If there is sudden occlusion of a major a clot can get dislodged and lead to
artery, initially skin becomes cold and pulmonary embolism.
white, then blue and later gangrenous.
Distal pulses are not palpable. WRITING OUT ROUTINE
Raynaud’s Phenomenon EXAMINATION
In certain connective tissue disorders Examination of a normal person should
when limbs are exposed to cold, they be described as follow. If there are
become pale and then blue; when abnormalities these should be described
spasm passes off they become red due to at appropriate places.
hyperemia (pallor, cyanosis, redness). Pulse is 72/minute, regular, normal volume,
normal character, no radiofemoral delay,
PERIPHERAL VENOUS SYSTEM vessel wall not palpable.
The most important disease affecting BP 130/80
venous system is deep venous thrombosis.
JVP not raised
Deep Venous Thrombosis Edema feet absent
Causes Precordium
1. Prolonged bed rest, particularly
after surgery Inspection
2. Congestive cardiac failure Shape normal, no scar, no pulsations
visible over the precordium.
3. Oral contraceptives
4. Long air travel Palpation
Apex beat palpable in 5th intercostal
Symptoms space medial to midclavicular line,
Patient usually presents with swelling of normal character. No other sound
of the legs and pain. palpable. No thrill. Left parasternal
heave not palpable.
Signs
+ There is edema feet. Auscultation
4- Skin is warm. Both heart sounds are of normal
+ Superficial veins are dilated which intensity. No added sounds, no murmur.
PDFelement
Chapter ■■mi
31 RESPIRATORY
SYSTEM
The yield in the examination of 2. Major Fissure: A line drawn from
respiratory system is variable. Diseases the 2nd thoracic spine to the 6th rib in
like asthma can be diagnosed with the mammary line represents the
confidence on the basis of clinical major fissure. Upper lobe is mainly
evaluation alone; on the other hand on the front and lower lobe on the
in tuberculosis disease may be fairly back.
advanced but clinical examination 3. Minor Fissure: A horizontal line
might still be normal. So, in addition to drawn from the sternum at the
detailed history and thorough physical level of 4th costal cartilage laterally
examination, appropriate investigations till it cuts the line of major fissure,
are necessary to arrive at the correct represents the minor fissure on the
diagnosis. right side.
4. Base of Lung: On the right side it is
ANATOMICAL represented by a line joining 6th rib
CONSIDERATIONS in the mammary line, 8th rib in the
Both lungs are divided into upper and midaxillary line and 10th rib in the
lower lobes by the major fissure. Right scapular line. It is slightly lower on
upper lobe is further divided into upper the left side.
and middle lobes by the minor fissure.
SYMPTOMS
So the right lung has three lobes and the
left has two.
Cough
SURFACE ANATOMY
Types of cough >
1. Bifurcation of Trachea: It
corresponds with the sternal angle Dry (pharyngitis)
(also called angle of Louis)**
* in front Productive (bronchiectasis,
and the disc between 4th and 5th chronic bronchitis, resolving
thoracic vertebrae behind. pneumonia)
* It is junction of manubrium sterni with body of Persistent (pharyngitis)
the sternum. Move your finger from the suprasternal
notch downward along middle of the sternum; first Episodic (asthma)
prominence felt is the sternal angle.
83
PDFelement
It is a very common symptom of, both, Types

upper and lower respiratory tracts 1. Frank Hemoptysis: Pure
disease. It may be dry (pharyngitis) or blood is coughed up. It occurs
productive (bronchiectasis, chronic in bronchiectasis, pulmonary
bronchitis, resolving pneumonia), infarction, tuberculosis and
persistent (pharyngitis) or episodic sometimes mitral stenosis.
(bronchial asthma). 2. Blood stained Sputum: Blood
Sputum is mixed with sputum. Two
important causes are tuberculosis
Note the following characteristics of
and carcinoma bronchus.
the sputum. For proper assessment you
3. Blood streaked Sputum: Blood
should see the sputum yourself.
is present on the side of sputum.
Amount It is commonly seen in chronic
For exact measurement ask the patient bronchitis.
to collect the sputum in a graduated 4. Rusty Sputum: The sputum
container for 24 hours. Large amount of is of golden yellow color due to
sputum is produced in bronchiectasis degradation of hemoglobin. It
and lung abscess. occurs in pneumococcal pneumonia.
Character Types and causes of hemoptysis

1. Serous: It is clear and frothy. It Types Causes
occurs in acute pulmonary edema. + Bronchiectasis
Frank
2. Mucoid: It is white and is seen in Hemoptysis + Pulmonary
chronic bronchitis.
infarction
3. Purulent: It is yellow or green in
4 Tuberculosis
color. It occurs in bronchiectasis,
pneumonia and lung abscess. + Mitral stenosis
4. Mucopurulent: It is a combination Blood stained 4 Tuberculosis
of mucoid and purulent. It is seen in Sputum 4 Carcinoma
chronic bronchitis with secondary bronchus
infection.
Blood streaked 4 Chronic
Viscosity Sputum bronchitis
Sputum is viscous, tenacious and difficult Rusty 4 Pneumococcal
to cough up in bronchial asthma. Sputum pneumonia
Odor Chest Pain
Sputum is foul smelling in bronchiectasis It is a common symptom. Site and
and lung abscess with anaerobic character of the pain varies with the
bacterial infection. diseases.
Hemoptysis Retrosternal Pain

It means coughing up of blood. It is It may be due to:
important to note its duration, amount, 1. Acute tracheitis (there is associated
frequency and type. dry cough).
PDFelement
CH 3 RESPIRATORY SYSTEM
2. Mediastinal emphysema or Wheeze

mediastinitis: These are uncommon It is a musical, whistling sound and can
conditions. Pain resembles cardiac be described as a loud ronchus audible
pain but intensity is not severe and without a stethoscope. It is due to
it is not related to exertion. narrowing of small airways.
Retrosternal pain can also occur due to
diseases of other systems, eg, ischemic
Stridor
heart disease, reflux esophagitis. It is similar to wheeze and occurs due to
obstruction of major airways by tumor
Pleuritic Pain or foreign body. It is audible only during
It is due to pleurisy. Pain is felt in inspiration. Differentiation between
the sides of the chest and is typically wheeze and stridor is discussed on page 99.
exacerbated by breathing and coughing.
In spontaneous pneumothorax, initially SYMPTOMS OF UPPER
there is sudden, severe, sharp pain RESPIRATORY TRACT DISEASE
followed by feeling of tightness across Nasal obstruction, nasal discharge and
the front of the chest. post nasal drip are symptoms of local
nasal pathology.
Musculoskeletal Pain
It is felt at the site of the disease. It may Headache
be due to: In sinusitis, headache increases on
bending forward and is of maximum
1. Fracture of ribs
intensity a few hours after sun rise.
2. Metastatic deposits in the ribs
3. Costochondritis Epistaxis
4. Spinal root lesion
It means bleeding from the nose. Local
nasal pathology is the usual cause but it
5. Herpes zoster may also be due to:
Dyspnea + Bleeding and clotting disorders.
It means difficulty in breathing. It can 4- Hypertension.
be, either due to cardiac disease (page Hoarseness
33) or respiratory disease. In bronchial It may be due to:
asthma and acute exacerbation of 1. Laryngitis
chronic bronchitis dyspnea occurs
in episodes while in emphysema and 2. Abuse of voice
chronic interstitial lung disease like 3. Hypothyroidism
fibrosing alveolitis dyspnea occurs on 4. Paralysis of 10th nerve or its branch,
exertion and is progressive. In addition recurrent laryngeal nerve
to above mentioned conditions, acute HISTORY
dyspnea can also occur due to following
In addition to details of presenting
respiratory diseases:
symptoms it is important to find out:
1. Spontaneous pneumothorax + Past history of chest infection,
2. Pulmonary embolism particularly tuberculosis.
3. Massive, rapidly accumulating + History of BCG vaccination.
pleural effusion + History of allergic disorders.
4. Pneumonia + Any previous x-ray available.
PDFelement
+ Family history of similar problem.

+ Home circumstances, particularly
any pets like birds (eg, pigeons) or
animals (eg, cats).
+ Details of occupation (a number
of respiratory disorders, .eg,
pneumoconiosis are related to
occupation).
+ Cigarette smoking (chronic
bronchitis and carcinoma are very
common in smokers; find out age
at which smoking started, number
of cigarette smoked per day and
their brand, and when did he stop
smoking in case of an ex-smoker).
EXAMINATION
Examination of the respiratory system
consists of inspection, palpation,
percussion and auscultation. Examine
both the front and back of the chest.
First complete the examination on
the front or back and then change the
patient's position to examine the other
side. Compare both sides of the chest
with each other.
First complete the examination

on the front or back and then
change the patient's position
to examine the other side.
Always compare both sides of
the chest with each other.
POSITION OF THE PATIENT

Expose the chest fully baring the chest
and the abdomen upto the umbilicus. For
examination of the front and sides of the
chest, the patient should lie supine with
arms abducted (fig 3.1). For examination
of the back the patient should sit up,
with arms crossing front of the chest
and each hand on the opposite shoulder
(fig 3.2). (Female patient should not be
exposed except when it is necessary and
then only by a female doctor or student Fig 3.2: Position of the patient for examination of the
back of the chest
with adequate privacy).
PDFelement
CH 3 RESPIRATORY SYSTEM 87
Inspection males use diaphragm; respiration is

Inspect the front from the foot end thoracoabdominal in females and
(fig 3.3) and the back from behind. abdominothoracic in males. In babies it
This is important because if patient is is abdominothoracic. This pattern can
examined from the side or obliquely, change:
small asymmetries can be missed. Note 1. If there is peritoneal irritation or
the following features: increased intra abdominal pressure,
1. Respiratory rate respiration becomes exclusively
2. Type of respiration thoracic.
3. Shape of the chest 2. In ankylosing spondylitis, pleural
pain and intercostal paralysis it
4. Deformity
becomes exclusively abdominal.
5. Prominent veins, pulsations, scar
Acidotic Breathing: In metabolic
6. Chest movements acidosis (renal failure, ketoacidosis)
breathing becomes rapid and deep.
Cheyne-Stokes Breathing: Periods of
over ventilation alternate with complete
apnea (cessation of breathing). This is due
to decreased sensitivity of the respiratory
center to carbon dioxide. Over ventilation
leads to fall in PaCO2and apnea occurs.
Carbon dioxide accumulates, stimulates
respiratory center and there is over
ventilation again.
Causes
1. Left ventricular failure
2. Increased intracranial pressure
3. Brain stem lesion
Fig 3.3: Inspection of front of the chest from foot end 4. Narcotic overdose
of the patient
Shape of the Chest
Respiratory Rate Normal shape is elliptical. Ratio of the
This is counted by observing movements antero-posterior (AP) diameter to the
of the chest. In order to divert patient's transverse diameter is 5:7.
attention, feel his pulse while counting Barrel Shaped Chest: Antero-posterior
respiratory rate. Normal is 14 -16 /minute. diameter and transverse diameter
Tachypnea means fast respiratory rate. become equal. It occurs in emphysema. It
is more likely to occur if disease process
Type of Respiration starts before the age of 30. (Antero
Normally females mostly use posterior diameter is also increased in
thoracic muscles for respiration and kyphosis.)
PDFelement
Deformity
Pectus Carinatum: It is also called
pigeon chest. There is prominence of
the sternum and costal cartilages (fig
3.4). This is a common complication of
chronic respiratory disease in childhood.
This may also occur as a result of rickets.
Fig 3.5: Pectus excavatum (funnel chest)
Harrison's Sulcus: This is a horizontal

grove due to indrawing of ribs where
diaphragm is attached. This occurs
as a result of strong contractions of
diaphragm due to respiratory disease in
early childhood.
> Thoracic Kyphoscoliosis: Kyphosis
(increased backward curvature of spine
-fig 3.6), scoliosis (lateral curvature of
Fig 3.4: Pectus carinatum (pigeon chest) spine) and kyphoscoliosis (combination
of both) in minor form are common
Pectus Excavatum: It is also called deformities. In severe form trachea and
funnel chest. It is a developmental apex beat may be shifted, and respiratory
anomaly. There is localized depression of and cardiac failure may occur.
the lower end of the sternum. Sometimes
Local Bulging of Chest Wall: This
whole of the sternum may be depressed
may be due to:
(fig 3.5). Severe form interferes with
cardiorespiratory function. 1. Pleural effusion
PDFelement
2. Pneumothorax ■ be bent forward to look for these

3. Fracture and malunion of ribs pulsations.
+ Scar indicates previous trauma or
surgery.
Movements of the Chest
Compare movements of both sides of the
chest. Following abnormalities may be
present:
Reduced Movements
A part of the chest may be moving less
or may not be moving at all. It may be
due to:
1. Pleural effusion
2. Pneumothorax
3. Consolidation
4. Collapse
5. Fibrosis
Abnormal Movements
Most of the abnormal movements occur
in airway obstruction (emphysema,
severe bronchial asthma, obstruction of
major airways like larynx, trachea).
A. Movements due to extra
Fig 3.6: Kyphosis
respiratory muscles: Due to
contraction of extra respiratory
Local Flattening or Retraction of muscles (sternomastoids, scaleni,
Chest Wall: This may be due to: trapezii) whole thoracic cage moves
1. Fibrosis of lung up during inspiration.
2. Collapse of lung Normally expiration is a passive
3. Pneumonectomy act. In severe airway obstruction
it becomes an active process with
Prominent Veins, Pulsations, Scar contraction of abdominal piuscles
+ Prominent veins are seen in superior and latissimus dorsi. Patient sits up
vena cava obstruction. Direction and supports himself against his
of flow of blood is from above arms. In this way the shoulder girdle
downwards. is fixed so that latissimus dorsi
4- On the front apex beat may be can be used to increase expiratory
visible. On the back pulsations are efforts. The patient purses his lips to
seen in the interscapular region in maintain intra bronchial pressure
coarctation of aorta. Patient should above that of surrounding alveoli so
PDFelement
that bronchial walls don't collapse. either side of the trachea and compare
B. Inward movements: There is the space between the trachea and the
indrawing of: / clavicular head of sternomastoid on
either side. This space is equal if trachea
1. Supraclavicular fossae
is in the center and reduced on the side
2. Suprasternal notch towards trachea is deviated. A slight
3. Intercostal spaces shift towards right is normal.
4. Epigastrium
C. Paradoxical movements: If there
is double fracture of the ribs or
fracture of the sternum, part of the
chest wall moves inwards during
inspiration.
Palpation
Palpate for:
1. Tenderness, crepitus
2. Position of the trachea and apex
beat
3. Movements of the chest wall
4. Expansion of the chest Fig 3.7: Palpation of trachea; one finger method
5. Vocal fremitus
Two Fingers Method: Push tips of
6. Palpable added sounds two fingers (index and middle) in the
Position of the Trachea and Apex suprasternal notch and compare space
Beat**
* on either side of the trachea and the
The patient should lie straight, head clavicular head of sternomastoid (fig 3.8).
and neck in line with the body, and the
neck slightly extended (which can be
achieved by placing a pillow under the
shoulders). Trachea can be palpated by
one finger, two fingers or three fingers.
One Finger Method: Gently push tip
of the index finger into the suprasternal
notch exactly in the midline and note
any deviation of the trachea (fig 3.7). To
confirm it further, push the finger on
* Tracheal Tug: In chronic obstructive airways
disease length of the trachea in the neck is shortened
and it moves downwards during inspiration. This can
be detected by placing a finger between the cricoid Fig 3.8: Palpation of trachea; two fingers method
cartilage and suprasternal notch. During inspiration
finger is squeezed due to downwards movement of Three Fingers Method: With two
the trachea.
fingers compare the space as described
PDFelement
above while third is stabilized in the of outstretched thumbs approximate

midline (fig 3.9). in the midline (fig 3.10, 3.11). Thumbs
should not touch the chest wall. Ask
the patient to take a deep breath and
compare movements of the thumb away
from the midline on both sides. Side on
which movement of the thumb is less, is
abnormal. It should be performed at two
places in front and at three places on the
back. Causes of decreased movements
are given on page 89.
Fig 3.9: Palpation of trachea; three fingers method
Palpation of apex beat is described on

page 49. Shift of apex beat can also occur
due to respiratory disease as a part of
shift of mediastinum.
Causes of Shift of Trachea and

Apex Beat (Mediastinum)
Fig 3.10: Palpation for chest movements anteriorly
A. A. Conditions which pull the
mediastinum towards the
diseased side:
1. Collapse of the lung
2. Fibrosis of the lung
B. B. Conditions which push
the mediastinum towards the
healthy side:
1. Pneumothorax
2. Pleural effusion
Note: Tracheal shift may be due to
enlarged thyroid and it should be Fig 3.11: Palpation for chest movements ppsteriorly
excluded. Both trachea and apex beat
may be shifted due to chest deformity. Palpation of Apices: While standing
Movements of the Chest
behind the patients, put the palms of
the hands on the trapezii, fingers loosely
Compare movements of both sides by hanging over the supraclavicular fossae
palpation. and clavicles (fig 3.12). Compare upward
Method: Grasp sides of the chest with movements of fingers with inspiration
the fingers in such a way that the tips on both sides.
PDFelement
it is abnormal. There is high degree of

inter observer variation and this is not a
reliable test of vital capacity.
Causes of reduced chest

expansion:
1. Emphysema
2. Bronchial asthma
3. Diffuse pulmonary fibrosis
4. Ankylosing spondylitis
Fig 3.12: Palpation for chest movements at apex
Vocal Fremitus
Ask the patient to say one, one, one (or
similar words in other languages) and
feel the vibrations by placing palm on
/ A
J
A
Fig 3.13: Measurement of chest expansion
Expansion of the Chest

■ • <
Measure circumference of the chest

just below the nipple with a measuring
tape at the end of deep inspiration and _____ J
full expiration. Difference between the
two is chest expansion. Normally it is Fig 3.14: Palpation of chest for vocal fremitus;
comparing two sides
more than 5 cm. If it is less than 2 cm,
PDFelement
the chest. These vibrations are called Palpable Added Sounds

vocal fremitus. Examine whole chest Ronchus, if loud, may be palpable.
anteriorly, laterally and posteriorly, Pleural rub may also be palpable as a
comparing corresponding areas of grating sensation.
both sides. If there is any abnormality,
further localize it by palpating with-the Percussion
ulnar border of the hand, placing it in This is a useful technique in the
the intercostal spaces. When examining examination of the respiratory system,
front of the chest, keep in mind the as abnormal percussion note is found
change due to presence of heart on in a number of respiratory conditions
the left side. Normal vocal fremitus is like pleural effusion, pneumothorax,
learned with practice. It can be increased consolidation etc. Gain experience of
or decreased. technique of percussion and learn normal
percussion note by percussing yourself
Causes of Increased Vocal or a colleague. Be gentle, as heavy and
Fremitus repeated percussion is uncomfortable.
1. Consolidation At first, percuss for upper border of the
2. Cavitation liver and then compare percussion note
3. Collapse with patent main on two sides.
bronchus
Technique and Rules of
Causes of Decreased Vocal Percussion
Fremitus
1. Place left middle finger
1. Pleural effusion
(pleximeter) parallel to the border
2. Pneumothorax of the organ being percussed (fig
3. Collapse with obstructed main 3.15). It should be in firm contact
bronchus
with the body surface.
Tenderness, Crepitus
Tenderness may be due to trauma or
inflammation (costochondritis). In
subcutaneous emphysema or surgical
emphysema (air in the subcutaneous
tissue) crackling sensations (crepitus)
are felt on palpation of skin.
Causes of Subcutaneous
Emphysema
1. Penetrating chest injury
2. Accidental injury to lung during
thoracic paracentesis
3. Escape of air during intubation
of chest for pneumothorax
4. Mediastinal emphysema where 2. Flex right middle finger at proximal
air escapes into the neck interphalangeal joint and use it as
PDFelement
plexor (fig 3.16} It should strike the 5. Line of percussion should be

middle phalanx of pleximeter at perpendicular to the border of the
right angle (fig 3.17). organ to be percussed.
6. Percuss from resonant to dull area.
Sites of Percussion
Percuss anteriorly, laterally and
posteriorly. Keep pleximeter in
intercostal spaces wherever possible. If
sites described below are percussed, most
of the lung is covered.
Anterior
At first mark upper border of the
liver. Start percussing from right 2nd
intercostal space and move downward in
midclavicular line. Normally it is in the
Fig 3.16: Position of the plexor finger 4th or 5th intercostal space in midclavicular
line. Then compare percussion note on
two sides by percussing alternately at
corresponding sites. Take care of normal
cardiac dullness. Percuss the following
sites:
1. Supraclavicular fossae (place the
pleximeter above the clavicles)
2. Clavicles (percuss with 3 fingers of
the right hand over the medial third
of the clavicle directly without
Fig 3.17: Position of pleximeter and plexor while

percussing
3. Movement should be entirely at the

wrist, not at the elbow.
4. Strike the plexor twice and then lift
it off. If it remains in contact with
the pleximeter, character of note
will change.
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3. Second to 6th • intercostal spaces 2. Above the spine of scapulae

(fig 3.19) 3. At a distance of 4 - 5 cm below the
4. Fourth to 7^ intercostal spaces on spine of scapulae down to the 11th rib
lateral side (fig 3.19). For lateral (fig 3.21)
percussion arms of the patient
should be adequately abducted
Types of Percussion Note

Posterior
Normal percussion note over the lung is
1. Apices (place pleximeter on the resonant. It may become hyper resonant,
anterior border of the trapezius impaired or dull. When an abnormal
and percuss in downward direction note is found, delineate its boundaries
(fig 3.20) by percussing from normal to abnormal
area. Definitions and examples of
various notes are given below.
1. Resonant: This note is produced by
percussing over normal lung tissue.
2. Increased Resonance:
a. Tympanitic: This note is produced
by percussing over large air filled
cavity organ, eg, empty stomach.
b. Hyper resonant: This type of
note is present if lung is hyper
inflated, eg, emphysema or if there
is pneumothorax. It is very difficult
to distinguish between normal
resonance and hyper resonance
when percussion note is equally
Fig 3.20: Percussion of apex of the lung
resonant on both sides.
PDFelement
BEDSIDE TECHNIQUES
SSHBfl
3. Decreased Resonance: Tidal Percussion

a. Impaired note: This note is This is done for movements of
normally present at the junction diaphragm. Determine lower limit of
of a solid organ with the lung, eg, resonance posteriorly both on expiration
upper border of the liver, borders and inspiration. Distance between the
of the heart. Impaired note is also two gives a crude impression about
diaphragmatic movements.
present in fibrosis of lung.
b. Dull note: This is normally present Auscultation
over solid organs like liver, heart. It is the most useful step in the
Dull note is also found in collapse examination of respiratory system.
and consolidation of lung. Recognition of normal breath sounds
c. Stony dull note: This is present requires practice, you can auscultate
yourself to familiarize with normal
over fluid, eg, pleural effusion,
breath sounds.
empyema.
Percussion Note Learn to recognize normal
breath sounds by auscultating
Type of Causes yourself.
Note
Tympanitic 4 Hollow viscus Position of the patient is the same
(empty stomach) as described for other techniques of
examination. If patient is too sick to sit
Hyper reso 4 Pneumothorax up, auscultate the back by turning the
nant 4 Emphysema patient first on one side and then on the
Resonant 4 Normal lung other. Auscultate at corresponding sites
on two sides and compare findings.
Impaired 4 Junction of liver,
heart with the Auscultate most of the chest anteriorly
lung (from above the clavicle down to the 6th
rib), laterally (from the axilla to the 8th
4 Pulmonary
rib) and posteriorly (from the trapezius
fibrosis
down to the 11th rib), as abnormality may
4 Pulmonary be confined to a very small area.
consolidation,
collapse (some Auscultate most of the chest
cases) anteriorly, laterally , and
Dull 4 Over liver, heart posteriorly.
4 Pulmonary
consolidation, Don't auscultate within an inch of
collapse (some midline as findings can be misleading.
cases) Conventionally diaphragm of the
4 Pleural thickening stethoscope is used because most of the
respiratory sounds are high pitched,
Stony dull 4 Pleural effusion
in some thin individuals it may not
PDFelement
@1
be possible to achieve full contact 2. Pneumothorax
between the diaphragm and the skin 3. Collapse with obstructed bronchus
and rubbing of the diaphragm with hair 4. T hickened pleura
and skin may produce artificial sounds
5. Emphysema (reduction in intensity
resembling pleural rub particularly if
of breath sounds is generalized)
diaphragm is placed in the intercostal
space and there is indrawing of that Character of Breath Sounds
space. These sounds will disappear if you
carefully auscultate with the bell. Vesicular Breathing:
Note the following: This is the character of normal
breath sounds. It has the following
1. Breath sounds (intensity and characteristics (fig 3.22):
character) 1. Inspiration is longer than expiration
2. Added sounds because sounds are audible
3. Vocal resonance throughout inspiration but during
only initial one third of expiration.
Breath Sounds 2. There is no pause between
Ask the patient to open the mouth and inspiration and expiration.
take deep breath in and out. Concentrate 3. Quality of sounds is rustling.
on intensity, duration and character
of both inspiration and expiration, and
note any interval between them.
Patients with pleural pain should not be
asked to cough or take deep breath until
pain is controlled. In such patient test
vocal resonance first and if there is an
area with abnormality, ask him to take Fig 3.22: Vesicular breathing
one or two deep breath to assess breath
sounds. Bronchial Breathing:
When abnormal breath sounds are It has following characteristics (fig 3.23):
heard, map out the area by moving from 1. Expiration is as long and as loud
normal to abnormal area as inspiration because sounds are
audible throughout expiration.
Intensity of Breath Sounds
2. There is a definite pause between
Normal intensity is learned with inspiration and expiration.
experience. If intensity of breath sounds
3. Character of both inspiratory and
is diminished repeat auscultation after
expiratory sounds is blowing.
forceful cough; intensity of sounds
will increase if it was diminished due
to bronchial obstruction by secretions
which are dislodged by cough.
Causes of diminished breath sounds
are:
1. Pleural effusion Fig 3.23: Bronchial breathing
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(Breath sounds are produced by the

passage of air through major airways
and are originally bronchial in character.
Their character is modified while being
conducted through the lung tissue to the
chest wall and becomes vesicular. If the
intervening lung tissue is cut off and the
Fig 3.24: Vesicular breathing with prolonged
sounds produced at major airways are
expiration
directly conveyed to the chest wall, their
character remains bronchial.) Added Sounds
Bronchial breathing is normally heard If added sounds are present, note their
over the trachea and the upper part of type, number and site where they are
midline. heard. You should repeat auscultation
after forceful cough. It will help to
Causes
differentiate between various added
1. Consolidation sounds if there is any doubt; ronchi or
2. Cavitation (may be amphoric crepitations will alter while pleural
resembling the sound produced rub will remain unchanged. Similarly,
by blowing across the top of a crepitations at apex after coughing
bottle) may be the only sign of pulmonary
3. Collapse with patent main tuberculosis.
bronchus Ronchi
Above mentioned causes are of These are continuous, musical, whistling
high pitched bronchial breathing. sounds produced by passage of air
Sometimes low pitched bronchial through narrowed airways. These are
breathing is heard in fibrosis and audible all over the chest.
bronchiectasis.
In some cases of pleural effusion Causes
and tension pneumothorax faint 1. Bronchial asthma
bronchial breathing may be heard due
to underlying compression collapse. 2. Chronic bronchitis
Combination of consolidation and 3. Emphysema
pleural effusion may be difficult
to diagnose clinically. Percussion In chronic bronchitis and severe asthma
note will be stony dull, breath sounds ronchi are audible, both, in inspiration
will be bronchial but of diminished and expiration. In mild asthma they
intensity. are audible at the end of expiration
only when patient is asked to open the
Bronchovesicular Breathing: mouth, take a deep breath in and then
expire fully as much as he can. In severe
Inspiration is bronchial while expiration asthma the chest may be silent if air
is vesicular. It has no significance. entry is markedly reduced. A constant
Vesicular Breathing with prolonged low pitched ronchus (fixed ronchus) is a
expiration (fig 3.24): It is heard in feature of partial obstruction of a major
chronic bronchitis, emphysema and bronchus, eg, due to tumor or foreign
bronchial asthma. body.
PDFelement
Stridor Pleural Rub

It is a sound resembling ronchus This is a superficial, scratchy, rough
produced by partial obstruction of larynx sound (similar to pericardial rub) and
and trachea. Its intensity is louder in is produced by rubbing of inflamed
inspiration (ronchus is more prominent pleural surfaces. It does not change with
during expiration) and decrease as one coughing. It is audible at the end of
auscultates away from the center. inspiration and just after the beginning
of expiration. It may be audible only on
Crepitations deep breathing. It disappears with the
These are interrupted, crackling sounds development of effusion but may persist
produced by the following mechanisms: above the effusion.
+ Bubbling of the air through
secretions in the bronchi and Table Differential diagnosis of
pulmonary cavities: These are pleural rub and crepitations
heard throughout inspiration and Pleural rub Crepitations
change on coughing. Causes are
bronchitis, bronchiectasis, resolving + It is audible 4 These are
pneumonia, tuberculous cavity and at the end of audible
lung abscess. These are heard over inspiration only during
the affected part of the lung. and just after inspiration
4 Explosive reopening of thickened the beginning
alveoli: These are heard at the end of expiration
of inspiration and don't change on + It increases in 4 These are not
coughing. Causes are pulmonary intensity on affected
edema and fibrosing alveolitis. As pressing the
closure of alveoli is more likely to stethoscope
occur at bases, such crepitations are
more common there. 4 It remains 4 These usually
unchanged on change on
Causes of Crepitations coughing coughing
Type of crepi Causes Vocal Resonance

tations It is similar to vocal fremitus but is heard
on auscultation. Ask the patient to repeat
+ Pan + Bronchitis words like one, one, one or equivalent,
inspiratory 4 Bronchiectasis and auscultate the chest. A resonant
+ Resolving sound is heard and is called vocal
pneumonia resonance. Compare it at corresponding
+ Tuberculous sites on both sides. Vocal resonance may
cavity be normal, decreased or increased.
+ Lung abscess + Normal vocal resonance conveys
the impression as if it is being
4 End + Pulmonary produced just at the chest piece of
inspiratory edema the stethoscope.
+ Fibrosing 4 If it seems that the sound is being
alveolitis produced nearer the ear than at
PDFelement
the chest piece, vocal resonance is Forced Expiratory Time (FET)

increased.
Place the chest piece of stethoscope over
+ Bronchophony: Sometimes vocal
resonance is increased to the extent the trachea. Ask the patient to take full
that it coveys the impression of deep inspiration and then expire fully
being produced near the ear piece at maximum speed. Note the time taken
of the stethoscope. It is called by expiration. Normally it is less than
bronchophony. 4 seconds. It is prolonged in chronic
+ Aegophony: Sometimes a nasal bronchitis, emphysema and bronchial
or bleating quality is added to the
sound of vocal resonance. It is called asthma.
aegophony. It usually occurs above
the level of a large pleural effusion. Coin Test
Whispering Pectoriloquy This test is sometimes helpful in

Ask the patient to whisper words like confirming the presence of tension
one, one, one. Normally these are not pneumothorax. Take help of another
clearly appreciated on auscultation. person. Ask him to place a coin on the
If individual syllables are distinctly posterior chest wall of the patient and
appreciated, whispering pectoriloquy is
said to be present.
tap it with a second coin while you
auscultate on front. Normally a dull
Causes thud is heard. If a ringing metallic sound
1. Increased Vocal Resonance and is heard, test is positive.
Whispering Pectoriloquy:
Same as those of increased vocal Succussion Splash
fremitus and bronchial breathing
(page 93) If the chest of a patient with
hydropneumothorax is shaken, a
2. Decreased Vocal Resonance:
splashing sound is heard. It should not be
Same as those of decreased vocal
fremitus and decreased intensity confused with gastric succussion splash
of breath sounds (page 93) (page 130).
PDFelement
CH 3
SIGNS OF VARIOUS RESPIRATORY CONDITIONS
Patholo Shape and Movements Mediastinal Percussion Breath Vocal Added
RESPIRATORY SYSTEM
gical deformity of chest displacement note sounds resonance sounds
condition of the wall
chest
Consoli Normal May be None Impaired or Bronchial Increased, Crepitations
dation reduced on dull whispering
affected side pectoriloquy
Cavitation Normal May be None Impaired Bronchial Increased, Coarse
reduced on whispering crepitations
affected side pectoriloquy
Collapse Local May be Towards lesion Impaired or Bronchial Increased, None
with patent flattening reduced on dull whispering
bronchus may be affected side pectoriloquy
present
Collapse Local May be Towards lesion Impaired or Diminished Reduced None
with flattening reduced on dull or absent
obstructed may be affected side
bronchus present
Fibrosis, Local May be Towards lesion Impaired May be May be Coarse
bronchiec flattening reduced on bronchial Increased crepitations
tasis may be affected side
present
Pleural Local Reduced or Towards Stony dull Diminished Reduced or Pleural rub
effusion bulging absent on opposite side or absent absent above the
may be affected side effusion in
present some cases
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Pneumo Local Reduced or Towards Hyper Diminished Reduced or None o

thorax bulging absent opposite side resonant or absent absent
may be
present
Bronchial Normal, Diminished None Normal Vesicular Normal Expiratory
asthma may be all over with ronchi
barrel prolonged
shaped expiration
Chronic Barrel Diminished None Normal Diminished Normal or Ronchi

obstructive shaped all over or hyper vesicular reduced (may
airway chest resonant with be both
disease prolonged 'inspiratory
expiration and
expiratory)
Interstitial Normal Diminished None Normal Vesicular Normal End
lung disease all over inspiratory
crepitations,
not affected
by coughing
BEDSIDE TECHNIQUES
PDFelement
CH 3 RESPIRATORY SYSTEM [103
INSPECTION Respiratory rate
Type of respiration Abdomino-thoracic or thoraco
abdominal
Acidotic breathing
Cheyne-Stokes breathing
Shape of the chest Normal
Barrel shaped
Deformity Pectus carinatum (pigeon chest)
Pectus excavatum (funnel chest)
Harrison's sulcus
Thoracic kyphoscoliosis
Local bulging or flattening of the
chest
Prominent veins, pulsa
tions, scar
Chest movements Reduced movements
Indrawing of intercostal spaces and
supraclavicular fossa
Paradoxical movements
Use of extra respiratory muscles
Pursing of lips
PALPATION Position of trachea and
apex beat
Movements of chest
Expansion of chest
Vocal fremitus
Tenderness, crepitus
Palpable sounds
PERCUSSION Upper border of liver
Comparison of percus
sion note on both sides
Tidal percussion
AUSCULTA Breath sounds Intensity
TION Character
Added sounds Ronchi
Crepitations
Pleural rub
Vocal resonance
Whispering Pectoriloquy
Forced expiratory time
PDFelement
gllg> BEDSIDE TECHNIQUES
WRITING OUT ROUTINE of FEV1 and FVC in percentage (FEVj/

EXAMINATION FVC%) is a useful index. Normally it is
greater than 70%. Mid Expiratory Flow
Examination of a normal person should Rate (MEFR) which is obtained from
be described as follows. If there are the same record is a better parameter
abnormalities, these should be described for airway obstruction compared with
at appropriate places. PEFR (see below).
Inspection In obstructive lung diseases (chronic
Respiration rate is 16 per min. Respiration bronchitis, emphysema, asthma) rate
is abdomino-thoracic. Shape of the chest at which air is exhaled is decreased
is normal. No deformity, scar, prominent throughout expiration. Total length of
veins or pulsations visible. Apex beat expiration is increased. FEVj is markedly
is visible close to the nipple. Chest is reduced and FEV1/FVC% is decreased.
moving equally on both sides with In restrictive lung diseases (fibrosing
respiration. alveolitis, ankylosing spondylitis) FEV1
and FVC both are reduced in same
Palpation proportion and FEV1/FVC% is normal.
Trachea is central. Apex beat is
palpable in 5th intercostal space medial Peak Expiratory Flow Rate
to midclavicular line; it is of normal (PEFR)
character. No tenderness or crepitus This is measured by a device called peak
demonstrated. Movements of chest are flow meter. A simple version in common
equal on both sides. Expansion of the use at home and on the bedside is mini
chest is 5 cm. Vocal fremitus is equal on peak flow meter. Ask the patient to blow
both sides. No sounds are palpable. forcefully into it after a full inspiration
and note the reading. Calculate average
Percussion of three readings. Normal value is
Upper border of the liver is in 5th greater than 400 L/min. It is reduced
intercostal space. Percussion note is in obstructive airway disease. This is
resonant and equal on both sides.
very useful for bedside and at home
Auscultation assessment of airway obstruction and
Breath sounds are vesicular and of response to treatment.
normal intensity. There are no added
sounds. Vocal resonance is equal on both ASPIRATION OF PLEURAL
sides. FLUID
LUNG FUNCTION TESTS Diagnostic aspiration is done when the
cause of effusion is not known. A sterile
Spirometry needle is inserted posteriorly at the site
There are different types of spirometers
but they all give similar information. of maximum dullness. About 20 ml of
Ask the patient to take in as deep a breath fluid is aspirated and sent for estimation
as possible and then exhale as hard and of proteins and sugar, number and type
as fast as possible. Total amount of air of cells, staining, culture and cytology.
expelled is called forced vital capacity Large quantity has to be drained by slow
(FVC). The volume of air expelled in continuous aspiration through a “giving
first second is called forced expiratory set" if pleural effusion is contributing to
volume in one second (FEVj). Ratio respiratory distress.
PDFelement
Causes
A. Exudate (more than 3 grams proteins per dl)
1. Tuberculosis
2. Malignancy
3. Post-pneumonic
4. Pulmonary infarction
5. Connective tissue disorders (SLE, rheumatoid arthritis)
B. Transudate (less than 3 grams proteins per dl)
1. Congestive cardiac failure
2. Hypoproteinemia including nephrotic syndrome
3. Meig's syndrome (can be exudative too)
DIFFERENTIAL DIAGNOSIS OF PLEURAL FLUID

Condition Color of Proteins Cells Other features
fluid concentra
tion
Tuberculosis It is straw >3 g/dl Lymphocytes AFB may be iso
colored lated from fluid
It may be on ZN staining
hemor or culture
rhagic DNA may be
detected
a a
Malignancy It is usu RBCs Malignant cells
ally hemor may be seen on
rhagic cytology
a u
Post-pneu It is straw Mainly polys It is sterile on
monic colored culture
a «
Pulmonary It is hemor RBCs Diagnosis is
infarction rhagic made on the
basis of other
features of the
disease
a a u a a
Connective It is straw Mainly
tissue disor colored lymphocytes
ders
Congestive It is straw Mainly a u a
<3 g/dl
cardiac fail colored mesothelial
ure cells
PDFelement
BEDSIDE TECHNIQUES
RESPIRATORY FAILURE Type II Respiratory Failure

Respiratory failure is said to be present if PaO2 is reduced and PaCO2 is elevated.
either PaO2 is less than 8 kPa (60 mmHg)
or PaCO2 is more than 6.5 kPa (50 mmHg).
It is of two types. Causes
1. Chronic bronchitis
Type I Respiratory Failure
2. Emphysema
PaO2 is reduced but PaCO2 is normal or low.
3. Respiratory paralysis
Causes 4. Severe kyphoscoliosis
1. Bronchial asthma 5. Depression of respiratory center,
2. Pneumonia particularly by narcotics and
3. Pulmonary edema sedative drugs
4. Pulmonary embolism 6. Acute severe bronchial asthma
5. Allergic and fibrosing alveolitis (late stage)
PDFelement
Chapter mhhbhmmbhhhhhhbbmhh
M ALIMENTARY AND
-J GENITO-URTNARY
SYSTEM
These two systems are discussed while inflammatory disorders pain
together because most of their organs is of slower onset and has no relation
lie in the abdomen. The clinical features with activity.
may point towards the site of disease + Pain of peritonitis is relieved by rest
and sometimes, underlying pathology; while pain of peritonitis is relieved
however, quite frequently, diagnosis by sitting forward.
becomes clear only after investigations. + Abdominal pain may be due to
disorders not primarily affecting
SYMPTOMS alimentary tract, eg, diabetic
All the details should be asked about ketoacidosis.
each symptom to differentiate between + Pain may be referred to the abdomen
its various causes. from surrounding structures, eg,
pleuritic pain and pain of myocardial
ALIMENTARY SYSTEM infarction.
Pain + Root or nerve involvement may
cause abdominal pain, eg, vertebral
This is the most common symptom of
collapse, herpes zoster.
disease of abdominal viscera. Ask all the
questions described on page 6. Keep the Differential diagnosis of common
following facts in mind while analyzing causes of abdominal pain is discussed on
possible cause of abdominal pain: page 9 Some characteristics of common
abdominal pain are shown in fig 4.1.
+ Pain from unpaired structures (eg,
appendix) usually starts in the
center.
+ Unilateral pain of paired organs (eg,
kidneys) does not cross the midline.
+ Pain due to mechanical obstruction
(biliary stone, ureteric stone,
intestinal obstruction) is colicky, of
sudden onset and usually preceded
by activity in the previous few hours
107
PDFelement
BEDSIDE TECHNIQUES
+ In structural lesion of esophagus

(eg, stricture - benign or malignant)
dysphagia is more marked for solids.
Patient may point exactly to the site
where food sticks.
+ In neuromuscular disorders (eg,
bulbar and pseudobulbar palsy,
myasthenia gravis, achalasia)
dysphagia is more marked for liquids.
Attempted swallowing may lead to
choking and coughing. In achalasia
nocturnal cough and recurrent
pneumonia due to inhalation of
regurgitant food are common.
+ Globus hystericus is a psychogenic
disorder in which there is a feeling
of constant lump in the throat. There
is no difficulty in swallowing.
Vomiting
This is a non-specific symptom and can
occur due to diseases of other systems
as well, eg, meningitis, renal failure.
Effortless projectile vomiting is a feature
of pyloric stenosis or high intestinal
obstruction. In peritonitis vomiting is
small and persistent. Persistent vomiting
with diarrhea of short duration is due
Fig 4.1: (A) Intermittent severe pain of intestinal colic. to gastroenteritis. Other diseases of
(B) Fluctuant severe pain of ureteric colic. (C) Steady alimentary system causing vomiting are
and severe pain of biliary colic. (D) Steady, mild to hepatitis and cholecystitis.
moderate pain of peptic ulcer
Hematemesis
Dysphagia It means vomiting of blood. Common
+ It means difficulty in swallowing. causes are peptic ulcer, esophageal
varices and drug induced gastric
+ Patient may be afraid of eating
erosions. It should be differentiated from
due to pain in the presence of
hemoptysis (see below). It is usually
inflammatory lesions of oral cavity,
associated with melena.
eg, tonsillitis.
PDFelement
CH 4 ALIMENTARY AND GENITO-URiNARY SYSTEM 109
DIFFERENTIAL DIAGNOSIS OF HEMOPTYSIS AND HEMATEMESIS
Hemoptysis Hematemesis
+ Blood comes up on coughing + Blood comes up on vomiting
+ Color of blood is bright red + Color of blood is blackish
+ May be mixed with sputum + May be mixed with food particles
or air (frothy)
+ Other features of respiratory 4- Other features of GI disease may be
disease may be present, present, eg, pain epigastrium, jaundice or
eg, fever, chest pain or • ascites
breathlessness
Heartburn irritable bowel syndrome is a common
It means retrosternal burning sensation. cause of constipation, particularly if it
It is a common symptom and reflux of alternates with diarrhea; it may also
gastric contents into the esophagus is the be due to intestinal tuberculosis. In
usual underlying mechanism. It may be intestinal obstruction there is absolute
worse after large meal, on lying flat or constipation, ie, there is no passage of
on stooping. feces or flatus. Drugs are also a frequent
cause of constipation.
Jaundice
It means yellow discoloration of the Tenesmus
skin and mucous membrane. It may be This is a feeling of incomplete evacuation
prehepatic (due to hemolysis), hepatic and occurs in proctitis and carcinoma of
(due to disease of the liver) or posthepatic rectum.
(due to biliary obstruction). The most
common cause in Pakistan is viral Diarrhea
hepatitis in which jaundice is associated It may be defined as frequent passage of
with anorexia, vomiting and pain right unformed stools.
hypochondrium. + Food poisoning and viral
gastroenteritis are common causes
ALTERATION IN BOWEL HABITS of acute diarrhea without blood
and mucus. Vomiting is common
Constipation accompaniment.
Normal bowel habits are variable. > In small intestinal diarrhea stool is
The term constipation is used when liquid and of uniform consistency.
stools are infrequent and/or too hard In colonic diarrhea stool contains
to evacuate and patient has to strain. numerous small pieces of feces.
If there is a recent change in bowel
habits in an elderly person, carcinoma of + Presence of blood and mucus
colon must be excluded by appropriate must be noted. Common causes of
investigations. In younger people diarrhea with blood and mucus are
dysentery (amebic and bacillary),
PDFelement
BEDSIDE TECHNIQUES
ulcerative colitis and Crohn's disease. carcinoma stomach, carcinoma colon

Blood in the stools is also a feature of and carcinoma pancreas are important
carcinoma of colon. causes of weight loss and anorexia. In
4 Pale, bulky, foul smelling stools malabsorption there is weight loss but
which are difficult to flush, are appetite is good.
characteristic of steatorrhea
Abdominal Distention
(malabsorption).
Common cause of distention of
Melena abdomen is obesity. Ascites, ovarian
It means black colored stools. These occur cyst, pregnancy, intestinal obstruction
when there is sudden loss of more than and massive enlargement of the liver
20 ml of blood into the upper gut. With and spleen are other causes. Distention
large quantity of blood, stools become starts from flanks in case of ascites and
loose, sticky like tar and foul smelling. from lower abdomen in case of ovarian
Iron intake will also color the stools cyst. In pregnancy there is history of
black but these are not foul smelling. amenorrhea. In intestinal obstruction
other symptoms (pain, vomiting,
Bleeding per Rectum absolute constipation) are present. In
It is a serious symptom and its cause hepatosplenomegaly only part of the
should always be determined. abdomen is distended.
4 Hemorrhoids are very common but Wind
they should not be accepted as a sole 4 Recurrent belching is often a
cause of bleeding per rectum unless feature of anxiety.
other causes have been excluded,
4 Normal amount of flatus is
clinically or after investigations.
variable. Persistent, offensive
Important causes include colonic
flatus is common in malabsorption.
carcinoma (in old patients), polyps
Complete absence of flatus occurs in
(in young patients), inflammatory
intestinal obstruction.
bowel disease and anal fissure.
4 Anal bleeding is bright red in Dyspepsia, Indigestion
color. In hemorrhoids it occurs These are vague terms commonly
after defecation and it may splash used by the patients. They should be
the toilet bowel. In anal fissure encouraged to explain what exactly they
blood coats the side of the stool and mean by these complaints.
defecation is painful.
4 In inflammatory bowel disease GENITOURINARY SYSTEM
blood is mixed with stool.
Dysuria
4 In polyps and carcinoma colon
This means pain on passing urine.
bleeding may be frank or blood may
be mixed with stool. Urgency
There is strong desire to pass urine and
Loss of Appetite and Loss of incontinence may occur if opportunity
Weight to void urine is not available.
Among gastrointestinal diseases
PDFelement
CH 4 ALIMENTARY AND GENITO-URlNARY SYSTEM 111
Frequency urine. It may be gross or microscopic.

This means frequent passage of small Painful hematuria is usually due to
amount of urine. Find out frequency stone. In case of painless hematuria,
during the day and the night. tumor of the urinary tract must be
Dysuria alone is a feature of urethritis excluded. Hematuria also occurs in
while in combination with urgency glomerulonehpritis.
and frequency it occurs in cystitis, Renal Pain, Ureteric Colic
prostatitis and tumor and stone of the
bladder. Urgency alone is a feature of Renal pain is felt as dull ache in the
neurological diseases affecting bladder flanks. Ureteric colic is severe pain and
control. radiates from loin to groin (see page 107).
Polyuria Prostatic Pain

It means passage of excessive amount of It is felt in the perenium and is due to
urine in 24 hour. It should be confirmed prostatitis.
by collecting 24 hour urine. Common
causes are diabetes mellitus, diabetes Pain due to Cystitis and
insipidus, chronic renal failure and Bladder Stone
compulsive polydypsia. Pain due to cystitis occurs in the
hypogastrium and is associated with
Oliguria and Anuria dysuria, urgency and frequency. Pain of
Oliguria means amount of urine bladder stone is typically felt at the tip
passed in 24 hour is less than required of the penis.
to maintain normal body biochemistry.
In a healthy man at rest, on protein free EXAMINATION
diet, upto 200 ml may be sufficient while
Examination of the abdomen (which
in a patient with chronic renal failure
includes Gastrointestinal Tract and
2000 ml may be insufficient.
Genitourinary System) should start
Anuria means complete cessation from oral cavity followed by abdomen,
of urine. Retention of urine must be genitalia and rectal examination.
excluded by palpating and percussing
lower abdomen for a distended bladder. Oral Cavity
Causes of anuria are bilateral ureteric Ask the patient to sit up and open the
obstruction and acute tubular necrosis mouth. Use a torch for illumination.
after, for example, massive blood loss A tongue depressor is required for the
and severe gastroenteritis. examination of the posterior part of
the oral cavity. Inspect lips, gums, teeth,
Nocturia tongue, mucous membrane of oral
It means frequent passage of urine cavity, tonsils and oropharynx. Cyanosis,
during the night. It may be due to pallor, jaundice and dehydration have
prostatic hypertrophy, diabetes mellitus, been discussed under general physical
chronic renal failure or cardiac failure. examination (page 26 - 27).
Hematuria Lips
It means passage of blood in the 1. Herpes labialis: It is a common
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eruption caused by the virus herpes benign condition in which there

simplex and frequently occurs after are islands of loss of papillae and
fever, particularly malaria and pattern resembles a map.
pneumococcal pneumonia. These 4. Black hairy tongue: This is due to
are groups of vesicles on red base fungal infection.
with crusted lesions. 5. Leukoplakia: These are whitish
2. Angular stomatitis: This occurs opaque patches, usually on the side
in iron and riboflavin deficiency of the tongue and are potentially
and appears as cracks at the angle pre malignant.
of the mouth which are inflamed 6. Ulcers: There are a number of
and painful. Ill fitting dentures are causes of tongue ulcers. A persistent
another cause. ulcer on the side of the tongue
Gums should be biopsied to exclude
1. Gingivitis: The margins of gums malignancy.
are inflamed; pus may be present. Mucous Membrane of Oral Cavity
2. Hypertrophied gums: These are
1. Pigmentation: It may be an
seen in phenytoin therapy, pregnancy isolated finding. It is also a feature
and acute myelomonocy tic leukemia. of Addison's disease, Peutz-
3. Bleeding gums: These may Jegher syndrome (other features
be due to scurvy, leukemias or are familial polyposis of small
thrombocytopenia. intestine) and hemochromatosis.
4. Blue line: It runs along the edge of 2. Koplik's spots: They are white spots
the gums and is seen in chronic lead on an erythematous background
poisoning. opposite the molar teeth, seen in
Teeth measles before the appearance of
Discoloration and caries reflects poor rash and are of diagnostic value.
oral hygiene. Tetracycline therapy in Tonsils and Oropharynx
early childhood can lead to yellow grey
staining of teeth. Hutchinson's teeth of Depress the tongue with a tongue
depressor and ask the patient to say 'ah'.
congenital syphilis are now rare.
The soft palate elevates and the fauces,
Tongue tonsils and oropharynx are exposed.
Neurological examination will be 1. Tonsils: Look for the size of
discussed under nervous system. the tonsils and evidence of
1. Size: Tongue is enlarged in inflammation. In streptococcal
primary amyloidosis, acromegaly, tonsillitis there is yellow follicular
myxedema and cretinism. exudate. In diphtheria there is a
2. Bald tongue: Tongue is bald if white to green membrane covering
there is atrophy of the papillae. It the tonsils. If this membrane is
occurs in iron, B12 and riboflavin removed, bleeding occurs.
deficiency. 2. Pharynx: In pharyngitis the
3. Geographical tongue: This is a mucosa is hyperemic and congested.
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CH 4 ALIMENTARY AND GENITO-URINARY SYSTEM 113
General Disease of Oral Cavity and two vertical. Upper horizontal line
1. Carcinoma: It can involve any part connects the lowest points on the costal
of the oral cavity. It occurs in the margins and lower horizontal line
form of a chronic ulcer; any such connects tubercles of the iliac crests.
Two vertical lines pass through mid
suspicious lesion must be biopsied.
inguinal points. Names of the regions are
2. Aphthous ulcers: These are small as follow:
shallow ulcers with white or yellow
On each side from above downwards are
base, surrounded by red margins, right and left hypochondrium, right and
and are painful. Common sites are left lumbar regions and right and left
inner side of lips, inside of cheeks, iliac fossae. In the middle from above
palate and sides of tongue. downwards are epigastrium, umbilical
3. Thrush: It is a fungal infection region and hypogastrium (fig 4.2). The
caused by Candida albicans. There advantages of this division are:
are white deposits, raised from the 1. It is easy to describe abnormal
surface, on the mucous membrane clinical findings.
with very little evidence of 2. It helps to draw the conclusions
inflammation. These may be as we know which organ lies
confused with milk curd which can in a particular region, eg, if a
be easily removed, while thrush is mass is palpable in the right
removed with difficulty and leaves hypochondrium, it could be related
behind a raw surface. to the liver or gall bladder; a similar
mass on the left side is related to the
EXAMINATION OF ABDOMEN spleen or left kidney.
Position of the Patient A
The patient should be examined in a \ 11 ■

well lighted room. He should lie flat on a XL
firm couch with his arms alongside the
body. The abdomen should be exposed ' A; D
from the xiphisternum to the pubic
1
1
symphysis.
-
LU
For examination of groin and genitalia

special permission should be taken and
1
1
1
1
---------------------
adequate privacy should be ensured. In

: 1
■n
case of a female patient, a female doctor/

n
1 Z'
student should be asked to perform 1
the examination. If it is not possible \l
and examination is necessary, then a ^1
chaperon (female attendant) must be

1 — 1 J
present. Fig 4.2: Regions of abdomen (A) right hypochondrium
(B) right lumbar region (C) right iliac fossa (D)
Regions of the Abdomen epigastrium (E) umbilical region (F) hypogastrium (G)
The abdomen is divided into nine regions left hypochondrium (H) left lumbar region (I) left iliac
fossa
by four imaginary lines; two horizontal
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HMSKMBMMOMai
Examination of the abdomen is carried left to right across the upper ab domen.
out by: Congenital pyloric stenosis presents
a. Inspection in the early infancy. In adults it may
b. Palpation be due to chronic duodenal ulcer or
carcinoma stomach.
c. Percussion
+ In intestinal obstruction
d. Auscultation
distended loops of intestine stand
Inspection out in a step ladder pattern.
Look for the following physical signs: Umbilicus
1. Shape of the abdomen Normally it is circular and inverted. It is
2. Movements of the abdominal wall- everted in massive ascites and umbilical
3. Umbilicus (shape and position) hernia. It is transversely slitted and at its
4. Pulsation normal position in ascites, and vertically
5. Scar slitted and displaced upwards in ovarian
cyst.
6. Striae
7. Prominent veins Pulsation
8. Pubic hair Aortic pulsations may be normally
9. Hernial orifices visible in the epigastrium in a thin
individual. Other important causes are
Shape of the Abdomen aneurysm of the aorta and mass in front
Normal abdomen is neither protuberant of the aorta. In aneurysm, pulsations are
nor sunken. Sunken (scaphoid) expansile (when two fingers are placed
abdomen is seen in starvation or wasting on either side of the pulsating mass, they
disease like malignancy. Generalized move away from each other with each
distention of abdomen could be due pulsation). In case of mass transmitting
to fat (eg, obesity), fluid (eg, ascites), pulsations, these are not expansile.
flatus, feces (eg, intestinal obstruction)
or fetus. In obesity umbilicus is sunken Scar
while in other conditions it is flat or Presence of scar indicates previous
everted. Localized distention may be due surgery or trauma.
to enlarged viscera like hepatomegaly or
splenomegaly. Striae
White or pink striae are due to rupture
Movements of the Abdominal Wall of the elastic fibers. These indicate a
Respiratory movements: Normally recent change in the size of the abdomen,
the abdomen moves out during eg, previous pregnancy, loss of weight
inspiration and moves in during or treated ascites. Purple striae are
expiration. In generalized peritonitis
characteristic of Cushing’s syndrome (a
these movements are absent.
condition in which serum cortisol levels
Visible peristalsis: These may be are raised).
normally visible in elderly patients.
+ In pyloric stenosis peristaltic Prominent Veins
movements are seen moving from In order to look for prominent veins
PDFelement
CH 4 ALIMENTARY AND GENITO-URlNARY SYSTEM 115
examine the patient preferably in Method of detecting the direction

standing position or at least in sitting of flow of blood: Place index fingers
position. There are two causes of such of both hands on the vein. Squeeze the
veins. vein by moving these fingers away
1. Obstruction of the inferior from each other. First lift one finger and
vena cava: Veins are mainly in note speed of refilling of the empty vein.
the flanks and direction of flow of Repeat the process, lift 2nd finger and
blood is from below upwards (fig note speed of refilling of the empty vein
4.3). from other direction. The direction in
2. Portal hypertension: Classically,
the veins are arranged around the
umbilicus in radiating manner
(this is called caput Medusae).
The direction of flow of blood
is away from the umbilicus,
ie, from below upwards above
the umbilicus and from above
downwards below the umbilicus
(fig 4.3). This phenomenon is rare.
More commonly veins are seen in
the flanks and cause is not portal
hypertension but compression of
the inferior vena cava due to ascites.
Fig 4.4: Method of detecting the direction of flow of
blood in the veins
Pubic Hair
These appear as secondary sex character
at the time of puberty. They don't appear
in hypogonadism and hypopituitarism.
In female, upper border of pubic hair
is concave while in male- it is convex
and extends upto umbilicus. If male
distribution of pubic hair is seen in a
female, it could be due to secretion of
male sex hormones by the' adrenals
(adrenal virilism). A female distribution
in a male is seen in hepatic cirrhosis.
Hernial Orifices
Fig 4.3: Abnormal veins of abdominal wall (1) caput
Inspect the hernial orifices. Ask the
Medusae (2) dilated veins in inferior vena caval patient to cough and look for cough
obstruction impulse which is an important feature
of a hernia. Common hernias are:
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OMH
1. Umbilical and paraumbilical Light Palpation

hernia: It is common in babies Palpate the abdomen gently starting
and multiparous women (women from the left iliac fossa and moving
who have given birth to many
to the left lumbar region, left
children).***
2. Epigastric hernia: It consists
of extra peritoneal fat bulging
through linea alba. It is felt as a
small swelling in the epigastrium.
3. Incisional hernia: If wound is
weak, abdominal contents may
bulge through weak scar.
4. Femoral and inguinal hernia:
These are described in detail in
books of surgery.
Palpation
Patient's abdominal wall
muscles must be relaxed for a
successful palpation.
The success of palpation lies in the

relaxation of patient's abdominal
wall muscles. This can be achieved by
gaining patient's confidence. Explain
to the patient that you will be gentle.
Temperature of the room and palpating
hands should be appropriate. If hands
area cold, rub them or wash them with
warm water. Ask the patient to point out
any tender site and palpate that site at
the end. Flexion of the legs at the hip and
knee also helps in achieving abdominal
relaxation but it is not mandatory.
Types of Palpation
1. Light palpation
2. Deep palpation
3. Palpation for the viscera
4. Dipping
* Weakness of linea alba (midline junction of
recti) is also common in multiparous women and
contents of the abdomen bulge out as they lie supine
(divarication of the recti). Ask the patient to raise
her head against resistance to contract abdominal
muscles and palpate the midline, the gap between
recti will become obvious to the palpating hand.
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hypochondrium, epigastrium, umbilical talking to the patient during palpation

region, hypogastrium, right iliac to distract him.
fossa, right lumber region and right
/ 1"-------------------------
hypochondrium (fig 4.5A). You can also
start from the right iliac fossa and move
in reverse direction (fig 4.5B). Purpose-of
light palpation is:
+ To gain patient's confidence.
+ To assess tone of abdominal
muscles and to detect guarding,
rigidity or tenderness. Guarding
is localized rigidity produced by
reflex contraction of abdominal
muscles overlying an inflamed
viscus eg appendicitis. Affected
part of abdominal wall feels hard.
Generalized or board-like rigidity is
a feature of diffuse peritonitis; whole
abdominal wall feels hard like board
and slight pressure of palpating
hand produces severe pain.
Deep Palpation
Place the right hand flat on the
abdominal wall, wrist and elbow being in
the same horizontal plane. Hand should
be relaxed and moulded to the abdominal
wall (fig 4.6). Avoid sudden poking with
finger tips. Movements of the hand
should coordinate with respiratory
movements of the abdominal wall. Press
the hand during expiration and keep it
steady during inspiration so that if there
is a mass, it may move downward and
become palpable. Keep looking at the
patient's face for any grimacing due to
tenderness. Follow the same sequence as
for light palpation and look for:
a. Tenderness and rebound tenderness
b. Mass
Tenderness: It means pain on touching.
This is a sign. When a tender point Fig 4.6: Palpation of abdomen (A) correct method;
is touched, there is grimacing on the hand is held flat, relaxed and moulded to the
patient's face. If there is doubt whether abdominal wall (B) incorrect method; hand is rigid
tenderness is genuine or not, keep and mostly not in contact with the abdominal wall
PDFelement
Rebound tenderness: Press the hand resistance. As abdominal muscles

gradually and deeply, then suddenly contract, an intra abdominal mass will
release it; if there is change in the facial become less conspicuous, a mass in
expression (patient may complain of the muscle wall will not change while
pain), rebound tenderness is present. subcutaneous mass will become more
This indicates peritonitis.*** prominent.
Mass: If a mass is palpable, note the
following features:
1. Site
2. Size
3. Shape
4. Consistency*** (cystic, soft, firm,
hard)
5. Surface (smooth, irregular, nodular)
6. Tenderness
7. Movement with respiration (liver,
spleen, kidney and gall bladder
move with respiration)
8. Mobility (masses originating from
small intestine, transverse colon,
omentum and mesentery are
mobile; retroperitoneal masses, eg,
Fig 4.7: Palpation of the aorta
pancreas and masses attached to
the anterior or posterior abdominal
wall are not mobile) Following masses other than the
9. Upper and lower limits of the mass viscera discussed later could be
(upper limits of liver, spleen and palpable.
gall bladder and lower limits of Sigmoid colon: It lies in the left
urinary bladder and uterus are not iliac fossa. It may be palpable as
reachable) a tubular structure normally, as
10. Bimanually palpable or not a tender mass in diverticulitis
(kidneys are bimanually palpable) and as a hard ill defined mass in
In order to differentiate between intra carcinoma sigmoid.
abdominal and extra abdominal mass, Mass in right iliac fossa: A
ask the patient to raise his head against normal cecum is sometimes
palpable in the right iliac fossa
* Signs of peritonitis: Absent respiratory as a soft ill defined mass. Other
movements of the abdominal wall, rigidity, guarding,
tenderness, rebound tenderness and absent bowel masses at this site may be due
sounds (if‘peritonitis is generalized). to appendicular mass, ilio cecal
** Consistency. Cystic (like water filled balloon), tuberculosis, carcinoma cecum
very soft (jelly like), soft (like relaxed muscle), firm
(like tip of the nose), hard (like contracted biceps of a
or ameboma. In a female, masses
body builder), stony or bony hard (stone or bone like).
PDFelement
CH 4 ALIMENTARY AND GENITO-URINARY SYSTEM
related to fallopian tubes and hypochondrium. If very large, it may

ovaries may be palpable in both extend to the right iliac fossa. There
iliac fossae. are a number of different methods of
palpation of the liver.
Hard feces: In a constipated
patient fecal masses may be 1. Right hand is placed vertically
palpable. These are identified in the right iliac fossa, index and
by the observation that finger middle fingers being outside the
pressure causes indentation of the rectus and tips of fingers facing the
lump. right costal margin (fig 4.8). This is
Abdominal aorta: It is palpated the most commonly used method.
by pressing deeply the extended
fingers of both hands, held side by
side, above and to the left of the
umbilicus (fig 4.7). In aneurysm
of the aorta expansile nature of
the pulsations can be determined
(page 147).
Gastric mass: In congenital
pyloric stenosis a tumor like mass
is palpable in the epigastrium. In
adults a gastric mass may be due to
carcinoma stomach.
Abdominal lymph nodes: Para
aortic lymph nodes are palpable
in the area between epigastrium
and umbilicus, as hard, fixed mass.
They are particularly enlarged
in tumor of the testes. Mesenteric
lymph nodes, if enlarged, may also
be palpable as nodular masses.
Mesenteric cyst: This is palpable
as mobile cystic mass.
Tendinous insertions of rectus
2. Sometimes both hands are placed
abdominis: Sometimes beginner
side by side, fingers facing the right
hypochondrium (fig 4.9).
can confuse them as a mass.
3. In an obese or muscular patient, left
Palpation for the Viscera hand is placed over the top of the
right hand to aid in exerting the
Liver pressure (fig 4.10).
It lies under the right lower chest. Its left 4. Some people still use radial border
lobe extends to the epigastrium. When of the index finger. Hand is placed
enlarged, liver is palpable in the right parallel to the right costal margin
(fig 4.11). It is a less sensitive method.
PDFelement
tEE> BEDSIDE TECHNIQUES
the height of inspiration release inward

pressure and maintain upward pressure.
If liver is palpable, its edge will descend
during inspiration and palpating fingers
will slip over it. If liver is not palpable
in the right iliac fossa, move the hand
gradually upwards with each respiration
till right costal margin.
Fig 4.9: Palpation of liver; two hands are placed side

by side
Fig 4.11: Palpation of liver with radial border of index

finger
If liver is palpable, repeat the maneuver

from right to left to define its edge as
it extends to the epigastrium. Gently
palpate part of the liver below the right
costal margins and note all the features
discussed under mass, particularly:
1. Size (how many cm or fingers
breadth below the right costal
margin is the liver edge palpable)
Fig 4.10: Palpation of liver; left hand over the top of
2. Edge (sharp or rounded)
right hand
3. Surface (it is smooth in hepatitis and
Start from the right iliac fossa. Ask the congestive cardiac failure; irregular
patient to breath deeply. Press the hand in cirrhosis and malignancy)
inwards and upwards during expiration 4. Consistency (it may be cystic in
and keep it steady during inspiration. At hydatid cyst and abscess; soft in
PDFelement
CH 4 ALIMENTARY AND GEN ITO-URINARY SYSTEM
hepatitis and congestive cardiac

failure; firm or hard in cirrhosis
and malignancy)
5. Tenderness** * (liver is tender in
hepatitis, amebic liver abscess and
congestive cardiac failure)
6. Pulsations (these are palpated by
placing the left hand posteriorly
over the right lower ribs and the
right hand over the enlarged liver -
fig 4.12; liver is pulsatile in tricuspid
regurgitation)
Common Causes of Hepatomegaly

1. Viral hepatitis
2. Cirrhosis (early)
3. Right heart failure
4. Amebic liver abscess
5. Enteric fever
6. Malignancy
Causes of Tender Hepatomegaly
1. Acute hepatitis
2. Congestive hepatomegaly (due
to right heart failure, pericardial
effusion or constrictive
pericarditis)
When liver is palpable, percuss for its 3. Amebiasis
upper border as it may be displaced 4. Hepato-cellular carcinoma
downward due to pulmonary disease, eg, 5. Pyogenic abscess
emphysema.
Edge of the right lobe of the liver Gall Bladder
and left lobe are normally palpable, It lies under the inferior surface of the
particularly in thin persons. Riedel's liver. Normally it is not palpable. Method
lobe is a congenital variant of the right of palpation is the same as for the liver.
lobe which extends as a tongue-shaped When enlarged, it is felt as a smooth
process downward in the lateral part of globular swelling (except in carcinoma
the abdomen (fig 4.13). when the mass is hard and irregular)
* Tenderness can also be elicited by percussing with distinct borders, lateral to the edge
on the side of right chest cage with the right fist. of the rectus abdominis. It moves with
PDFelement
respiration. The upper border disappears the ninth costal cartilage and patient is
under the liver or right costal margin. It asked to take a deep breath, he suddenly
lies just behind the anterior abdominal holds his breath when the inflamed
wall and cannot be palpated bimanually gall bladder touches the palpating
(to differentiate it from the right fingers. This sign is not found in chronic
kidney). When grossly enlarged it may cholecystitis (fig 4.14).
extend upto the right iliac fossa.
Spleen
Spleen lies under the left lower ribs. It
Causes of palpable gall bladder** * ** only becomes palpable below the costal
1. Mucocele of the gall bladder margin when it has enlarged to more
2. Carcinoma head of pancreas than twice its normal size*** . Direction
3. Carcinoma gall bladder of enlargement is towards the right iliac
fossa (fig 4.15).
Murphy's Sign: In acute cholecystitis

if the thumb or fingers are placed over Very big spleen is easily palpable;
the right costal margin near the tip of problem is to palpate a just palpable
spleen. Place the right hand in the right
* Mucocele of the gall bladder: Gallstone gets
impacted in the neck of uninfected empty gall
iliac fossa, fingers facing towards left
bladder. The mucus continues to be secreted, gall hypochondrium (fig 4.16). Press the hand
bladder becomes distended and palpable. Patient is during expiration and keep it steady
not jaundiced. during inspiration (similar to palpation
Carcinoma head of pancreas: Patient is deeply
jaundiced. (^Courvoisier's iau» states if gall bladder is of the liver). Release the pressure at the
palpable in a jaundiced patient, it is unlikely to be due height of inspiration so that fingers
to impaction of gallstone in the common bile duct.
Most common cause is carcinoma head of pancreas'). ** The spleen has a very variable axis and will
Carcinoma gall bladder: Mass is hard and irregular become palpable with lesser degree of enlargement
and may not resemble the typical gall bladder mass. when almost vertical than when almost horizontal.
PDFelement
slip over the edge of the spleen if it apply constant pressure medially and
is palpable. Move the hand gradually downwards (fig 4.17). Palpate spleen with
towards left hypochondrium. tips of right fingers under the left costal
margins starting medially and moving
laterally (4.18). Encourage the patient to
If spleen is still not palpable, turn the

patient to right lateral position, flex left
leg at hip and knee and repeat the whole
maneuver (fig 4.19).
Fig 4.19: Bimanual palpation of spleen in right lateral

Fig 4.17: Bimanual palpation of spleen in supine position
position
When spleen is palpable, note its size
If spleen is not palpable, place your left below the costal margin. Differential
hand over left lower ribs posteriorly and
PDFelement
diagnosis of spleen and left kidney is hand. Press the right hand backward
given on page 126. with each expiration to achieve as
much approximation of two hands as
Causes of splenomegaly
1. Malaria
2. Enteric fever
3. Viral hepatitis
4. Portal hypertension
5. Lymphomas
6. Leukemias
7. Myelofibrosis
8. Hemolytic anemias
9. Miliary tuberculosis
10. Systemic lupus erythematosis
11. Infective endocarditis
12. Infectious mononucleosis
13. Kala azar
Causes of Massive Splenomegaly
1. Chronic malaria
2. Chronic myeloid leukemia
3. Myelofibrosis
4. Kala azar
Causes of Hepatosplenomegaly
1. Enteric fever
2. Cirrhosis
3. Chronic active hepatitis
4. Acute viral hepatitis
5. Leukemias
6. Lymphomas
Kidneys
Place the right hand anteriorly in
the lumbar region and the left hand
posteriorly in the loin outside the erector Fig 4.20: Palpation of right kidney (A) both hands
spinae. Both hands should be horizontal held horizontally, one above the other (B) right hand
and at the same level (fig 4.20A, 4.21). is placed vertically anteriorly; left hand is placed
Apply forward pressure with the left horizontally posteriorly
PDFelement
is possible. If kidney is palpable, it will

move downward between two hands
during inspiration. Anterior hand can be
placed vertically too (fig 4.20B). Kidney
is also ballotable (when mass is pushed
forward with the left hand it is felt by
the right hand). Lower pole of the right
kidney may be normally palpable in a
thin person.
Fig 4.23: Method of eliciting renal punch
Causes of palpable kidney

Unilateral
1. Tumor (Wilm's tumor in children,
Murphy’s renal punch renal cell carcinoma in adults)
Ask the patient to sit up. Place your 2. Hydronephrosis
3. Pyonephrosis
left hand over the renal angle (the 4. Compensatory hypertrophy
space between costal margin and spine) with contralateral absent/small
and percuss it with the right fist (fig kidney
4.23). If there is tenderness, punch is Bilateral
positive. It occurs in perinephric abscess, 1. Polycystic disease of kidney
hydronephrosis and pyonephrosis. 2. Bilateral hydro/pyonephrosis
PDFelement
[ 126 BEDSIDE TECHNIQUES
DIFFERENTIAL DIAGNOSIS OF LEFT KIDNEY AND SPLEEN

Left Kidney Spleen
4 It enlarges downward 4 It enlarges downward and medially
4 Notch is not present 4 Notch is usually present in the
lower medial border
4 It is bimanually palpable 4 It is not bimanually palpable
4 Fingers can be pushed between the 4 Fingers cannot be pushed between
mass and the left costal margin the mass and the left costal margin
4 Percussion note is resonant in front 4 Percussion note is dull
due to descending colon
Urinary Bladder 4.24). Its lower limits cannot be reached.

It is not palpable when empty and Pressure induces a desire of micturition.
becomes palpable as a rounded swelling In a female, it should be differentiated
in the hypogastrium when distended, from the gravid uterus which is
more mobile; history is also helpful.
Dipping Method of Palpation
In large ascites viscera cannot be palpated
by usual method and dipping technique
is used. Place the hand over possible site
of enlarged viscous and make quick
dipping movements with it. Fluid is
displaced and if viscous is palpable, it is
felt by the fingers.
Percussion
Method and rules of percussion are the
same as described on page 93. In abdomen
percussion is done:
4 To define boundaries of various
organs and masses.
4 To detect ascites and differentiate it
particularly in retention of urine. It
from ovarian cyst.
can be felt during general palpation of
abdomen with the right hand, but its Liver
upper limit can be better defined with Borders of the liver are easily mapped
the left hand placed in the hypogastrium, out by heavy percussion from above and
grasping the upper border of the bladder light percussion from below. For upper
between thumb and index finger (fig border of the liver start percussing from
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CH 4 ALIMENTARY AND GENITO-URlNARY SYSTEM
right 2nd intercostal- space and. move

downward in midclavicular line till note
becomes impaired (fig 4.25). It is usually
in the 4th or 5th intercostal space. It may
be displaced downward in emphysema
and pneumothorax. The lower border is
determined by percussing from the right
iliac fossa upwards. Place pleximeter
(finger to be percussed-left middle
finger) parallel to the costal margin (fig
4.26). Normal resonant note will change
to dull when the lower border of the liver
is encountered. It helps to confirm the
findings of palpation. If note is resonant
upto the right costal margin, the liver is
unlikely to be enlarged. Vertical size of Fig 4.26: Percussion for lower border of the liver
the liver in mid clavicular line is 12 -15
cm. It may be reduced in: Spleen
1. Advanced cirrhosis The upper border of the spleen is under
the left lower ribs and can't be detected.
2. Fulminant hepatitis
For the lower border place pleximeter in
3. Air under the diaphragm, eg, due to the right iliac fossa parallel to the left
rupture of a hollow viscous costal margin and percuss towards left
hypochondrium. Note will change from
resonant to dull where the lower border
Fig 4.25: Percussion for upper border of the liver Fig 4.27: Percussion for spleen
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of the spleen is present. Dullness over a from the epigastrium towards the
mass palpable in the lef t hypochondrium hypogastrium to find out the upper
indicates that mass is likely to be spleen. limit of dullness in the midline - fig 4.29.)
A small degree of splenomegaly can be Percuss from the midline, usually at the
detected by percussing at the junction level of the umbilicus (or above upper
of the left anterior axillary line and the limit of dullness in the midline) towards
costal margin. Normally percussion note flank. Pleximeter should be parallel to
is resonant in both phases of respiration.
the flank. Normally note is resonant
Dullness at this point during inspiration
except in the extreme flank where it
may indicate early splenomegaly.
becomes impaired to dull. If ascites
Urinary Bladder is present, note will become dull well
Percuss from the epigastrium towards before the extreme of flank. Keep the
hypogastrium. Percussion note will fingers where note became dull and ask
become dull in the hypogastrium if the patient to turn towards opposite side.
urinary bladder is distended. Wait for few seconds to let possible fluid
to move towards other side and percuss
again. If note becomes resonant shifting
dullness is said to be positive and ascites
is present. To confirm it further, percuss
towards dependent side to demonstrate
that site which was resonant before has
become dull due to movement of fluid
(fig 4.30).
Other Masses
Boundaries of masses can be determined
by percussing from different directions,
from resonant to dull area.
Ascites
It means free fluid in the peritoneum.
Abdomen looks distended. There are two
signs on percussion.
Shifting Dullness: The patient should
lie supine. (Some clinician first percuss
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CH 4 ALIMENTARY AND GENITO-URINARY SYSTEM
pulse is transmitted through fat of the

abdominal wall. In order to dampen
this transmission, ask the patient or an
assistant to place side of his hand in the
midline longitudinally and firmly; if
fluid thrill is still positive it indicates a
large and tense ascites (fig 4.31).
Ovarian Cyst
In ovarian cyst percussion note is dull in
the midline and resonant in the flank
because intestinal loops are pushed
laterally.
Causes of Ascites
A. Transudative (protein content of
ascitic fluid is less than 3.0 gm/
dl)
1. Cirrhosis of liver
2. Cardiac diseases (right heart
Fluid Thrill: The patient should lie on failure, constrictive pericarditis,
his back. Place your left hand flat over pericardial effusion)
the left lumbar region and tap the right 3. Hypoproteinemia (eg, nephrotic
lumbar region with your right hand. syndrome, malabsorption,
If a definite wave or impulse is felt by malnutrition)
the left hand, fluid thrill is positive. 4. Meig's syndrome
Sometimes in the very obese similar 5. Budd-Chiari syndrome
B. Exudative (proteins are more
than 3.0 gm/dl).
1. Tuberculosis
2. Malignancy
3. Bacterial peritonitis
4. Chemical peritonitis
5. Acute pancreatitis
Hydatid Thrill: This is elicited over

an abdominal hydatid cyst. Place three
fingers of left hand (index, middle and
ring) over the swelling. Percuss the
middle finger with the middle finger
of the right hand; a thrill is felt by the
other two fingers if the swelling is due
Fig 4.31: Eliciting fluid thrill
to a hydatid cyst.
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Differential diagnosis of ascites and audible in pyloric stenosis. Stethoscope

ovarian cyst is placed in the epigastrium and patient
is shaken by placing hands over the
Ascites Ovarian Cyst
lower ribs. Sound resembling noise
+ Swelling + Swelling starts made by partially filled hot water
starts from from the lower bottle, when shaken, is heard. Such
the flanks abdomen sound may be normally audible several
+ Umbilicus + Umbilicus hours after a meal. Patient must be
is transverse is vertical fasting for succussion splash to be of any
and at its and pushed significance.
normal upwards
position
+ Percussion + Percussion note
note is dull is resonant
in the flanks in the flanks
and resonant and dull in the
in the center center
Auscultation
Bowel Sounds
These are produced by peristalsis of the
gut and are best heard to the right of the
umbilicus, close to the iliocecal junction.
Normally these are audible every 5 - 10
seconds. Auscultate for several minutes
and note down frequency and intensity
of bowel sounds.
Mechanical intestinal obstruction:
Sounds become loud and frequent; these
are called borborygmi. Other causes
of loud bowel sounds are small bowel
malabsorption, severe gastrointestinal Bruit
bleeding and carcinoid syndrome.
Aortic Bruit: This is audible above and
Paralytic ileus: Bowel sounds are to the left of umbilicus and indicates
absent. Occasionally faint, high pitched aortic narrowing.
sound is audible due to spillage of
Renal Bruit: This is heard in the lumbar
fluid from one air-fluid filled loop to
another loop. The most common cause
region and renal angle. This occurs in
of paralytic ileus is peritonitis. Other renal artery stenosis, an important cause
causes are strangulation, gangrene of of hypertension.
bowel and hypokalemia. Hepatic Bruit: This may be audible in
hepatoma and alcoholic hepatitis.
Succussion Splash: This is typically
Venus Hum: It is sometimes audible
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CH 4 ALIMENTARY AND GENITO-URlNARY SYSTEM
between the xiphisternum and the Patient should be informed and

umbilicus due to turbulent blood flow explained. He should be put in left lateral
in a well developed collateral circulation position, legs and spine being flexed.
from portal hypertension. Buttocks should be at the edge of the bed.
Friction Sounds Method
Sounds resembling a rub may be audible Use (surgical) gloves to protect the hand.
over the liver and spleen in perihepatitis Inspect perianal skin for evidence of
and perisplenitis respectively. scratching, external piles, fissure or
fistula. Lubricate the right fore finger
EXAMINATION OF GROIN AND and place it on the anterior anal margin
GENITALIA and press backwards; it will slip into the
anal canal. Palpate for:
Groin should be examined for hernias.
Male genitalia should be examined for 1. Prostate (male patient): Normally
ulceration, testicular swelling, hydrocele it is smooth and firm. The median
or lack of testicular sensation (due to groove is present and upper limit
testicular atrophy). Examination of is reachable. Upper limit is not
reachable when prostate is enlarged,
female genitalia is discussed under
eg, in benign hyperplasia. In
gynecological examination.
carcinoma of prostate it is enlarged,
hard and irregular with obliteration
RECTAL EXAMINATION
of the median groove. It is tender in
This is an important step in the prostatitis.
examination of gastrointestinal
2. Mass in the rectum: Majority
tract and should not be omitted. In
of the colonic carcinomas are in
case of a female patient, a nurse or
the descending colon and a large
female colleague should be present if
number are palpable in the rectum
examination is being performed by a
as a hard irregular mass.
male doctor or student.
3. Tone of the anal sphincter
Indications and tenderness: Painful rectal
1. Urinary symptoms in an old man examination with anal spasm
(to assess the size of the prostate) indicates anal fissure.
2. Bleeding per rectum 4. Any mass or tenderness outside the
3. Constipation rectum.
4. Chronic diarrhea 5. Cervix (female patient).
5. Anal pain, rectal pain, tenesmus 6. Fecal masses: Hard fecal masses
or lower abdominal pain in which may be palpable in long standing
cause is obscure. constipation.
Finger stall should be inspected for
Position of the Patient blood and color of feces, and stool should
be examined for occult blood.
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ORAL CAVITY Lips
Gums
Teeth
Tongue
Mucous membrane
Tonsils and pharynx
ABDOMEN
Inspection Shape of abdomen Normal
Scaphoid
Distended
Movements of abdominal Respiratory movements
wall Visible peristalsis
Umbilicus Position
Shape
Pulsation Site
Transmitted or expansile
Scar
Striae White/pink
Purple
Prominent veins Site
Direction of flow of blood
Pubic hair Distribution

Hernial orifices Epigastric
Umbilical and paraumbilical
Incisional
Inguinal
Femoral
Palpation Light Rigidity
Deep Tenderness
Rebound tenderness
Mass
Palpation for the viscera Liver
Gall bladder (Murphy's sign)
Spleen
Kidneys (Murphy's renal
punch)
Urinary bladder
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Dipping
Percussion For Viscera Liver
Spleen
Urinary bladder
Other masses
For ascites and ovarian cyst Shifting dullness
Fluid thrill
Auscultation Bowel sounds Intensity

Frequency
Bruit Aortic
Hepatic
Renal
Friction sounds Hepatic
Splenic
Groin and Hernias Inguinal
genitalia Femoral
Male Genitalia Ulceration
Testicular sensation
Testicular mass
Hydrocele
Female genitalia Under gynecological examina
tion
Rectal examination
WRITING OUT ROUTINE Abdomen is moving with respiration.

EXAMINATION Peristalsis are not visible. Umbilicus
is central and of normal shape. No
Examination of a normal person should
pulsations are visible. There is no scar,
be described as follows. If there are
striae or prominent veins. Pubic hair are
abnormalities, these should be described
of male distribution. Hernial orifices are
at appropriate places.
intact.
Oral Cavity Palpation
Lips, gums, teeth, tongue, mucous There is no rigidity or tenderness. No
membrane, tonsils and pharynx are viscera or mass palpable.
normal. Percussion
Abdomen There is no dullness or fluid thrill.
Inspection Auscultation
Shape of the abdomen is normal. Bowel sounds are 3 - 5 per minute, of
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£3 BEDSIDE TECHNIQUES
normal intensity. No bruit or friction Preferred site is right iliac fossa. After
sound audible. sterilization, insert a disposable syringe
with wide bore needle and aspirate
Tapping Ascites 20 ml of fluid if it is diagnostic tap.
Ask the patient to lie flat. Percuss from If therapeutic drainage is to be done,
the midline towards the right flank.-to connect the needle with rubber tubing
find the site of dullness. If there is less and a bag. Rate of drainage should be
fluid, tilt the patient towards right. slow to avoid vascular collapse.
DIFFERENTIAL DIAGNOSIS OF ASCITIC FLUID

Disease General Protein RBCs Other Other features
appear gm/dl cells
ance (per rnm^)
Cirrhosis It is straw <3.0. Nil < 250, en

colored dothelial
Cardiac dis It is straw <3.0 Nil Mesothelial
ease colored
Hypopro It is straw <3.0 Nil Mesothelial
teinemia colored
Tuberculosis It may >3.0 Present Lympho AFB on stain
be clear, cytes ing or culture of
turbid or fluid, DNA
hemor Peritoneal biopsy
rhagic (by laparoscopy)
reveal typical
granuloma
Malignant It is hem >3.0 Present Variable Malignant cells
orrhagic on cytology
Peritoneal bi
opsy (by laparo
scopy) confirm
the diagnosis
Bacterial It is turbid >3.0 Nil Full of Gram's staining
or puru polys and culture of
lent fluid will reveal
causative organ
ism
Pancreatitis It is turbid >3.0 Present Variable Amylase is in
or hemor creased in ascitic
rhagic fluid
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Chapter
Fear of neurology is common among patient himself or the surroundings.

medical students and doctors. It is Disturbance of the vestibular system is
unfounded because evaluation of a the most common cause.
neurological problem is mathematical
and follows a logical sequence. It is Syncopy
possible to localize the lesion and There is sudden loss of strength. The
even deduce the underlying cause in patient tends to fall down and lose
many cases on the basis of history and consciousness but recovers as soon as he
physical examination alone. Common is horizontal. Decreased cerebral blood
reason for this unjustified fear is lack of flow is the underlying mechanism.
knowledge of neuroanatomy and poor Vasovagal syncopy is the most common
understanding of neurophysiology. So variety which occurs in some individuals
working knowledge of anatomy and in response to emotional stress, eg, severe
physiology of nervous system is essential pain, frightening scene or a frightening
for learning neurology. news. Postural hypotension and cardiac
Neurological examination is lengthy arrhythmias are other causes.
and demands patience, both, from Dizziness is a loosely used term and
the examiner and the patient. For a every patient means differently.
successful examination give adequate Two common symptoms described as
explanation to the patient, be gentle and dizziness by the patient are vertigo and
avoid repetition. fainting (syncopy).
HISTORY Seizures (Convulsions)

Ask about the onset, duration and These are defined as an abrupt alteration
progress of each symptom. in cortical electrical activity. They can
present as a motor, sensory or beha ioral
SYMPTOMS symptom with or without loss of
Common symptoms are briefly consciousness. Epilepsy is defined as
described below: recurrent seizures over months or years.
Common types are:
Vertigo + Tonic clonic seizures in which
It is a feeling of spinning, either of the there are jerky movements of
135
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the whole body with loss of tingling, pins-and-needles, pricking,

consciousness. burning, constriction, tightness,
4 Jacksonian seizures in which electric current like sensations,
there are repeated contractions of feeling of warmth/cold or pain.
a part of the body, usually face and Common example of pain due to
hand. sensory system disease is sciatica.
+ Psychomotor seizures in which 2. Negative phenomena (hypoes-
there are hallucinations and the thesia or decreased sensations):
patient loses consciousness. Patient has an awareness that
sensations like touch, pain or
Motor Weakness temperature are diminished or
Motor weakness can be due to disease of: absent on the affected side. He may
1. Motor system inadvertently burn the affected
2. Neuromuscular junction part or he may not feel any pain
3. Muscles in an injured or infected foot eg,
Paralysis means complete loss of power
in diabetic neuropathy. Numbness
while paresis means partial loss of is another complaint but it means
power. weakness or heaviness to some
people rather than loss of sensation.
It is very important to find out
distribution of weakness. Intracranial Headache
disease usually results in monoplegia This is a common symptom.
(weakness of one limb) or hemiplegia + Tension headache is the most
(weakness of one half of the body). common variety; it is pressing in
The spinal cord lesion usually leads to character and worse in the evening.
paraplegia (weakness of both lower 4 Vascular headaches (eg, migraine)
limbs) or quadriplegia (weakness of all are throbbing in character and are
the four limbs), depending upon the site episodic.
of involvement (mono or hemiplegia 4 Headache due to meningitis and
may also occur). subarachnoid hemorrhage is
Weakness due to disease of peripheral associated with signs of meningeal
nerves (eg, neuropathy) mainly affects irritation.
distal muscles while weakness due 4 Headache due to space occupying
to muscle disease is more marked in lesion may be associated with
proximal muscles. vomiting and weakness of a part
Weakness may be of gradual onset and of the body; papilledema may be
slowly progressive, eg, neuropathies, present.
motor neuron disease, myopathies or of
APPLIED ANATOMY AND
sudden onset, eg, stroke.
PHYSIOLOGY
Sensory Symptoms If the following anatomical and
These are of two types: physiological facts are known, it becomes
1. Positive phenomena: These may easy to localize the lesion within the
be spontaneous (paresthesiae) nervous system on clinical grounds.
or induced by some stimuli like Motor Cortex
touch Qdysesthesiae). These include The motor cortex occupies the anterior
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CH 5 NERVOUS SYSTEM
afflsm
137
aspect of the central sulcus (Rolandic fibers cross to the opposite side and on
fissure) and adjacent parts of the pre its ventral aspect form protuberances
central gyrus (fig 5.1). called pyramids (corticospinal tracts
are also called pyramidal tracts). They
descend in the lateral part of the spinal
cord as lateral corticospinal (pyramidal)
tracts. The remaining fibers form the
anterior corticospinal tracts which cross
in the anterior commissure of the spinal
cord at various levels before terminating
in the anterior horn cells.
While passing through the brain stem
the fibers responsible for the cranial
musculature (corticobulbar fibers)
terminate in the nuclei of various
cranial nerves (fig 5.2). All cranial nerve
nuclei receive corticobulbar fibers
from both the cerebral hemispheres
The body is represented upside down.
The head and face are represented in the r
MOTOR AREA
inferior part while legs are represented
in the upper part and also medial aspect
of the hemisphere.
Those parts of the body which are more Corona radiata
frequently used and carry out skilled

movements, like the tongue, fingers and Internal Capsule
thumb have the largest areas of cortical
representation. Fibres to motor nuclei
of opposite side
Each hemisphere controls the opposite MIDBRAIN — Crus cerebri
half of the body. Most of the cranial \\—6th nerve nucleus
and axial musculature is represented in PONS
— 7th nerve nucleus
Corticospinal tract----- V
both the hemispheres. (This means these
muscles are not affected in unilateral MEDULLA
ft-Fibres to motor nuclei
' of opposite side
lesions.) Pyramid —" V~Decussation
Corticospinal Tracts SPINAL CORD

I
) Lateral corticospinal
Anterior corticospinal tract----- J ^(pyramidal) tract
______________________ J
Axons of motor neurons extend k_____________
downward and form the corona
Fig 5.2: Motor pathways
radiata. They pass through the anterior
2/3 of the posterior limb of the internal
except that part of the 7th cranial nerve
capsule. Here the body is represented
nucleus which supplies muscles of the
from front to back. These fibers
occupy the middle 3/g of the cerebral lower half of the face; it is connected
peduncles in the midbrain and are
with contralateral hemisphere only.
scattered in the pons. Extrapyramidal System
In the medulla oblongata most of the The extrapyramidal system consists
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BEDSIDE TECHNIQUES
of those parts of the central nervous Spinal Segments

system (other than motor cortex A part of spinal cord which gives rise to
and corticospinal tracts) which are a pair of spinal nerves is called a spinal
concerned with movements and posture. segment. Division of spinal segments is
They include: as follow:
+ Basal ganglia Cervical 8
+ Subthalamic nuclei Thoracic 12
+ Substantia nigra Lumbar 5
+ Red nuclei Sacral 5
Spinal Cord Coccygeal 1 or 2
It extends from the medulla oblongata As the length of the spinal cord is shorter
to the intervertebral disc between LI than that of the vertebral column,
and L2 (fig 5.3). spinal segments don't lie against the
corresponding vertebrae. Formula to
determine which spinal segment lies
against a particular vertebral body is as
follow:
+ For cervical vertebrae add 1, eg,
against 5th cervical vertebra will be
(5 + 1) 6th cervical spinal segment.
+ For thoracic 1-6 vertebrae add 2, eg,
against 4th thoracic vertebra will be
(4 + 2) 6th thoracic spinal segment.
+ For 7 - 9 thoracic vertebrae add 3, eg,
against 8th thoracic vertebra will be
(8 + 3) 11th thoracic spinal segment.
+ Tenth thoracic vertebra lies over
lumbar 1 and 2 spinal segments.
+ Eleventh thoracic vertebra lies over
lumbar 3 and 4 spinal segments.
4- Twelfth thoracic vertebra lies over
lumbar 5 and upper sacral spinal
segments.
+ First lumbar vertebra lies over lower
sacral and coccygeal spinal segments.
Roots of Spinal Nerves

As described above, spinal segments
don't correspond to respective vertebrae
but the roots of spinal nerves pass
through the intervertebral foramina of
the corresponding vertebrae.
The cervical roots from Cl to C7 enter/
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CH 5 NERVOUS SYSTEM 139
leave above the corresponding vertebrae. Section of the Spinal Cord

C8 enter/leave below C7 vertebra. It consists of grey matter and white
All other roots enter/leave below the matter.
corresponding vertebrae.
Conus Medullaris Grey matter
It lies in the center and forms projections
It is the terminal part of the spinal cord
called horns. The two anterior horns
(fig 5.4).
contain motor neurons and the two
Cauda Equina posterior horns contain sensory
It consists of the roots of lumbar, sacral neurons. In the center is the central
and coccygeal spinal nerves and their canal lined by ependymal cells (fig 5.5).
covering membranes (fig 5.4).
White matter
It lies outside and consists of various
tracts. The sensory tracts are the dorsal
column (or posterior column) and
lateral spinothalamic tracts. The
main motor tracts are the lateral
corticospinal tracts. Some motor
fibers also travel in the anterior
corticospinal tracts (fig 5.5).
Posterior column
Lateral cortico — Posterior horn

spinal tract Posterior spino-
Lateral spino cerebeller tract
thalamic tract - Anterior spino-
Anterior horn ■ cerebeller tract
Anterior spino Area of extra-

thalamic tract pyramidal tract
Anterior cortico
spinal tract
Fig 5.5: Transverse section of the spinal cord
Spinal Nerves
These consist of motor and sensory roots.
Motor Root (anterior root): This is
composed of axons of anterior horn cells
which end up at motor end plates of
muscles innervated by that root (fig 5.6).
Sensory Root (posterior root): This
consists of central axons of dorsal root
ganglion which enter the spinal cord.
Peripheral axons of these neurons join
motor root and form sensory part of a
Fig 5.4: Conus medullaris and cauda equina
spinal nerve (fig 5.6).
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140 MMMM
BEDSIDE TECHNIQUES
HMMU
Sensory cortex
CEREBRAL
HEMISPHERE
Internal capsule
Thalamus
5th nerve
PONS sensory nucleus
Medial lemniscus &
Spinothalamci tract
Nucleus gracilis
MEDULLA
Nucleus cuneatus Medial lemniscus
Posterior column Spinothalamci tract

Vibration
CORD Position -
Touch
Spinothalamci tract
(no relay)
Temperature
Touch (relay)
J
Fig 5.7: Sensory pathway
Types of Motor Neurons
Upper Motor Neurons: These extend Lateral Spinothalamic Tract: Fibers
from the motor cortex to the nuclei carrying sense of pain, temperature
of cranial nerves in the brain stem or and some fibers carrying sense of touch
anterior horn cells of the spinal cord. synapse with the neurons of dorsal horns
Lower Motor Neurons: These extend of the spinal cord. The fibers of these
from cranial nerve nuclei or anterior second order neurons ascend upwards
for few segments and then cross towards
horn cells to motor end plates of muscles.
opposite side. These fibers form the
Sensory System lateral spinothalamic tract and end in
the thalamus. The fibers from cervical
Sensory stimuli are perceived by the
segments lie centrally; fibers from
peripheral receptors and are transmitted
thoracic, lumbar and sacral segments
to the dorsal root ganglions through lie progressively laterally (fig 5.8). In the
peripheral sensory nerves. Central axons brain stem, these are joined by the fibers
of neurons of dorsal root ganglions (first of the trigeminal nerve.
order neurons) enter the spinal cord Sensory Cortex: From the thalamus,
where fibers are divided into two groups the fibers of third order-neurons pass
(fig 5.7): through the internal capsule and are
Dorsal Column: Fibers concerned with projected to the sensory cortex which
the sense of position, vibration, passive occupies the post central gyrus.
movements and some fibers carrying Dermatomes and Cutaneous Nerves:
sense of touch enter the posterior part The part of the skin supplied by a
of the spinal cord and ascend upwards sensory spinal root is called a dermatome.
on the same side as dorsal (or posterior) Cutaneous nerves have their own areas
column. At the lower end of the medulla of supply. Knowledge of the dermatomes
oblongata, they relay in the gracile and areas supplied by various nerves
and cuneate nuclei. The fibers from helps to localize the lesion and they must
these second order neurons cross to the be remembered for quick inference of
opposite side and pass upwards in the sensory abnormalities. Dermatomes are
medial lemniscus to the thalamus. shown in fig 5.9 to 5.13.
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Fig 5.8: Arrangement of fibers in lateral spinothalamic

tract in cervical region: fibers from cervical segments
(C) lie centrally; fibers from thoracic segments (T),
lumbar segments (L) and sacral segments (S) lie
progressively laterally Fig 5.10: Dermatomes of back of the upper limb
Fig 5.11: Dermatome of front of lower limb

Fig 5.12: Dermatomes of back of lower limb
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divides into two posterior cerebral

arteries (fig 5.14,5.15).
Posterior cerebral artery. It supplies
occipital lobe which includes visual
cortex (fig 5.14,5.15).
Circle of Willis
Each anterior cerebral artery is
connected with posterior cerebral artery
by posterior communicating artery
and with its counterpart by anterior
Fig. 5.13
communicating artery (fig 5.14). So there
V__________________________________ 7
is an effective collateral circulation
Fig 5.13: Dermatomes of perineal area between branches of both carotids and
vertebral arteries.
Blood Supply of Brain
Internal carotid artery
There are two main branches.
Middle cerebral artery. It supplies
lateral surface of frontal, parietal and
temporal lobes. It includes most of the
motor and sensory cortex except that
part which lies on the medial side and
controls lower limbs. It gives penetrating
branches (lenticulostriate arteries)
which, in addition to other structures,
supply internal capsule (fig 5.14, 5.15). It
also supplies occipital pole (visual cortex
responsible for macular vision)
Anterior cerebral artery. It It
supplies medial surface of the cerebral
hemisphere. It includes motor and
sensory cortex which controls lower
limbs (fig 5.14, 5.15). Soon after its origin, Blood Supply of the Spinal Cord
it gives a penetrating branch (Heubner's Anterior spinal artery: It is a branch
artery) which supplies internal capsule
of the vertebral artery. Arteries of both
containing fibers for upper limb and
sides combine to form one anterior
face. spinal artery which supplies anterior
Vertebral artery two thirds of the spinal cord including
pyramidal tracts
Two vertebral arteries combine together
to form basilar artery. Brain stem is Posterior spinal artery: It is also a
supplied by these vessels. Basilar artery branch of the vertebral artery. Arteries
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of both sides together supply posterior 5. Sensory system

one third of spinal cord including dorsal 6. Cerebellum
column.
7. Miscellaneous:
Artery of Adamkiewicz: Both spinal
a. Signs of meningeal irritation
arteries receive feeding vessels from
intercostal and abdominal arteries. b. Root irritation
Artery of Adamkiewicz is the most c. Auscultation of neck and cranium
important contribution to the anterior d. Tetany
e. Autonomic nervous system
Higher Mental Functions
Look for the following:
1. Appearance and behavior
2. Delusions and hallucinations
3. Orientation in place and time
4. Conscious level
5. Memory
6. General intelligence
7. Released reflexes
Appearance and Behavior
+ Is the patient alert and cooperative?
+ Is he restless and agitated?
> Is he well groomed or unkempt?
+ Does he take interest in his
surroundings?
Delusions and Hallucinations
Delusions are false beliefs to which the
patient firmly adheres despite the fact
that their falsehood is proved, eg, patient
Fig 5.15: Blood supply of lateral surface of cerebral believes that he is under the influence of
hemisphere some supernatural powers. These beliefs
cannot be corrected by arguments.
EXAMINATION Hallucinations are false perceptions
of visual, auditory, smell or tactile
Nervous system is examined under the
sensations in the absence of any external
following headings:
stimulus. For example, patient sees
1. Higher mental f unction objects, hears voices or appreciates smells
2. Speech in the absence of any external stimulus.
3. Cranial nerves These should be differentiated from
4. Motor system illusions which are misinterpretation
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144 nan
BEDSIDE TECHNIQUES
of external stimuli; eg, mistaking a Snout Reflex: Apply gentle pressure

shadow for a person. against patient's lips with your knuckles
or tap lightly with your finger or tendon
Orientation in Place and Time hammer. There will be puckering and
Ask the patient about approximate time protrusion of lips if reflex is present. It is
of the day (day or night, morning or seen in bilateral UMN lesion.
evening) and what place he is in (home Glabellar Tap Reflex: Tap the glabella
or hospital). (over the root of the nose) repeatedly
Conscious Level with your finger; normally blinking
of the eyes occurs 2 to 3 times and then
A conscious patient responds clearly response is inhibited. In Parkinsonism
to external stimuli including vocal and senile dementia, blinking continues
commands and various questions. Assess as long as glabella is tapped.
the conscious level using the Glasgow
coma scale given below. Glasgow Coma Scale
Memory Response
For testing the recent memory ask Score
names of public figures, day of the week Eye opening response (E)
or name of the month. For testing the Spontaneous 4
long term memory ask about important To speech 3
events of the past.
To painful stimulus 2
General Intelligence None 1
For general assessment of intelligence Best motor response (M)
ask about the patient's performance at (in upper limbs)
school or work place. Formal assessment
Obeys commands 6
requires detailed tests.
Localizes (to painful stimulus) 5
Released Reflexes Withdraws 4
Some reflexes are present in infancy and Abnormal flexion 3
then disappear. Reappearance suggests
Extensor response 2
brain damage.
None 1
Grasp Reflex (page 238): It occurs in
contralateral frontal lobe lesion. Best verbal response (V)
Avoiding Response: Stroke the ulnar
Oriented 5
side of the palm. Patient will move Confused conversation ’ 4
the hand away if response is present. Inappropriate words 3
It occurs in contralateral parietal lobe Incomprehensible sounds 2
lesion.
None 1
Palmo-mental Reflex: Scratch the
Glasgow Coma Scale score = E+M+V
skin near the thenar eminence; there
(minimum = 3; maximum = 15)
will be puckering of the chin if reflex is
present. It suggests brain damage. In deep coma score is less than 8.
PDFelement
Speech Motor Dysphasia

Commonly encountered speech It is also called expressive dysphasia
problems are defined below. or non-fluent dysphasia. Patient
Dysphasia: It means difficulty in understands speech and knows what
comprehension or production .--of to say but is unable to speak, although
language. Aphasia is sometimes used in he may utter a few words with errors
place of dysphasia. of articulation and grammar. Speech
Dysarthria: It means difficulty in is dysarthric with pauses, telegraphic,
articulation of speech. pithy but meaningful. Repetition is
Dysphonia: It means difficulty in
impaired, reading and writing are intact.
production of voice. Lesion is in the motor speech area.
Dyslexia: It means inability to read.
Lesion is in the dominant parietal lobe.
Dysgraphia: It means inability to write.
Lesion is in the frontal or parietal lobe.
Dysphasia
It means difficulty in comprehension or
production of language. It may be motor,
sensory or global.
Speech Area <_________________________7

It lies in the inferior part of the
Fig 5.16: Speech area (indicated by dotted lines) (F)
frontal and parietal lobes and frontal lobe (P) parietal lobe (T) temporal lobe (0)
superior part of the temporal Occipital lobe
lobe of the dominant hemisphere
which is the left one in all the Sensory Dysphasia
right handed people and also in 50 It is also called receptive dysphasia or
percent of the left handed people fluent dysphasia. Patient is unable to
(fig 5.16). answer even simple questions which
Motor Speech Area (Broca's need verbal answer like what is your
Area): It lies in front of the central name but command to be answered by
sulcus in the inferior part of the axial musculature (close eyes, sit, roll
frontal lobe and is concerned with over) may be preserved as these are
the production of language. controlled by the neural system outside
Sensory Speech Area the speech areas. He can speak omhis own.
(Wernicke's Area): It lies The contents of the speech are abnormal
posterior to the central sulcus in and incoherent. Speech is voluminous,
the infer ior part of the parietal lobe uninformative and contains new words
and superior part of the temporal (neologisms).
lobe, and is concerned with the
He can't name the objects (anomia) and
understanding of language. It is
has paraphasia ie uses wrong words. If
also concerned with the reading
word used is incorrect but legitimate
and writing.
(pen for pencil) it is called semantic
PDFelement
paraphasia; if word used is phonetically of the language network. Patient has

inaccurate (pentil for pencil) it is called difficulty in naming. Speech is fluent
phonemic paraphasia. He may describe but deficient in nouns and verbs. It
the object instead of naming it eg instead is paraphasic, circumlocutious and
of saying pencil he says “something for uninformative. It is the most common
writing", this is called circumlocutious language disturbance seen in head
description. Repetition, reading and trauma, metabolic encephalopathy and
writing are impaired. Lesion is in the Alzheimer's disease.
sensory speech area. Pure Word Deafness
Global Dysphasia Lesion is in the superior temporal gyrus.
Patient can neither understand nor Auditory information can't be conveyed
speak. Lesion is in the speech area as a to the language network, patient reacts
whole. to the speech as if it were in alien tongue;
otherwise he can speak, read and write
Conduction Dysphasia normally. Patient reacts normally to the
Patient is unable to repeat words or environmental sounds and otherwise
phrases spoken by the examiner. Lesion has normal hearing.
is in the perisylvian area with damage Pure Word Blindness (alexia without
to the arcuate fasciculus of fibers agraphia)
connecting motor and sensory speech
area. Lesion is in the left occipital cortex
and the splenium (post part of corpus
Transcortical Motor Dysphasia callosum. There is right hemianopia.
It is similar to the motor dysphasia but Patient reacts as if he is completely
repetition is intact. Language network illiterate when asked to read, otherwise
is disconnected from prefrontal areas of speech is normal. He can match the colors
the brain. but can't name them (color anomia).
Transcortical Sensory Dysphasia Dysarthria

It is similar to the sensory dysphasia but It means difficulty in articulation of
speech. Two important dysarthria are
repetition is intact. Language network
scanning speech and slurring speech.
is disconnected from other associated
temporoparietal association areas. Scanning Speech
Isolation Dysphasia Patient speaks slowly pronunciating
each syllable separately, eg, he says
It is combination of the two transcortical
artillery as ar-til-la-ry. It occurs in
dysphasia. Comprehension is severely
cerebellar dysfunction.
impaired and there is no purposeful
speech output. Patient may repeat heard Slurring Speech
speech (echolalia). Language network is Pronunciation is imprecise and slurred,
isolated from rest of the brain. eg, British Constitution becomes Brzh
Anomic Dysphasia Conshishushon. It occurs in bulbar and
supranuclear bulbar (pseudobulbar)
It is minimal dysfunction syndrome palsy.
PDFelement
sense (speech is incomprehensible).

Miscellaneous Speech
Disorders
Ask him his name, if he doesn't
answer ask him to close his eyes,
Stammering: There is abrupt halt
if he obeys the command he has
of the speech and is accompanied Wernicke's dysphasia. (He will not
by repetitive utterance of sounds be able to tell name of simple object,
or syllables. It is common in boys
repeat simple words, read or write.)
and is not associated with organic
If he doesn't close his eyes, he is
neurological disease.
confused or has psychiatric illness.
Bradilalia: Speech is unduly slow, Transcortical sensory dysphasia is
eg, in myxedema. similar to the Wernicke's dysphasia
Echolalia: Patient automatically but repetition is intact.
repeats examiner's questions. 2. Patient is quiet, ask him his name,
It is normal in early childhood where is he from or some other
but indicates widespread brain simple question. He utters words
damage in later age. with difficulty, usually incomplete
Palilalia: Patient repeats last with pauses without following
sentence, phrase or word of his usual rules of grammar but these
own speech. It occurs in extensive words do convey meaning, he
cerebrovascular disease and post has Broca's dysphasia. (He will
encephalitic parkinsonism. understand spoken and written
words and can write if literate.)
Dysphonia Transcortical motor dysphasia is
Voice is produced by the vocal cords. similar to the Broca's dysphasia but
Dysphonia (change in quality or loss repetition is intact.
of volume of voice) occurs in laryngitis 3. He doesn't look understanding the
or when vocal cords are paralyzed, eg, question and doesn't attempt to
in 10th nerve palsy. The most common answer it, he has global dysphasia.
cause of complete loss of voice (aphonia)
Articulation: If abnormal try to
is hysteria. It can also be due to bilateral
recognize type of dysarthria.
paralysis of the vocal cords.
Voice: Whether it is normal or abnormal.
Examination of Speech In case of aphonia ask the patient to
Concentrate on patient's speech during cough. In case of hysterical aphonia
history taking or ask him simple cough produces voice while in case of
questions to encourage him to talk. It organic aphonia it is silent. In case of
is important that patient should be organic aphonia examine vocal cords for
conscious and his hearing normal. inflammation or paralysis.
Note spontaneous speech and its contents Ask the patient to read and write (if
1. Patient is speaking fluently but patient is literate) to test for dyslexia
contents of his speech doesn't make and dysgraphia.
PDFelement
BEDSIDE TECHNIQUES
Examination of Speech
(Patient should be alert, responding to environmental sounds)
Note contents of speech
Normal Abnormal and incomprehensible
Normal speech
(Understands spoken and written
questions, can name, repeat words,
read and write)
Question 1: What is your name? What is your name?
No response No response Response

(Disturbed mentation) (Global dysphasia) Utters incomplete
(Wernicke's dysphasia) words with difficulty
but can convey meaning
(Broca's dysphasia)
Question 2:
Disturbed conscious or Wernicke's dysphasia

psychiatric patient
PDFelement
CH 5
SPEECH DISTURBANCES
Type of Site of le Comprehension Spontane Naming Repeti Reading Writing Charac
dyspha sion ous speech tion (aloud, (sponta teristics/
NERVOUS SYSTEM
sia compre neous, associated
hension) dicta- deficit
tionco-
pying)
Spoken Written
Wer Wernicke's Impaired, no Im Fluent, Para Im Impaired Impaired Can't un
nicke's area response to paired volumi phasia*, paired derstand,
(sensory) verbal command nous, unin circum can't express
which need formative, locutions** mean
verbal answer neologisms, ingfully,
but command to jorgan patient is
be answered by speech agitated as he
axial musculature doesn't know
(close eyes, sit, his speech is
roll over) may be incompre
preserved; these hensible.
are controlled by Hemianopia
neural system or quadran-
outside speech tanopia
areas
Transcor Discon Impaired Im Similar to Paraphasic Intact Impaired Impaired Hemianopia
tical nection of paired Wernicke’s
sensory language
(similar network
to Wer from tem
nicke's poroparietal
but rep associated
etition is areas(post
intact) watershed
zone)
Dyslexia Part of Wer Less severely af More Fluent Impaired, Im Impaired Impaired Visual
with dys- nicke's area fected severely paraphasic paired form of
graphia affected Wernicke's.
Auditory
comprehen
sion intact
Paraphasia (using wrong word): using incorrect but legitimate word (pen for pent il i is called semantic paraphasia; using phonetically inaccurate word ( pentil for pencil) is called
phonemic paraphasia.
** Circumlocutions description: instead of saying pencil he says "something for writing"
PDFelement
Type of Site of lesion Compre Spontaneous Naming Repeti Reading Writing Characteris
dyspha hension speech tion (aloud, (sponta tics/ associ
sia compre neous, ated deficit
hension) dicta-
tionco-
pying)
Spoken Writ
ten
Broca's Broca's area Intact Intact Non fluent, Impaired Im Intact Intact Utters incom--
(motor) ends of words paired plete words but
are used for are meaningful.
tenses, pos- Hemiplegia
sessives etc
(agramatism).
Speech is
dysarthric
with pauses,
telegraphic,
pithy but
meaningful
Transcor Language net Intact Intact Similar to Impaired Intact Intact Intact No deficit (mild
tical work is discon Broca's but hemiparesis
motor nected from agramatism is may occur)
(similar prefrontal areas less marked
to Broca's (ant half of wa
but rep tershed zone or
etition is supplementary
intact) motor cortex)
Global Both Impaired Im Non fluent Impaired Im Impaired Impaired Hemiplegia,
paired paired hemianesthesia,
hemianopia
Conduc Connection be Intact Intact Fluent Im Severely Reading Impaired Variable
BEDSIDE TECHNIQUES
tion tween twoyireas paired, im aloud is
parapha- paired impaired,
sic compre
hension is
intact
PDFelement
CH 5
Type of Site of lesion Compre Sponta Naming Repeti Reading Writing Characteris
dyspha hension neous tion (aloud, (sponta tics/ associ
sia speech compre neous, ated deficit
NERVOUS SYSTEM
hension) dictation-
copying)
Spoken Written
Isolation Language net Impaired Impaired Combina Relatively
work is intact tion of two spared;
but surround transcorti patient
ing brain is cal may go on
damaged dysphasia. repeating
Very little fragments
output. of heard
conversa
tion (echo-
lalia)
Anomic* Minimal Intact Intact Fluent, un Severely Intact Word find Most com- .
dysfunction informa im ing and mon language
syndrome tive paired, spelling deficit in head
of language para- impaired • trauma, meta
network. phasic, bolic encepha
Anywhere circum lopathy and
in language locutions Alzheimer's
network
Pure word Superior tem Impaired Intact Normal Intact Impaired Intact Intact Not deaf
deafness poral gyrus; as if lis because reacts
disconnection tening to to environ
of auditory an alien mental sounds
area and Wer tongue normally: no
nicke's area associated
deficit
Alexia Left occipi Intact Impaired Normal Normal Intact Can’t Intact Right hemia-
without tal cortex + in left read like nopia
agraphia splenium visual completely
(Pure (post part of field illiterate
word the corpus but can
blind callosum); match
ness) disconnec colors
tion between - can't
visual area' name
and language
network
Anomia: inability to name objects.
PDFelement
Cranial Nerves The Olfactory Nerve

There are 12 pairs of cranial nerves. It is the first cranial nerve.
Location of nuclei, names and major
functions are given below. Anatomy
Nuclei of the cranial nerves It carries the sense of smell. Receptors of
Cranial Nerve Site of Nucleus smell are present in the upper posterior
1st, 2nd Directly go to the part of the nasal mucosa. Fibers pass
cerebral cortex through the cribriform plate to the
3rd, 4th Midbrain olfactory bulb which contains 2nd order
5th, 6th, 7th, 8th Pons neurons. Fibers from here pass through
the olfactory tract to the temporal lobe.
9th, 10th, 11th, 12th Medulla oblongata
List of cranial nerves

Number Name Functions
First Olfactory + Sense of smell
Second Optic + Vision
Third Oculomotor + Motor (all the extraocular muscles except superior
oblique and lateral rectus)
+ Parasympathetic (ciliary muscles and sphincter
pupillae
Fourth Trochlear + Motor (superior oblique)
Fifth Trigeminal + Motor (muscles of mastication)
+ Sensory (face, anterior part of head and inside the
mouth)
Sixth Abducent + Motor (lateral rectus)
Seventh Facial + Motor (muscles of facial expression, stapedius muscle)
+ Sensory (part of external ear)
+ Taste (anterior 2/3 of tongue)
+ Parasympathetic (lacrimal, submandibular and
sublingual glands)
Eighth Vestibuloc + Balance
ochlear + Hearing
Ninth Glos + Motor (stylopharyngeus)
sopharyngeal + Sensory (pharynx, soft palate)
+ Taste (posterior I/3 of tongue)
+ Parasympathetic (parotid gland)
Tenth Vagus + Motor (muscles of soft palate, pharynx and larynx)
+ Parasympathetic (thorax and abdomen)
Eleventh Accessory + Motor (sternomastoid, trapezius)
Twelfth Hypoglossal + Motor (muscles of tongue)
PDFelement
MM
Testing Smell projected to the calcarine sulcus (visual

+ Exclude local nasal pathology. area) of the occipital lobe (fig 5.17,5.18).
4- Test each nostril separately.
+ Don't use irritating smells like
ammonia.
+ Ask the patient whether he can nerve
appreciate common smells? chiasma
+ Ask the patient to close the eyes and Lateral
geniculate body
one nostril. Present common smells
like peppermint, clove oil, kerosene
oil, soap, fruit etc. and ask him to
snuff and identify them.
Interpretation
Anosmia: It means loss of sense of smell. Fig 5.17: Visual pathways
If due to neurological lesion, it may be
due to:
a. Head injury
b. Tumor of anterior cranial fossa
c. Tuberculous meningitis
Parosmia: It means perversion of
smell. Offensive smells are perceived
as pleasant smells and vice versa. It is
usually psychogenic in origin.
Hallucinations of Smell: These
sometimes occur in temporal lobe
epilepsy. Fig 5.18: Visual pathways (OR) optic radiations (VA)
The Optic Nerve visual area
It is the second cranial nerve.
Anatomy The fibers concerned with the light
reflex don't relay in the geniculate body
Fibers from the retina converge at the
optic disc and pass backwards as the and go to the superior calculi, pretectal
optic nerve. Fibers from the nasal half area of the midbrain and then 3rd nerve
of each retina decussate at the optic nuclei of both sides (fig 5.19).
chiasma while fibers from the temporal
half remain on the same side. The optic
tract, thus formed, contains fibers from
the temporal half of the retina of the
same side and the nasal half of the retina
of the opposite side.
The fibers of optic tract go to the lateral
geniculate body and then pass through
the posterior limb of the internal
capsule as optic radiations. One group
of optic radiations passes through the
temporal lobe and other group through
the parietal lobe. Finally, they are
PDFelement
Examination At first test binocular field of vision.

In 2nd cranial nerve examine: You and the patient should focus at each
1. Visual acuity other's nose. Stretch your arms in a way
2. Color vision that your fingers are midway between
yourself and the patient (fig 5.20). Bring
3. Field of vision
the fingers in gradually and ask the
4. Fundus patient to indicate when he can see them
Visual Acuity: Test each eye separately, on one or both sides. In order to check it
both, for near and far vision. further, move the finger of one side and
Near vision is tested by asking the ask the patient to indicate which side's
patient to read standard charts (see Eye finger is moving. Note if patient can see
textbook). On the bedside, ask the patient at the same time when you can see or
to read a book or newspaper keeping it at there is any discrepancy (fig 5.21).
a distance of 10 inches from the eyes. '
Far vision is tested by Snellen chart
which consists of letters of various sizes
arranged in lines, normally readable
from a distance indicated against each
line (see Eye textbook). Make the patient
sit at a distance of 6 meters from the
chart and ask him to read from the top.
If he can read 2nd last line his vision is
6/g. It means he has read a line from a
distance of 6 meters which was supposed
to be read from the same distance.
Similarly, 6/12 means he can only read
upto a line which he should have read
from a distance of 12 meters. Fig 5.20: Testing field of vision by confrontation
If he cannot read even the top most line, method; needle (or finger) should be held midway
show him your hand and ask him to between patient and examiner
count the fingers (finger counting). If he

fails, wave your hand in front of his eyes
and ask him to tell whether the hand is
moving or not (hand movements); if
unable to tell, throw light into the eye
and ask if he can appreciate this or not
(light perception).
Color Vision: Ishihara charts are used
for this purpose. On the bedside ask the
patient to recognize various colors.
Field of Vision: Proper method of
testing the visual field is by perimetry.
On the bedside a rough assessment can
be made by confrontation method
in which examiner compares his own
visual field with that of the patient.
Sit in front of the patient at a distance
Fig 5.21: Testing field of vision by confrontation method
of about one meter, eyes of both of you
(A) binocular field of vision (B) uniocular field of vision
being at the same level.
PDFelement
In order to test uniocular field of

Definitions
vision, you and the patient should cover
corresponding eyes (ie, if patient has Hemianopia: Loss of vision
covered his left eye you should cover affecting one half of the visual
your right eye), and look into each field.
other's opened eye. Stretch your arm Heteronymous hemianopia: Loss of
keeping the fingers midway you and nasal or temporal halves of visual
the patient. Bring it in from all four fields of both sides. It is also called
quadrants (upper and lower temporal, binasal or bitemporal hemianopia.
upper and lower nasal). If a pin with Homonymous hemianopia: Loss
large head is available, hold it in your of vision affecting corresponding
outstretched hand. Ask the patient to halves (left or right) of both visual
indicate when he can see the pin or the fields.
finger. Normally the patient and the Quadrantanopia: Loss of one
examiner should see the finger at the quadrant of visual field.
same time. If the patient cannot see, keep Homonymous quadrantanopia:
bringing the finger in till he can see it. Loss of vision affecting
Make sure that you both focus into each corresponding quadrants of both
other's opened eye throughout. visual fields.
Second eye is tested in the same Visual inattention: When each
way. Major visual field defects, like side is tested separately, patient
quadrantanopia can be picked up by can see normally when both sides
this method. are tested simultaneously, he
Central defects (scotomas) can be ignores one side.
detected by passing a pin through the
visual field (fig 5.21). Optic Nerve: There is complete loss of
If the patient is drowsy or uncooperative, vision on the affected side (fig 5.22).
move your hand rapidly towards the Optic Chiasma: Midline lesions of the
patient's face from the side. Normally optic chiasma involving crossing fibers
there will be blinking of the eye; it will lead to bitemporal hemianopia. If lesion
not occur if the eye is hemianopic. involves uncrossed fibers, defect will be
binasal hemianopia (fig 5.22).
Interpretation of Visual Field Defects Optic Tract: In right optic tract lesion
Visual fields are divided into nasal and there is loss of nasal half of visual field
temporal halves. On each side the nasal of the right side (which is left half of
visual field is projected to the temporal the right visual field) and temporal half
half of the retina and the temporal of visual filed of the left side (which is
visual field is projected to the nasal half left half of the left visual field). In brief,
of the retina. Similarly, upper half of the there is loss of left halves of visual fields
visual field is projected to the lower part of both sides or left homonymous
of the retina and vice versa. Visual field hemianopia when right optic tract
defects due to lesions of various parts of is involved. Similarly, there is right
the visual pathway are given below. homonymous hemianopia if lesion
PDFelement
involves left optic tract (fig 5.22).

Fig 5.22: Visual field defects; lesion
Optic Radiations: The temporal optic on the left side: (1) Complete
radiations represent upper quadrants loss of vision due to a lesion of
of visual field and damage will lead the optic nerve. (2) Bitemporal
to superior quadrantanopia of hemianopia due to a lesion of
the opposite side. The parietal optic the optic chiasma. (3) Right
radiations represent lower quadrants homonymous hemianopia due to
of visual field and lesion will lead to a lesion of the optic tract. (4) Right
inferior quadrantanopia of the opposite upper quadrantanopia due to a
side (fig 5.22). lesion of the temporal fibers of
Visual Cortex (lesion due to posterior the optic radiation. (5) Right lower
cerebral artery occlusion): There is quadrantanopia due to a lesion
homonymous hemianopia of the of the parietal fibers of the optic
opposite side but macular vision is radiation. (6) Right homonymous
preserved because occipital pole (visual hemianopia with sparing of
cortex controlling macula) has dual macula due to a lesion of the optic
blood supply (posterior and middle radiation in the posterior part of
cerebral arteries). parietal lobe.
z
Visual fields
i defects R
<D
•? ®
O®
CP'®
®
Fig 5.22A: Visual pathway and site of lesion Fig 5.22B: Visual field defects; lesion on the left side:
PDFelement
CH 5 NERVOUS SYSTEM
Fundoscopy: The retina can be seen will be discussed first followed by brief
with the help of an ophthalmoscope. anatomy of the cranial nerves.
The part of the retina through which
Ocular muscles
fibers of 2nd nerve pass is called the optic
disc. It is paler than the rest of the retina Extraocular muscles: There are seven
and has definite margins. extraocular muscles: lateral, medial,
superior and inferior recti, superior and
Optic atrophy: Optic disc inferior oblique and levator palpebrae
becomes pale. It is of two types: superioris.
+ Lateral and medial recti move the
Primary (disc margins are well eye ball laterally (abduction) and
defined)
medially (adduction) respectively
Secondary (disc margins (fig 5.23).
are irregular and blurred; it
+ In midposition, superior rectus and
occurs due to long standing
papilledema) inferior oblique move the eye ball
upwards (elevation), and inferior
Papilledema: Following changes rectus and superior oblique move
occur: the eye ball downwards (depression)
Physiological cup is obliterated. (fig 5.23).
Margins of the disc are blurred. + If the eye ball is moved laterally,
Color of the disc is pink and upwards and downwar ds movements
hyperemic. are carried out by the superior and
inferior rectus respectively (fig 5.23).
Veins are congested.
Hemorrhages may be present. + If the eye ball is moved medially,
Causes upwards and downwards
1. Raised intracranial pressure movements are carried out by
the inferior and superior oblique
2. Malignant hypertension
respectively (fig 5.23). 1
3. Raised Pa CO2 (type II
respiratory failure) + Oblique muscles move the eyeball in
the direction opposite to their name.
Papillitis: It means inflammation
of the optic disc. Changes are 4- Levator palpebrae superioris elevates
similar to papilledema, but in the upper eyelid.
papillitis there is marked loss of 4 All the extraocular muscles are
vision while in papilledema the supplied by the 3rd cranial nerve
visual acuity is normal except for except superior oblique which is
enlargement of the blind spot. supplied by the 4th cranial nerve and
lateral rectus which is supplied by
The Oculomotor, Trochlear and the 6th cranial nerve.**
Abducent Nerves Intraocular muscles: These are ciliary
These are the 3rd, 4th and 6th cranial nerves * * There is a formula to remember nerve supply of
respectively. the extraocular muscles. All the muscles are supplied
by the 3rd nerve except SO4 and LR6 (ie, superior
Anatomy
oblique by the 4th cranial nerve and lateral rectus by
The ocular muscles and their function the 6th cranial nerve).
PDFelement
muscles, sphincter pupillae and dilator The Trochlear Nerve: Its nucleus
pupillae. The ciliary muscles make a also lies in the midbrain. It is the
circle to which suspensory ligament only cranial nerve which emerges on
is attached. They contract when near the dorsal surface. It supplies superior
objects are focused; the lens capsule oblique muscle.
relaxes and convexity of the lens is The Abducent Nerve: Its nucleus lies
increased. There are two muscles in in the pons. It supplies lateral rectus
the iris; concentric fibers or sphincter muscle.
pupillae constrict the pupil and radial Internuclear Connections: When
fibers or dilator pupillae dilate the pupil. we move eye balls up, down, right or
Ciliary muscles and sphincter pupillae left, both eyes move together. These
are supplied by the parasympathetic are called conjugate eye movements
fibers of the 3rd cranial nerve. Dilator and are coordinated by the Medial
pupillae is supplied by the sympathetic Longitudinal Bundle (MLB) which
fibers which travel along carotid/ connects nuclei of 3rd, 4th and 6th cranial
ophthalmic artery from superior nerves with each other. Conjugate
cervical ganglion. eye movements are also controlled by
centers in the frontal lobe and brain
MEDIAL LATERAL stem.
Examination
At first neurological examination of
the eye will be discussed and then
examination of individual nerve.
Examination of the eye

Palpebral fissure: Ask the
patient to look straight and
compare two sides to look for
drooping of eyelid (ptosis).
Fig 5.23: Ocular movements (MR) medial rectus (LR)
Ocular movements: Stabilize
lateral rectus (SR) superior rectus (IR) inferior rectus
the head of the patient with one
(SO) superior oblique (10) inferior oblique
hand. Ask him to focus at your
finger held at a distance of two
Nerves feet and follow it with his eyes.
The Oculomotor Nerve: Its nucleus Ask the patient to report double
lies in the midbrain. It supplies all the vision (diplopia) if it occurs. Move
extraocular muscles except superior the finger towards his right. In this
oblique and lateral rectus. In addition, way lateral rectus of his right eye
it also contains parasympathetic fibers and medial rectus of his left eye are
which relay in the ciliary ganglion; tested. Move the finger upwards;
the postganglionic fibers supply ciliary superior rectus of the right eye
muscles and sphincter pupillae. and inferior oblique of the left eye
PDFelement
are tested. Now move your finger Keep your finger at a distance
downwards; inferior rectus of the of two feet and stabilize the
right eye and superior oblique of patient's head with other
the left eye are tested. Move the hand so that he cannot move
finger towards left and repeat- his head while following your
up and down movements. In this finger.
way all the extraocular muscles
are tested individually (fig 5.23). Pupil: Look for size of the pupil and
If patient reports diplopia note reaction to the light and accommodation.
the direction in which images are Light Reflex: Its afferent path is
maximally separated. It usually through the 2nd nerve and efferent path is
occurs in the direction of action of through the 3rd nerve. Shine bright light
paretic muscle. into the eye from the side while patient
Pupil: Note size, shape, and test looks straight focusing a distant object to
light and accommodation reflexes. avoid accommodation response. A hand
Size: Compare the two sides and
should be placed over the nose to prevent
the light from entering the opposite eye.
note whether pupils are of normal
Normal response is brisk contraction of
size, dilated or constricted.
the pupil followed by slight relaxation.
Shape: Note whether it is regular This response occurs on the same side
or irregular. (direct light reflex) as well as on the
Light Reflex: Check both direct opposite side (consensual light reflex).
and consensual light reflex (page Both eyes should be tested separately and
159). both eyes should be inspected each time
Accommodation Reflex: (page to see direct and consensual response (fig
159). 5.24). Differentiation of lesion of 2nd and
Nystagmus: (page 163 ). 3rd nerve are discussed on page 162.
The oculomotor nerve

Look for ptosis.
Stabilize the patient's head with one
hand. Ask him to look straight at your
finger held at a distance of two feet and
follow it. Move your finger medially (to
test medial rectus) and then upwards
(to test inferior oblique). Now move the
finger laterally and then upwards (to test
superior rectus) and downwards (to test
inferior rectus). Note any abnormality
of the eye movements. Ask the patient
Accommodation Reflex: Ask the
if he sees double; note the direction of
patient to look at a distant object and
movement in which diplopia occurs.
then look at his nose or at your finger held
PDFelement
BEDSIDE TECHNIQUES
close to his nose. There is convergence of Causes

eyes and constriction of pupil.
1. Diabetes mellitus (movements
The trochlear nerve are painful and pupil is not
Ask the patient to follow your finger affected)
medially and then downwards (to test 2. Aneurysm of the posterior
superior oblique). communicating artery
3. Midbrain lesion (there is
The abducent nerve hemiplegia on the opposite side, it
Ask the patient to follow your finger is called Weber syndrome)
laterally (to test lateral rectus). 4. Cavernous sinus thrombosis (4th
and 6th nerves are also involved)’*
Interpretation
In addition to the causes of 3rd, 4th and 6th
nerve paralysis discussed below, ocular Fourth cranial nerve paralysis
movements are also weak or absent in + Superior oblique is paralyzed (fig
myasthenia gravis (pupils are normal), 5.26.
ocular myopathy and Wernicke's
encephalopathy*. The eye doesn't move
in the direction of action of paralyzed
muscle and patient sees double when
asked to look in that direction.
Third cranial nerve paralysis
+ There is ptosis due to paralysis of
levator palpebrae superiors.
+ Superior, inferior and medial recti
and inferior oblique muscles are Sixth cranial nerve paralysis
paralyzed. The eye ball cannot + Lateral rectus is paralyzed and eye
move medially and upwards, and ball is deviated medially (fig 5.27).
is deviated laterally and slightly
downwards due to unopposed
action of lateral rectus and superior
oblique.
+ Pupil is dilated and fixed. Light
and accommodation reflexes are
absent (5.25).
+ Because of its long intracranial route,
it is commonly involved in raised
intracranial pressure of any etiology
and is a false localizing sign.
+ In pontine lesion if 6th nerve is
< J involved, 7th is also affected and there
is hemiplegia on the opposite side.**
* * Wernicke's encephalopathy is due to acute ** * Third, 4th, 6th cranial nerves and ophthalmic
deficiency of vitamin B, All the three nerves are division of 5tb cranial nerve pass through the
involved along with encephalopathy. cavernous sinus.
PDFelement
Internuclear Ophthalmoplegia
When patient is asked to move

the eye laterally, there is
nystagmus of that eye (this is
called ataxic nystagmus) and Fig 5.29: Ptosis of left eye
the opposite eye cannot move
medially.
Pupil Size
Lesion is in the medial
longitudinal bundle on the Normal size of the pupil varies
side of weakness of adduction from 3 mm to 5 mm (fig 5.30A). It
(5.28). may be dilated (>5 mm) (fig 5.30B)
Bilateral internuclear or constricted (<3 mm) (fig 5.30C).
ophthalmoplegia ‘ is Causes of Dilated Pupil
characteristic of multiple Bilateral
sclerosis.
1. Anxiety
r A On the affected side
3rd nerve
MIDBRAIN i nucleus
1. Mydriatic eye drops (atropine,
homatropine)
i (Medial
i
rectus) 2. Third nerve palsy
Causes of Constricted Pupil
I
MLB — Bilateral
I
I
I
1. Old age
I
I
2. Pontine lesion
POND X
!<- — MID LINE Opium alkaloids overdose
4th nerve Parabducens nucleus 1. Miotic eye drops (pilocarpine)
nucleus
(Lateral rectus) 2. Horner's syndrome
k y
Fig 5.28: Medial longitudinal bundle (MLB) and its
connections
Ptosis
This means drooping of eyelid (fig
5.29).
Causes
1. Third nerve palsy
2. Myasthenia gravis
3. Horner's syndrome Fig 5.30A: Normal pupil
PDFelement
Lesion of the effe mt path (3rd

nerve): Pupil of tl affected eye
is dilated and fixed When light is
shone into the affected eye, there is
no response on that side but pupil
of normal side constricts. When
light is shone into the normal
eye, pupil of that side constricts
but there is no response on the
affected side.
Fig 5.30B: Dilated pupil Argyll Robertson Pupil
(ARP): Affected pupil is small
and irregular. Accommodation
reflex is present and light reflex
is absent. Lesion is in the pretectal
area of midbrain.
Holmes-Adie Pupil: Pupil is
large. Reaction to light is absent
and reaction to accommodation
is delayed and sustained (tonic
pupillary reaction). Lesion is in
the ciliary ganglion. It is also called
internal ophthalmoplegia. It
Fig 5.30C: Constricted pupil
may be accompanied by absent
ankle jerk and other deep tendon
Pupillary Reflexes reflexes (Holmes-Adie syndrome).
Lesion of the afferent path It is a benign condition of no
consequence.
(2nd nerve): When light is shone
into the affected eye, there is no
response on both sides. When
light is shone into the normal eye, Horner's Syndrome
pupil of both sides constrict. So
The postganglionic sympathetic
consensual light reflex is present fibers for the eye originate in
on the affected side but direct the superior cervical ganglion
light reflex is absent. This is also and travel along the carotid and
called amblyopic light reaction ophthalmic arteries and supply
or Gunn pupil* dilator pupillae, tarsal muscle
of upper eyelid and orbital
muscle which tends to hold the
eye ball forward. Some fibers
also supply sweat glands of face.
* * Gunn pupil: When light is thrown in normal Manifestations of damage to the
eye, there is constriction of pupil of blind eye due to sympathetic fibers are called
consensual light reflex. If, immediately afterwards,
light is thrown into blind eye, pupil, instead of Horner's syndrome. These are seen
constricting, dilates (as it is recovering form the on the side of lesion:
effect of consensual reflex). This is called Gunn pupil.
PDFelement
CH 5 NERVOUS SYSTEM
Ptosis in the other direction. Direction

of nystagmus is named after the
- Miosis (small pupil)
direction of the quick component.
Enophthalmos
Severity
Loss of sweating on the face
Grade I: Nystagmus is present
only when eye is moved in the
direction of quick component.
Nystagmus
Grade II: Nystagmus is present
These are involuntary oscillations
when eye is in midposition.
of the eye ball and should be
looked for when testing the ocular Grade III: Nystagmus is present
movements. Ask the patient even when eye is moved in
to focus at your finger held at direction opposite to that of quick
least two feet away at the level component.
of patient's eye. See if there are
Interpretation
any oscillations of the eye ball.
Ask the patient to follow your Commonly the nystagmus is
finger laterally, keep it there for horizontal and jerky.
sometime and note oscillations.
Repeat the process by taking - Jerky nystagmus of constant
your finger towards opposite direction is due to the
side, upwards and downwards. labyrinthine or cerebellar
Don't go to the extremes of lateral lesion.
gaze because some oscillations Nystagmus which changes its
may occur due to muscle fatigue.
direction with the direction
Nystagmus is seen better through
closed eyes and patient can be
of gaze is due to wide spread
asked verbally to look towards central involvement of
left, right, upwards or downwards. vestibular nuclei.
If nystagmus is present note the Upbeat nystagmus which
gaze, type, direction and severity. occurs on upward gaze with
Gaze fast component upwards is due
Nystagmus may be vertical, to lesion in upper part of the
horizontal or rotatory. midbrain.
Type Downbeat nystagmus with
Pendu I ar nys tagm us: fast component downwards
Oscillations are equal in rate is due to lesion in the lower
and amplitude on both sides of a medulla.
central point.
Pendular nystagmus is due to
Jerky nystagmus: Oscillations
loss of macular vision.
are quick in one direction and slow
PDFelement
BEDSIDE TECHNIQUES
The Trigeminal Nerve from the angle of the mandible are

It is the 5th cranial nerve. carried through C2 (fig 5.31).
Anatomy
It is a mixed nerve, ie, contains both
sensory and motor fibers.
The motor part
The nucleus lies in the pons. It passes
below the trigeminal ganglion and
leaves the skull through the foramen
ovale. It joins the mandibular division of
the sensory part and supplies muscles of
mastication (masseter, temporalis, and
pterygoids).
The masseter and temporalis elevate the
jaw. The pterygoids of both sides acting
together, depress and protrude the jaw. The
pterygoids of one side acting alone, push
the jaw laterally towards opposite side.
The sensory part
It carries touch, pain and temperature Fig 5.31: Sensory distribution of 5th nerve: (A)
sensations from the face, the anterior ophthalmic division (B) maxillary division (C)
part of the head and inside the mouth. mandibular division
There are three divisions:**
The ophthalmic division: If a line The cells of origin of the sensory part
is drawn from tragus to the outer of the 5th nerve lie in the trigeminal
canthus of eye, ophthalmic division (Gasserian) ganglion. The peripheral
carries sensations from above this line axons form the branches described
to the vertex including upper eyelid, above. The central axons are divided
conjunctiva, cornea and intraocular into two groups of fibers.
structures (fig 5.31).
The fibers carrying tactile sensations
The maxillary division: Draw another terminate in the principal sensory
line joining the tragus with the angle nucleus of the 5th nerve in the pons and
of the mouth; the maxillary division fibers of 2nd order neurons go to the
carries sensations between two lines
thalamus through the ascending tracts
including nose, upper gums and teeth,
of the 5th nerve.
and hard and soft palate (fig 5.31).
The fibers concerned with pain and
The mandibular division: It carries
temperature terminate in the nucleus
sensations from the jaw (except its angle),
lower teeth and gums, floor of the mouth, of the spinal tract which extends
tongue and mucosa of cheek. Sensations downwards from the principal sensory
* * Areas of distribution of three divisions of nucleus to the 3rd cervical segment of the
5th nerve given in the text are not precise but are spinal cord. Fibers from these neurons
adequate for clinical purpose.
PDFelement
cross to the opposite side and pass This is function of opposite pterygoids.
upwards to the thalamus. In unilateral paralysis jaw will not
move towards normal side.
Examination
Examine both motor and sensory
function.
Motor function
+ Place your hands on the sides of the
patient's cheek, fingers being on the
temple. Ask him to clench the teeth;
your hand will feel contracting
masseter and temporalis muscles
(fig 5.32). In unilateral paralysis,
muscles of the affected side will not
contract. In bilateral paralysis jaw
hangs loosely.
Fig 5.33: Testing pterygoids of both sides
Fig 5.32: Testing masseter and temporalis
> Ask the patient to open the jaw

against resistance to test the
pterygoids of both sides (fig 5.33).
Jaw will deviate towards weak side.
> Ask the patient to move the jaw
Fig 5.34: Testing pterygoids of left side
laterally against resistance (fig 5.34).
PDFelement
Jaw jerk: Ask the patient to open the reflex) with a wisp of cotton from the
mouth and hang the jaw loosely. Place lateral side (fig 5.37). Normally, there is
your thumb over the chin and strike it brisk closure of eyelids on both sides.
with hammer. There is closure of the The cornea should not be touched
jaw if reflex is present. Normally it is repeatedly as it can be easily damaged.
not elicitable. It is brisk in supranuclear Corneal reflex can also be elicited by
(UMN) paralysis of the 5th nerve (fig 5.35). blowing into the patient's eye. The
afferent part of the reflex arc is the
ophthalmic division of the 5th nerve and
the efferent part is the 7th nerve. If there
is 7th nerve paralysis on the side being
tested, there will be no closure on that
side but there will be brisk closure of the
other eye. Loss of the corneal reflex may
be an early sign of lesion of the 5th nerve.
Fig 5.35: Eliciting jaw jerk
Sensory function
Touch, pain and temperature should
be tested on both sides of the midline
in the territory of three sensory
divisions. Technique is described under
examination of the sensory system on < _________________7
page 201.
Fig 5.37: Testing conjunctival reflex
Corneal and conjunctival reflexes:
Ask the patient to look medially (fig 5.36). Interpretation
Touch the cornea (for corneal reflex) 4 Trigeminal neuralgia (episodic
or the conjunctiva (for conjunctival facial pain) is the most common
PDFelement
disease of the 5th nerve. In common

idiopathic variety, there are no 7th nerve
Geniculate
signs. If signs are present, it is ganglion
likely that there is a structural Nerve to ntermedius
lesion, eg, multiple sclerosis, tumor stapedius 8th nerve
involving the 5th nerve. Herpes zoster Lingual
Internal
auditory
commonly affects the ophthalmic nerve
meatus
division and postherpetic neuralgia
may occur. There will be a scar and Styloid
foramen
sensory loss over the forehead. The
ophthalmic branch is not involved
in idiopathic trigeminal neuralgia. facial muscles
+ Fifth nerve is involved in cerebello

pontine angle tumors along with
the 7th and 8th cranial nerves and Fig 5.38: Pathway of the facial nerve
cerebellum.
+ Ophthalmic division is involved in Branches and supply
lesions of cavernous sinus along 1. Nerve to stapedius: It originates in
with the 3rd, 4th and 6th cranial nerves. the temporal bone and supplies
+ Bilateral motor paralysis may the stapedius muscle which is
occur in bulbar palsy (there is responsible for dampening of noise.
wasting of muscles of mastication 2. Chorda tympani: It carries taste
and fasciculations are present) and sensation from the anterior 2/3 of
pseudobulbar palsy (jaw jerk is the tongue. It traverse the middle
brisk).
ear cavity and joins the facial
The Facial Nerve nerve in the facial canal. The first
It is the 7th cranial nerve order neurons lie in the geniculate
ganglion; the central axons travel
Anatomy with the 7th nerve as a separate
The nucleus lies in the pons. It winds bundle called nervus intermedius.
round the 6th nerve nucleus before 3. Motor branches:!?acial nerve divides
emerging from the pons. It enters the into five main branches under the
internal auditory meatus with the 8Jh parotid gland and supplies all the
nerve. In the temporal bone it lies in the muscles offacial expression.
facial canal. After running laterally, it
4. Sensory supply:Cutaneous sensation
bends backwards** and then downwards
from a small part of the external ear
to emerge from the skull through
stylomastoid foramen. It divides into a are carried by the 7th nerve.
number of branches under the parotid 5. Secretomotor (parasympathetic)
gland (fig 5.38). fibers: Facial nerve supplies
secretomotor fibers to the lacrimal,
* * This bend is called the genii where geniculate submandibular and sublingual
ganglion lies and contains neurons concerned with
taste. glands.
PDFelement
Examination side if nerve to stapedius muscle is

Routinely only the motor function of involved.
the 7th nerve is tested. 4 Pouting of the lips and transverse
smile are the manifestations of
Motor function bilateral facial weakness.
4 When the 7th nerve is paralyzed/ the
patient may complain of inability
to close the eyelid, collection of food
in the mouth and dribbling of saliva
on the affected side, and deviation
of the angle of the mouth towards
opposite side.
4 On inspection, palpebral fissure may
be wide and nasolabial fold may be
flattened on the paralyzed side.
+ Ask the patient to frown or wrinkle
the forehead. There- will be no
wrinkling on the affected side.
4 Ask the patient to close the eyes; the
affected side will remain opened and
there will be brisk upwards rolling
of the eye ball (BeU's phenomenon)**.
To test the power of the orbicularis
oculi, ask the patient to close the eyes
as strongly as possible while you
try to open the upper eyelids. The
affected side will be weak (fig 5.39).
Fig 5.39: Forceful closure of eyelids
+ Ask the patient to inflate the cheeks
and tap on both sides with the finger. Taste
The weak side will be deflated easily.
Test taste of anterior 2/3 of the tongue
4 Ask the patient to show the teeth. by the following technique.
The angle of the mouth will be 4 Get solutions of four common tastes
deviated towards healthy side. In - sweet, salt, sour and bitter.
an unconscious patient, deviation 4 Instruct the patient to identify the
of the angle of the mouth can be taste, either by writing or raising
demonstrated by applying pressure fingers, eg, one finger if taste is
over the supraorbital notch. sweet, two fingers if salty and so on.
4 The patient cannot whistle as air 4 Ask the patient to protrude the
escapes from the paralyzed side. tongue. Hold it with a gauze, dry it
4 The patient will complain of and test each side separately.
unusually loud sounds on paralyzed 4 Put a drop of each solution one by
one and ask for response.
* * This is only seen in lesion of the facial nerve
and is not a feature of UMN facial palsy. 4 Test bitter at the end.
PDFelement
Secretomotor function the stapedius and internal auditory

Lacrimation and salivation can be meatus, there is hyperacusis on
tested by various tests but it is not done affected side, in addition to motor
routinely. weakness and loss of taste.
+ Geniculate ganglion can be infected
Interpretation
by herpes zoster (Ramsay Hunt
The facial nerve is the most commonly syndrome). In addition to other
affected cranial nerve by lesion of both features of facial palsy, there are
upper motor neuron and lower motor vesicles in that part of the external
neuron. auditory meatus which gets sensory
Upper motor neuron lesion supply from facial nerve.
Manifestations are on the opposite + If the lesion is in the internal
side. Upper half of the face (wrinkling auditory meatus, in addition to the
of the forehead, closure of the eyelid) features of 7th nerve palsy, 8th nerve
is less severely affected because the is also paralyzed.
part of the facial nerve nucleus which + If the lesion is in the cerebello
supplies muscles of the upper half pontine angle, there are signs of
of the face is connected with both cerebellar dysfunction and 5th, 6th, 7th
cerebral hemispheres; the part of the and 8th nerves are involved.
facial nerve nucleus which supplies 4- In pontine lesion, alongwith the
muscles of the lower half of the face is facial nerve, the 6th nerve is also
connected only with the contralateral paralyzed and there is upper motor
cerebral hemisphere. Smiling and other neuron hemiplegia on the opposite
emotional movements are usually side.
preserved in UMN lesion because there
is a separate path for these movements
(fig 5.40).
Lower motor neuron lesion
Whole of the ipsilateral half of the face is
affected. Bell's paIsy is the most common
cause of isolated lower motor neuron
facial palsy. Etiology is not known. The
lesion is in the facial canal (fig 5.41).
As facial nerve has a long route and
gives off branches at various sites, the
site of the lesion can be localized with
considerable precision.
+ If the lesion is after the nerve
exits from the skull, there is only
weakness of the facial muscles.
+ If the lesion is in the facial canal,
between the chorda tympani and
branch to the stapedius, in addition
to motor weakness, there is loss of
taste as well.
+ If the lesion is between the branch to
PDFelement
Fig 5.40A: UMN facial palsy of right side: (A) forehead

is wrinkled, eyebrows are raised, angle of mouth r ■
Closing eyes
is deviated towards left (B) eye closes with slight
weakness, nasolabial fold is flat on the right side
< _______________________ 7
Fig 5.41 A: LMN facial palsy of right side: (a) forehead
<_____________________________________ 7 is not wrinkled, eyebrows are not raised on the right
side; angle of the mouth is deviated towards left side
Fig 5.40B: UMN facial paralysis: connections of (b) eye doesn’t close, eyeball roles up, nasolabial fold
facial nerve and site of lesion is flat
PDFelement
CHB
Whisper test (Voice test): Ask the patient
to close the eyes. Whisper patient's name
or some other words and go on decreasing
the distance from his ear till he can hear.
Compare the distance on two sides. It
should be equal if both ears are normal.
It will be less on the deaf side.
Watch test: Ticking of a wrist watch
(not digital) and rubbing of finger
and thumb also can be used in place of
whisper.
Tuning fork tests: These are used to
differentiate between sensory neural
deafness and conductive deafness.
Normally air conduction is better than
bone conduction. In conductive deafness,
bone conduction becomes better than
Fig 5.41 B: LMN facial paralysis: connections of facial
air conduction. A 256 or 512 frequency
nerve and site of lesion
tuning fork is usually used for this
purpose.
The Vestibulocochlear Nerve
Rinne's test: It compares air conduction
It is the 8th cranial nerve.
and bone conduction of the same ear.
Anatomy Place the base of a vibrating tuning fork
The nucleus lies in the pons. It has two on the mastoid process. If patient cannot
components: hear, there is severe sensoryneural
1. The cochlear component is deafness. If he can hear, ask him to
concerned with hearing. indicate when he stops hearing. Then
bring the tuning fork close to his
2. The vestibular component is
external auditory meatus; if he can hear,
concerned with equilibrium and
balance, and is connected with the
it means air conduction is better than
cerebellum. bone conduction and Rinne's test is
positive.
Examination
If he cannot hear, repeat the test in
The cochlear and vestibular divisions reverse order. Keep the tuning fork
will be discussed separately.
close to the external meatus and, when
The cochlear division he stops hearing, place it on mastoid
Exclude local pathology of the ear by process; If he can still hear, it means bone
auriscopic examination. Formal tests of conduction is better than air conduction
hearing are performed by audiometery. and Rinne's test is negative.
On the bedside, the following simple A quick method for Rinne's test is to
tests are used for gross assessment. Test place the tuning fork on the mastoid
each ear separately while the other ear process and then quickly bring it close
is occluded. to the external auditory meatus and
PDFelement
ask the patient which one is louder (fig In conductive deafness Rinne's test is
5.42A). negative.
In mixed deafness bone conduction is
better than air conduction but both are
reduced.
Weber's test It compares bone conduction
of both ears. Place a vibrating tuning
fork on middle of the forehead or vertex
and ask the patient in which ear hearing
is better. If it is equal on both sides, test
is central; it indicates, either normal
hearing or equal deafness on both sides
(fig 5.42B).
Fig 5.42A: Rinne’s test
Positive Rinne's test is normal.

In sensoryneural deaf ness air conduction
is better than bone conduction but both
are reduced (reduced positive Rinne's
test). Fig 5.42B: Weber’s test
PDFelement
In sensory neural deafness it is lateralized

to the normal ear while in conductive
deafness it is lateralized to the diseased ear.
Absolute bone conduction
Bone conduction of patient and the
examiner is compared. Plug both ears of
the patient and your own with cotton
or ear muff. Place a vibrating tuning
fork on mastoid process of the patient
and ask him to indicate when he stops
hearing. Place it on your own mastoid
process of the same side. If you can still
hear, it means patient has sensoryneural
deafness. In conductive deafness patient
and examiner hear equally. The Glossopharyngeal Nerve
Audiometery
Using a machine called audiometer, . Anatomy
range of hearing frequencies is recorded. The motor part arise from the nucleus
The vestibular division ambiguous in the medulla oblongata
and leaves the skull through the jugular
Special tests of vestibular function foramen along with the 10th and 11th cranial
(caloric stimulation and rotation tests) nerves. It supplies the stylopharyngeus
are not possible on the bedside but the muscle. The sensory component carries
presence of positional nystagmus can sensations from the pharynx, tonsillar
be looked for. region, posterior I/3 of the tongue, soft
Project the patient's head beyond the palate, tympanic cavity and Eustachian
couch. Extend the head fully and rotate tube. It also conveys taste sensation from
it to one side. If nystagmus appears posterior I/3 of the tongue. It supplies
transiently and then disappears; this is secretomotor (parasympathetic) fibers to
called positional nystagmus (fig 5.42C). the parotid gland.
This is due to lesion of the otolith organ
of the ear. After some time, extend and Examination
rotate the head towards other side. Most of the functions of the 9th nerve
are intermingled with the 10th nerve.
Taste on the posterior I/3 of the tongue
is difficult to test on the bedside.
Sensory function
Gag reflex: Ask the patient to open the
mouth and depress the tongue with a
spatula. Touch the posterior pharyngeal
wall with a stick having cotton wrapped
on that end, first on one side of the
PDFelement
midline and then the other. There In bilateral paralysis, soft palate will not
will be contraction and elevation of move. In unilateral paralysis, affected
the pharyngeal wall on that side. The side will remain immobile and uvula
sensory component of this reflex arc is will deviate towards normal side. Ask the
the 9th nerve and motor component is patient to puff out the cheek. Normally
the 10th nerve. the palate elevates and occludes the
Palatal reflex: When soft palate is nasopharynx; in 10th nerve paralysis air
touched it moves upwards. Each side is will audibly escape from the nose.
tested separately. Pathway is the same as Patient will also give history of
that of gag reflex. dysphagia and nasal regurgitation of
Motor function fluid. This can be confirmed by asking
the patient to take a drink.
It cannot be tested independent of 10th
nerve. Posterior pharyngeal wall
Interpretation Observe movements of the posterior
Isolated 9th nerve lesion is rare. pharyngeal wall when patient says 'ah'.
If one side is paralyzed, wall will move
The Vagus Nerve laterally towards normal side like a
It is the 10th cranial nerve. curtain. Examine the gag and palatal
reflexes as well.
Anatomy
It mainly carries parasympathetic fibers Vocal cords
to the organs of chest and abdomen, but Observe movements of the vocal cords
there is also a motor component which on laryngoscopy. Paralyzed side will not
originates in the nucleus ambiguous move.
of the medulla oblongata. It leaves
the skull through the jugular foramen Interpretation
and supplies muscles of soft palate and + The recurrent laryngeal nerve (a
pharynx and intrinsic muscles of larynx. branch of the 10th nerve) can be
Examination damaged during thyroid surgery or
by malignant tumors.
Only its motor function is tested.
+ Bilateral 10th nerve palsy occurs in
Speech bulbar and pseudobulbar palsy.
If the larynx is paralyzed, there is
dysphonia (hoarseness). If soft palate
The Accessory Nerve
is paralyzed, voice has nasal quality. It is the 11th cranial nerve.
Ask the patient to cough. In 10th nerve
Anatomy
paralysis cough becomes nasal or bovine.
It has two parts. The spinal part arises
Soft palate from the upper cervical segments of the
Ask the patient to open the mouth and spinal cord and enters the skull through
depress the tongue with tongue depressor the foramen magnum. It is joined by
to visualize the uvula. Ask him to say 'ah'. the cranial part which arises from the
PDFelement
medulla oblongata. As the nerve left and you resist with your hand
leaves the skull through the jugular placed on left side of the face. This
foramen, the cranial part separates, joins will test the right sternomastoid. For
the 10th nerve and supplies laryngeal left sternomastoid ask the patient to
muscles. The spinal part of the 11th nerve turn the head towards right against
supplies sternomastoid and upper part*of resistance. Contracted muscle can be
trapezius. seen and palpated (fig 5.43B).
Examination
+ Ask the patient to bend the head
downwards against resistance. This
is action of both sternomastoid (fig
5.43A).
Fig 5.43B: Testing sternomastoid of right side:

patient turning his head towards left
+ For the trapezius, inspect the patient

from behind. If the muscle is
paralyzed upper part of the, scapula
is displaced away from the spine and
lower part towards the spine. The
Fig 5.43A: Testing sternomastoid of both sides: whole arm droops and the fingers
patient bending his head downwards on that side are nearer the ground
compared with the normal side.
+ Each sternomastoid pushes the head + Ask the patient to shrug the shoulder
towards the opposite side. Ask the against resistance to test the power
patient to turn the head towards of the trapezius (fig 5.43C, 5.43D).
PDFelement
Interpretation
Accessory nerve is paralyzed along with
other nerves in bulbar palsy.
The Hypoglossal Nerve
Anatomy
Its nucleus lies in the medulla
oblongata. It exits the skull through
the hypoglossal canal and supplies all
the muscles of the tongue.
Examination
+ Ask the patient to open the mouth
and inspect the tongue as it lies
on the floor of the mouth for size,
shape, wasting and fasciculations
(page 177-178).
+ Ask the patient to protrude the
tongue; it will deviate towards
Fig 5.43C: Testing trapezius of both sides: patient the paralyzed side as normal
shrugging his shoulders genioglossus will push it towards the
opposite side (fig 5.44).
Fig 5.43D: Testing trapezius of one side: patient

shrugging his shoulder; arrow indicating belly of
muscle
PDFelement
CH 5 NERVOUS SYSTEM
Mam
+ Ask the patient to press the tongue 5. Coordination of movements

against the cheek while you resist 6. Involuntary movements
with finger pressure on the outside 7. Gait
of the cheek. In unilateral paralysis
movements towards normal side Bulk and Nutrition of Muscles
will be weak. Expose the limbs and compare
Interpretation corresponding parts of both sides. The
muscles of the dominant limb have a
+ In bilateral UMN lesion (eg, little more bulk than the non-dominant
pseudobulbar palsy), the tongue limb. It may be decreased (wasting or
looks small and conical, and is atrophy) or increased (hypertrophy).
immobile.
4- In unilateral UMN lesion, the tongue Bilateral symmetrical wasting
may sometimes deviate towards can only be picked up when it
the paralyzed side when protruded. is fairly advanced.
There is no wasting. It is usually seen
in acute stroke and disappears over Wasting: Bilateral symmetrical wasting
days. is difficult to pick up until it is fairly
4 In bilateral LMN lesion (eg, bulbar advanced while unilateral or localized
palsy), there is generalized wasting wasting is easily detected. The wasted
with fasciculations. muscles are small, soft and flabby.
+ In unilateral LMN lesion, wasting If there is any doubt, measure and
and fasciculations are present on the compare the circumference of both the
affected side only. limbs at corresponding sites - at an equal
+ In bilateral tongue paralysis there is
distance from a bony reference point
as described in the box below. Repeated
dysarthria.
measurements can be used to follow the
progress of the disease.
Muscles that push towards
opposite side
Forearms: Measure the distance
Pterygoids
from styloid process to a point
SternomastoidO at forearm where muscle bulk
Genioglossus is maximum and measure the
circumference of forearm at that
Motor System site. Repeat process on the other side
by measuring circumference at the
Examine the following and compare same distance from styloid process.
two sides. Note any abnormality and its
Upper arms: Mark midpoint
location.
between the acromion of scapula
1. Bulk and nutrition of muscles and olecranon of ulna (elbow
2. Tone of muscles flexed at 90°). Measure the
3. Power of muscles circumference of upper arm at
4. Reflexes that site on both the sides.
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twitching that occurs spontaneously

Legs: Measure the distance from
or is induced by light percussion.
medial malleolus to a point at calf
Fasciculations can be perceived by the
where muscle bulk is maximum patient as pulsations or quivering within
and measure circumference of
muscle.
calf at that site. Repeat process...
on the other side by measuring Causes
circumference at the same distance
Atrophy
from the medial malleolus.
1. Lower motor neuron disease
Thighs: Measure the distance
from the lateral tibial condyle 2. Motor nerve lesion
to a point at thigh where muscle 3. Systemic illness
bulk is maximum and measure 4. Disuse atrophy in joint diseases
circumference of thigh at that site. Hypertrophy
Repeat process on the other side 1. Body builders/athletes
by measuring circumference at
the same distance from the lateral 2. Myotonic disorders
tibial condyle. 3. Muscular dystrophy (Duchenne)
(pseudohypertrophy)
Wasting is a feature of lower motor Expose the part you want to examine.
neuron lesion (disease of motor Light should be adequate. Put the limb in
neuron or motor nerve). It is also seen a position that muscle being examined
in cachexia due to a systemic disorder is at rest because some twitching may
and in patients who are bedfast for a be seen in a normal incompletely
long time. In joint diseases, muscles relaxed muscle. As fasciculations are
responsible for the movements of the intermittent, inspect the muscle for
affected joints are wasted; this is called a few minutes. Percuss the muscle
disuse atrophy. lightly if fasciculations are not visible
Hypertrophy: In true hypertrophy otherwise.
both muscle bulk and power are These are seen in wasted muscles
increased. It occurs in response to resulting from disease of lower motor
excessive use of muscles, as in body neurons/motor nerves.
builders and athletes. It can also occur
Tone of Muscles
in myotonic disorders. In certain primary
muscle diseases (Duchenne muscular For clinical purpose it is defined as the
dystrophy), the bulk of the muscles is resistance felt when joint is moved
increased although power is reduced; passively.
it is called pseudohypertrophy. It is Patient's cooperation and relaxation are
due to fibrosis and fatty replacement of necessary for proper assessment of the
affected muscles. tone. Patient should lie supine, and be
Fasciculations: These are involuntary relaxed and comfortable.
contractions of a group of muscle fibers At first grasp the patient's forearm and
innervated by a single motor neuron. shake it; observe the movements of the
These appear as fine, flickering, irregular wrist. This gives information about
PDFelement
CH 5 NERVOUS SYSTEM
muscle tone around the wrist. Then

movements of the wrist. It occurs
repeat the act in lower limb by grasping
in Parkinsonism.
the leg below the knee and moving it
from side to side while supported on the Hysterical rigidity resembles
bed; observe movements of the ankle. lead pipe rigidity but resistance
Compare both the sides. increases proportionate to the
amount of force applied to perform
Then carry out full range of passive
the passive movement.
movements at wrist, elbow, hip, knee
and ankle joints, at first rapidly and then Hypotonia
slowly; assess the resistance encountered It is difficult to differentiate
during these movements. hypotonia from good relaxation.
Tone may be increased (hypertonia) or Hypotonia occurs in:
decreased (hypotonia). 1. LMN lesion and lesion of
sensory pathways
Hypertonia
2. Early stages of strokes
There are two types of hypertonia: (neuronal or spinal shock)
spasticity and rigidity.
3. Cerebellar dysfunction
Spasticity
The resistance increases with
the speed of passive movements.
Power of Muscles
In one form it rapidly increases As power varies in individuals, it is
during the first few degrees of important to compare muscles on both
passive movement and then as sides to detect mild weakness.
movement continues, it suddenly Definitions
decreases. It resembles opening or
closure of a clasp knife and is also Hemiplegia: Weakness of one
called clasp knife spasticity. It upper and one lower limb on the
occurs in UMN lesion. same side of the body.
Rigidity Uncrossed Hemiplegia: Cranial
nerve paralysis and hemiplegia
There is uniform increased
are on the same side.
resistance throughout the range of
passive movement. This resembles Crossed Hemiplegia: Cranial
bending of a lead pipe and is also nerves are paralysed on one side and
called lead pipe rigidity. It occurs hemiplegia is on the opposite side.
in lesions of the basal ganglia. Monoplegia: Weakness of one
If rigidity is accompanied by limb.
tremor, resistance to passive Paraplegia: Weakness of both the
movements is jerkily increased lower limbs.
resembling slipping of ratchets Diplegia: Weakness of both the
over the teeth of a cog; this is upper limbs.
called cog-wheel rigidity. This Quadriplegia (tetraplegia):
is best detected by slow rotatory Weakness of all the four limbs.
PDFelement
Grades of power
Grade 0 Complete paralysis
Grade 1 A flicker of contraction
only
Grade 2 Patient can move his limb
when gravity is excluded,
eg, moving limbs horizon
tally on the bed
Grade 3 Patient can move against
gravity (can lift the
limb off the bed) but not
against resistance
Grade 4 Patient can move against
resistance but power is .
less than normal
Grade 5 Normal power
Upper Limb
Small muscles of the hand
All small muscles of hand are supplied
by T1 spinal segment.
k_____________________________________ y
Abductor pollicis brevis: It is supplied
by the median nerve. Ask the patient to Fig 5.46: Testing opponens pollicis; two different
abduct the thumb at right angle to the methods (see text)
palm against resistance (fig 5.45).
Adductor pollicis brevis: It is
supplied by the ulnar nerve. Ask the
patient to adduct the thumb towards
the palmar surface of the index finger
against resistance (fig 5.47A). The nail
of the thumb should be in side view
(in opposition nail of the thumb is in
the plane of the palm) (fig 5.47B). Ask
the patient to hold a thin book between
clenched fingers and extended thumb.
Opponens pollicis: It is supplied by If adductor pollicis is paralyzed, there
the median nerve. Ask the patient to is flexion at metacarpophalangeal and
touch the little finger with the thumb interphalangeal joints (fig 5.47C)
and then try to separate them with your Lumbricals: First andsecondlumbricals
index finger. Or resist movements of the are supplied by the median nerve while
thumb while patient is trying to touch third and fourth are supplied by the
base of the little finger (fig 5.46). ulnar nerve. Ask the patient to flex the
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metacarpophalangeal joints and extend Interossei: All the interossei are

the interphalangeal joints against supplied by the ulnar nerve. The dorsal
resistance (fig 5.48). interossei abduct (DAB) and the palmar
interossei adduct (PAD) the fingers. Place
the palm of the patient on a flat surface.
To test the dorsal interossei ask him to
spread the fingers against resistance (fig
5.49A). To test the palmar interossei ask
the patient to move the finger towards
mid line (fig 5.49A), or to hold a card or
paper between two fingers while you
pull it towards yourself (fig 5.49C).
k_____________________________________ 7
Fig 5.48: Testing the first lumbrical muscle
Fig 5.47: (A) testing adductor pollicis brevis (B)

difference between adduction (1) and opposition (2)
(C) normal and paralyzed adductor pollicis brevis
PDFelement
Now try to flex the fist while he resists it.

There is another method; ask the patient
to grasp something firmly in his hand. If
extensors are weak, the wrist is flexed**.
Paralysis of extensors of wrist, as in
radial nerve palsy, leads to wrist drop.
Fig 5.49: (A) testing the first dorsal interosseus

muscle; arrow indicating the belly of the muscle (B)
testing the second palmar interosseus muscle (C)
testing the second palmar interosseus muscle by
asking the patient to hold a piece of paper between
fingers
Flexors offingers
Override your index and middle fingers.
Ask the patient to squeeze them while
you pull to free them (fig 5.50).
Fig 5.51: Testing bilateral hand grip
Brachioradialis
Ask the patient to flex the elbow against
resistance while arm is midway between
supination and pronation (fig 5.52).
Extensors offingers
Ask the patient to open the fist against
resistance.
Flexors of wrist
Ask the patient to bring tips of his
fingers towards front of his forearm
against resistance.
Extensors of wrist
Ask the patient to make a fist; this
involves firm contraction of the flexors * * Flexors of fingers and extensors of wrist are
of the fingers and extensors of the wrist. commonly tested by hand grip.
PDFelement
'I
CH 5 NERVOUS SYSTEM
Biceps
Ask the patient to flex the elbow against
resistance while arm is in full supination
(fig 5.53.
Fig 5.55: Testing supraspinatus; arrow indicating

belly of the muscle
Fig 5.53: Testing biceps; arrow indicating belly of the

muscle
Triceps
Ask the patient to straighten the flexed
forearm against resistance (fig 5.54).
Fig 5.56: Testing deltoid; arrow indicating belly of the

muscle
Serratus anterior
Ask the patient to push against the wall;
Fig 5.54: Testing triceps; arrows indicating belly of if serratus anterior is paralyzed, there is
the muscle winging of the scapula (fig 5.57). Patient
is also unable to elevate his arm above
Supraspinatus and deltoid right angle.
Ask the patient to abduct the arm against
Pectorals
resistance; first 30 degrees of abduction
are carried out by the supraspinatus (fig Ask the patient to stretch his arm out in
5.55) and next 60 degrees by the deltoid front of him and then clasp his hands
(fig 5.56). together against resistance.
PDFelement
Plantar flexion of the toes

Ask the patient to move the toes
downwards against resistance (fig 5.60).
Fig 5.57: Testing serratus anterior
Lower Limb
Dorsiflexion of the toes
Ask the patient to move the toes upwards
Fig 5.60: Testing plantar flexors of the toes
Plantar flexion of the foot

Ask the patient to move the foot
Dorsiflexion of the foot downwards against resistance (fig 5.61).
Ask the patient to move the foot upwards
against resistance (fig 5.59).
Fig 5.61: Testing plantar flexors of the foot; arrow

indicating belly of the muscle
PDFelement
Extensors of the knee extended and ask the patient to push it

Bend the knee and ask the patient to down against resistance (fig 5.64).
straighten it against resistance (fig 5.62).
Fig 5.64: Testing extensors of the hip
Flexors of hip
Place your right hand above the knee.
Ask the patient to bend the leg at hip
against resistance (fig 5.65).
Fig 5.62: Testing extensors of the knee; arrow
indicating belly of the muscle
Flexors of the knee

Raise the leg up from the bed. Support
the thigh with the left hand and hold
the ankle with the right hand. Then
ask the patient to bend the knee against
resistance (fig 5.63).
k_____________________________________ y
Fig 5.65: Testing flexors of the hip
Adductors of thigh
Place your right hand on medial side
of the leg. Ask the patient to bring
abducted limbs towards midline,against
Fig 5.63: Testing flexors of the knee; arrow indicating

belly of the muscle
Extensors of the hip

Place your right hand on Achilles
tendon. Lift the leg up while knee fully
PDFelement
Abductors of thigh . Reflexes

Place your right hand on lateral side of These are dependent on the reflex arc
the leg. Place the patient's legs together which consists of an afferent limb and
an efferent limb. The afferent (sensory)
and ask him to separate them against
limb transmits the impulses generated
resistance (fig 5.67). by the stimulation of receptors to the
communicating neuron (or neurons)
which in turn sends stimulus to the
effector organ (eg, muscle) through the
efferent (motor) limb (fig 5.68). Whole
reflex arc should be intact for the reflex
to be elicited. Each reflex is carried out
by one or two spinal segments which is
called root value of that reflex; it should
be remembered. Reflexes are of two
types: deep reflexes - also called tendon
jerks - and superficial reflexes.
Muscles of the Trunk

To test the muscles of abdominal wall,
place your right hand on forehead and
ask the patient to lift his head up from
the pillow against resistance. Abdominal
muscles can be felt to contract. If muscles
of lower abdomen are paralyzed, the
umbilicus moves upwards and vice
versa. This is called Beevor's sign.
To test the muscles of the back, ask the Fig 5.68: Reflex arc (1) receptor (2) afferent (sensory)
patient to lie on his face and try to raise limb (3) communicating neuron (4) anterior horn cell
(5) efferent (motor) limb (6) effector organ (muscle)
his head from the bed.
Reflex Root value
Routinely, only power of
Ankle jerk SI, 2
the muscles responsible for
movements of the major joints is Knee jerk L3, 4
tested. Biceps jerk C5, 6
Upper limb: Hand grip, flexion Brachioradialis jerk C5,6
and extension of wrist, flexion
Triceps jerk C6,7'
and extension of elbow, abduction,
adduction, flexion and extension Plantar reflex SI
of shoulder. Abdominal reflexes T8 - T12
Lower limb: Plantar and Cremasteric reflex LI, 2
dorsiflexion of toes and ankle,
Anal reflex S3,4
flexion and extension of knee,
abduction, adduction, flexion and Conjunctival and V, VII cra
extension of hip. corneal reflexes nial nerves
PDFelement
CH 5 NERVOUS SYSTEM CO
Deep Reflexes (Tendon Jerks) There are more than one methods of
These are: eliciting tendon jerks. In order to avoid
confusion we will describe only one
1. Ankle jerk method that we consider easy, and is
2. Knee jerk practised by the majority of physicians.
3. Biceps jerk
4. Triceps jerk
5. Brachioradialis jerk
Observe the following precautions while
eliciting the tendon jerks:
4- Ask the patient to relax and be
comfortable.
+ The muscle being tested should be
visible and look for its contraction
rather than movement of the limb.
+ Hold the flexible shaft of the
hammer from its end and let the
heavy end of the hammer fall on the
tendon to be tested.
4 Strike the tendon, not the muscle,
because mechanical stimulation
of the muscle belly produces
contraction of the muscle that is not
dependent on the reflex arc.
4 Compare each jerk with its fellow on
the opposite side.
4 If reflex is absent, elicit it again after
reinforcement** . For reflexes of
lower limb ask the patient to clench
the hands or hook the fingers of
both hands together and then pull
them away from each other without
disengaging (fig 5.69). For reflexes
of upper limb, ask the patient to
clench the teeth. This phenomenon
of reinforcement only lasts for
less than a second; therefore, ask Fig 5.69: Reinforcement phenomenon
the patient to perform appropriate

maneuver when you are about to
Biceps jerk (C5, 6)
strike the tendon.
Flex the elbow at right angle and place
the forearm in a semipronated position.
* * Reflexes are increased in amplitude when Place the thumb or index finger of your
muscles remote from those being tested are contracted
forcefully. This is called reinforcement.
left hand over the tendon of the biceps
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MMJMM
in the cubital fossa and strike it with the Brachioradialis jerk (C5, 6)
hammer. See contraction of the biceps This is also called supinator jerk. Flex
(fig 5.70). the forearm at elbow and place it in
semipronated position. Bend the hand
slightly towards ulnar side. Strike
the tendon of the brachioradialis,
proximal to the styloid process of
the radius. See contraction of the
brachioradialis (fig 5.72).
Fig 5.70: Eliciting biceps jerk
Triceps jerk (C6, 7)

Place the forearm on the patient's Inversion of reflexes
abdomen, elbow being flexed at right If a tendon jerk being elicited is
angle. Strike the tendon of the triceps absent/diminished but there is
above the olecranon. See contraction of contraction of muscles innervated
the triceps (fig 5.71). from an adjoining spinal segment,
this is called inversion of that
reflex. It indicates combined
spinal cord and root pathology
and has a precise localizing value.
Inversion of the biceps and
brachioradialis jerk: When
biceps or brachioradialis 'jerk is
elicited, it is absent/diminished
but there is flexion of the fingers.
Lesion is at the C5 spinal segment.
Inversion of one or both of these
jerks has the same significance.
If flexion of fingers occurs and
these jerks are normal/brisk,
PDFelement
and strike it between the patella and

this is a feature of hyperreflexia
tibial tuberosity with the hammer. See
and should not be confused with
contraction of the quadriceps (fig 5.74).
inversion.
Inversion of triceps jerk: When
triceps jerk is elicited, it is absent
but there is contraction of biceps.
Lesion is at the C7 spinal segment.
This is less common.
Crossed reflex induction:
It means elicitation of a jerk
produces reflex contraction of
muscles on the contralateral side,
eg elicitation of knee jerk on one
side may produce reflex adduction
on the opposite side. This is a sign
of spinal cord lesion.
Clonus
Ankle jerk (Si, 2) This is involuntary, oscillatory muscular
Patient should lie supine. Flex the leg contraction and relaxation invoked by a
slightly and place it in an externally sudden stretch of the muscle.
rotated position. Place your left hand on
Ankle clonus
sole of the foot and dorsiflex it; strike the
Achilles tendon with the hammer. See the Flex the knee and support it with the
contraction of the calf muscles (fig 5.73). left hand. Grasp the forepart of the
foot with the right hand, dorsiflex it
suddenly 2 - 3 times and then maintain
the dorsiflexed position by sustained
pressure on the sole. If clonus is present,
there are regular oscillations of the foot
due to contraction and relaxation of the
calf muscles (fig 5.75).
Fig 5.73: Eliciting ankle jerk
Knee jerk (L3, 4)

Patient should lie supine. Flex the knee
and support it with your left hand.
Feel for the tendon of the quadriceps Fig 5.75: Eliciting ankle clonus
PDFelement
JOI BEDSIDE TECHNIQUES
Patellar clonus paralysis of relevant muscles. Reflexes

Extend the knee and grasp the patella are usually normal in myopathies.
between the thumb and index finger. Delayed relaxation: In
Push it sharply towards the foot 2-3 hypothyroidism relaxation time of the
times and then maintain the position. reflexes is increased. This is best seen in
Regular movements of the patella occur the ankle jerk.
if clonus is present. Pendular jerk: (page 208)
A few beats of clonus may be elicited
in a nervous patient. This is called ill-
Don't declare a reflex to be
sustained clonus and has no significance. absent before eliciting it with
Sustained clonus - the clonus that reinforcement.
continues as long as stretch is applied - is
a sign of UMN lesion and is associated
with brisk reflexes (fig 5.76). Superficial Reflexes
These are:
1. Plantar reflex
2. Abdominal reflexes
3. Cremasteric reflex
4. Anal reflex
5. Conjunctival and corneal reflexes
(page 166)
Fig 5.76: Eliciting patellar clonus
Plantar reflex (Si)
The patient should lie supine with
Interpretation of Tendon Jerks legs extended. Scratch the outer edge
Reflexes may be normal, increased or of the sole of the foot with some blunt
diminished. object like a key, starting from the heel
Increased (brisk) tendon jerks: These towards the little toe and then medially
are a sign of UMN lesion, particularly if across the metatarsals. Stop as soon as
present in one limb or one half of the first movement of the big toe occurs. It is
body. If reflexes of all the four limbs a nociceptive reflex and stimulus must
are symmetrically increased (brisk), it is be painful, but injury to the foot should
difficult to decide whether they are due be avoided.
to UMN lesion or not, because they are Normal response is plantar flexion of
also seen in anxiety, thyrotoxicosis and the great toe alongwith flexion and
tetanus. Decision, then, depends upon adduction of the other toes '(fig 5.77).
plantar response (see below). This is also called downgoing plantar
Diminished tendon jerks: Reflexes or negative Babinski's sign.
are diminished if there is LMN damage, If there is extension (dorsiflexion) of
as in neuropathy, motor neuron disease, the great toe (usually accompanied
poliomyelitis and tabes dorsalis. Reflexes by fanning of the other toes), this is
are absent when sensory part of the called upgoing plantar, extensor
reflex arc is affected or there is complete plantar or positive Babinski's sign.
PDFelement
Sometimes extensor plantar response is

accompanied by reflex flexion of the
Oppenheim's sign: Extensor
plantar response is elicited by
ankle, knee and hip joints; this is called
rubbing over the crest of the tibia.
withdrawal response. Its significance
is the same as that of upgoing plantar Gorden's reflex: Extensor plantar
alone. If movement of the big toe is-not response is elicited by pinching
clear it is recorded as equivocal. the Achilles tendon.
Both these signs are present when
corticospinal lesion is widespread
and severe.
Hoffman's sign: Hold terminal
phalanx of patient's middle
finger between your thumb and
index finger. Flex it at terminal
interphalangeal joint, and then
flick it into extension with your
thumb. If sign is positive, there
is quick flexion of the patient's
thumb. It is a sign of hyperreflexia;
if unilaterally positive, it strongly
suggests UMN lesion. It should
not be confused with Homan sign
seen in deep venous thrombosis
(page 82).
Finger flexion jerk: Place tips
of your middle and index fingers
across the palmar surface of
Interpretation the proximal phalanges of the
Upgoing plantar is the most significant patient. Then lightly tap your
sign of UMN lesion. There are other own fingers. A slight flexion of
causes as well. the patient's fingers is normal
but a brisk contraction suggests
In UMN lesion upgoing plantar may be
hyperreflexia.
unilateral or bilateral, depending upon
the site of lesion. In other situations it is Rossolimo's sign: Flick the
always bilateral. distal phalanges of the toes into
extension with your finger§ and
Causes of upgoing plantar then allow them to fall back
into normal position. A positive
1. UMN lesion response is brisk plantar flexion
2. Hypoglycemia of the great toe. This is a sign of
3. Deep coma pathological hyperreflexia. It is
4. Post epileptic fit counterpart of the Hoffman's sign
in the lower limb. It is particularly
5. Below the age of one year
PDFelement
+ Abdominal reflexes are also absent

helpful when plantar response
if there is UMN lesion above their
cannot be obtained because of
segmental level or if there is LMN
paralysis of the extensor hallucis
lesion of the concerned spinal roots
longus.
or nerves.
Absent plantar response
Sometimes no plantar response
is obtained with usual stimulus.
One of the following could be the
reason:
1. Coldness of feet; test should be
repeated after warming the
feet.
2. Sensory loss over the SI
dermatome
3. Paralysis of the muscles of the
great toe
4. Spinal shock due to transection
of the spinal cord
Abdominal reflexes (T8 - T12)

The patient should be warm and Cremasteric reflex (LI, 2)
relaxed, lying in supine position with a
Scratch the inner aspect of the upper part
low pillow supporting the head. Draw
a pin from lateral part of the abdomen of the thigh. Normally there is elevation
towards midline on either side. It should of testes. This reflex may be lost in UMN
be below and parallel with the costal lesion.
margins for upper abdominal reflexes Anal reflex (S3, 4)
and above and parallel with the inguinal
ligaments for lower abdominal reflexes. Scratch the skin near the anal margin
Avoid any injury to the patient. Nerve with a sharp object. There is contraction
supply of this area is T8 - T12 from above of the anal sphincter.
downward.
Coordination
Interpretation It means smooth and accurate
+ Brisk contraction of muscles of the performance of purposeful movements.
stimulated area and movement of It requires intact motor, sensory and
the umbilicus towards that side is cerebellar system. Loss of coordination is
normal response. called ataxia which may be cerebellar or
A Abdominal reflexes are normally sensory - due to loss of sense of position.
absent in the obese people, old age Ill the presence of gross motor weakness
and multiparous women. coordination cannot be tested.
PDFelement
CH 5 NERVOUS SYSTEM
Upper Limb Lower Limb

Finger nose test
Ask the patient to touch with his index Heel knee test
finger the tip of his nose and your Patient should lie in the bed. Ask him to
index finger, alternately, rapidly and place the heel on his opposite knee and
repeatedly. Keep your index finger at slide it downward along the shin to the
such a distance that patient has to extend
ankle. Then lift it, making a semicircle,
his arm fully to touch it (fig 5.79).
place it again on the knee and repeat the
Perform the test with patient's eyes open movement (fig 5.80).
and test each arm in turn.
In order to further increase the Another test is to ask the patient to lift
sensitivity of this test, move your finger the extended leg and touch your index
from place to place. finger with the great toe.
To test for sensory ataxia ask the patient As said earlier, movements are clumsy
to close his eyes outstretch his arm and and jerky if coordination is lost.
then touch the tip of his nose.
Fig 5.79: Finger nose test
Finger to finger test

Ask the patient to extend and abduct Fig 5.80: Heel knee test
his arms fully and then bring tips of the

index fingers together, through a wide
Heel-toe test of gait (tandem
circle at first with the eyes open and
walking)
then with the eyes closed.
Another test for coordination is to ask Ask the patient to walk along a straight
the patient to make circles in the air at line so that the heel of one foot comes
first with the eyes open and then with directly in contact with the toes of the
the eyes closed. other foot. The rare foot is then advanced
Normal person can perform these so that its heel is then placed in front
movements smoothly. If coordination of the previously front foot (fig 5.81).
is lost, movements become clumsy and Patient with cerebellar dysfunction is
jerky, and patient may overshoot the unable to so and tends to fall towards
target. diseased side.
PDFelement
finger tests) become worse when patient

closes the eyes; otherwise loss of sense of
position is compensated through vision.
Closure of the eyes has no effect on
cerebellar ataxia.
Sensory ataxia becomes worse

when patient closes the eyes
while cerebellar ataxia is not
affected.
Romberg's sign: Ask the patient to

stand with his feet close together. A
patient of sensory ataxia is steady when
eyes are opened and becomes unsteady
when eyes are closed. (A patient of
cerebellar ataxia is equally unsteady
whether eyes are opened or closed).
Involuntary Movements
Tremors
These are rhythmic involuntary
movements resulting from alternating
contraction and relaxation of groups of
muscles. These involve peripheral parts
of the body like hands, head and tongue.
In order to look for tremors in the hand,
ask the patient to outstretch the arms
and abduct the fingers. If tremors are
still not obvious but suspected, place
a piece of paper on the dorsum of the
hands and observe its movements.
Remember: movements of the paper
could be due to wind or a running fan
rather than tremors.
Causes
Anxiety: Tremors are fine and become
Fig 5.81: Tandem walking
obvious only when arms are outstretched
and fingers are spread. Hands are sweaty
Differential Diagnosis of Sensory but cold.
and Cerebellar Ataxia Thyrotoxicosis: Tremors are similar to
Sensory ataxia is due to the loss of sense those of anxiety but hands are sweaty
of position. Unsteadiness and tests of and warm.
coordination (finger nose and finger to Essential familial tremors: Tremors
PDFelement
CH 5 NERVOUS SYSTEM
are coarse and are present, both, at rest Titubations

and during activity. These are tremors of the head, either to
Senile tremors: These are similar to and fro or rotatory, seen in cerebellar
essential familial tremors; occur in old age. dysfunction; may occur as a part of
Parkinsonian tremors: These are essential tremors.
slow and coarse. Typically, there are
pill rolling movements of the thumb. Tics or Habit Spasms
Tremors are partially suppressed These are repetitive and stereotyped
during voluntary movements and movements - the same movement
disappear during sleep. Other features is repeated again and again. Facial
of Parkinsonism (rigidity, hypokinesia) grimaces are a common example.
are present.
Intention tremors: Ask the patient to Choreiform Movements
catch an object, say, a pencil held in your These are semipurposive movements
hand. Tremors are absent at rest, become which look like fragments of normal
prominent as patient approaches
movements, but are repeated in a
the object and disappear thereafter.
disorderly manner. Movements tend to
Intention tremors are a feature of
cerebellar dysfunction. move from one part of the musculature
to another in quick succession which
Flapping tremors: Ask the patient to
differentiates them from tics. These
outstretch arms and dorsiflex hands at
occur in Huntington's chorea and
wrists. Jerky movements of the hands
occur due to flexion and extension rheumatic fever (Sydenham's chorea).
of the wrists and fingers. Causes of
Athetoid Movements
flapping tremors are respiratory, renal,
hepatic and cardiac failures. To detect These are slow writhing movements
flapping tremors in an unconscious or principally affecting the distal parts of
uncooperative patient, hold the patient's the limbs. Combination of choreiform
arm with one hand and dorsiflex his and athetoid movements may occur in
hand and maintain that position with the same patient.
the other (fig 5.82).
Myoclonus
These are sudden shock like contractions
that involve one or more muscles or a
whole limb. These sometimes occur in
normal people when falling asleep; are
also a feature of epilepsy.
Hemiballismus
There is sudden, violent, flail like
throwing movement of the limbs on
one side. Lesion is in the contralateral
Fig 5.82: Flapping tremor
subthalamic nucleus.
PDFelement
BEDSIDE TECHNIQUES
Dystonic Movements (Torsion Drunken Gait

Spasms) Patient walks on a broad base in a reeling
These are similar to the athetoid manner. This occurs in cerebellar
movements but involve proximal parts; lesion. In unilateral lesion patient tends
there are turning or twisting movements to stagger towards the affected side.
of limbs or trunk. Sustained abnormal
Waddling Gait
contractures and limb posturing
may result. Spasmodic torticollis and The body sways from side to side as each
dystonia musculorum deformans are step is taken. This occurs in proximal
the examples. muscular weakness, as in myopathies.
This also occurs in the congenital
Spasmodic Torticollis dislocation of hip joints.
It is a type of torsion spasms. These Parkinsonian Gait

are repetitive rotatory movements of
Patient bends forward with flexion at
the head and neck to one side, may be
the hips and knees. Arms are flexed at
accompanied by extension of the neck.
the elbows and adducted at the shoulder;
there are no associated movements
Gait
during walking. Initially walk is slow
Ask the patient to walk in a straight line with short rapid steps, feet dragging or
and observe the gait. Following are some sliding along the floor (shuffling gait).
of the abnormal types of gait. As the upper body gradually leans
further ahead of the feet, the speed is
Spastic Gait increased in an attempt to maintain an
upright posture (festinant gait).
This is seen in UMN paraplegia.
Patient does not lift his feet from the
ground completely so that toes remain Apraxia
in contact with the ground. Legs swing It means inability to perform
learned act in the absence of
outward and forward in a circular
incoordination, weakness or
fashion. Hemiplegic gait is a spastic sensory deficit. Ask the patient to
gait in which only one leg is affected. carry out commonly performed
acts like combing thea hair,
High Stepping Gait buttoning the shirt, or drawing
square or triangle on the paper.
This is seen in patients with bilateral Patient with apraxia will not be
foot drop as a result of weakness of the able to carry out these acts. Lesion
extensors of the feet, as in polyneuropathy. is in the dominant parietal lobe if
Patient lifts the foot high to clear the toes apraxia is bilateral and in the non
from the ground and then returns it with
dominant parietal lobe if apraxia
is of the non-dominant limb only.
a loud slapping noise.
PDFelement
Differential diagnosis of upper Localization of Motor Lesion

motor neuron paralysis and lower
motor neuron paralysis Upper Motor Neuron Lesion
The cardinal signs of UMN damage are
Feature UMN pa LMN pa
hypertonia, hyperreflexia and upgoing
ralysis* ralysis
plantar. Manifestations of lesions at
Bulk and There is no There is various sites along the course of UMN
nutrition wasting marked pathway are given below. The site of
wasting lesion may be:
Power Groups of Individual 1. Motor cortex
muscles are muscles are 2. Internal capsule
involved involved 3. Brain stem
Tone It is in ; It is dd-iV (.) 4.( ’) Spinal cord
creased creased
Motor Cortex
Tendon These are These are
jerks brisk diminished As motor area is spread over a large
or absent area, cortical lesion usually gives rise
to monoplegia rather than hemiplegia.
Plantar It is upgoing It is down Other manifestations like apraxia or
(Babinski's going agnosia may also be present. There are
sign is posi (Babinski's
specific manifestations due to lesions
tive) sign is of various lobes, eg, there is inferior
negative)
quadrantanopia if lesion is in the
Abdomi These may These are parietal lobe; there is homonymous
nal and be absent present hemianopia if lesion is in the occipital
cremas (these are lobe; grasp reflex is present and the
teric absent if patient is emotionally labile if the lesion
reflexes concerned is in the frontal lobe.
spinal roots
or nerves Internal Capsule
are affect As both the motor and sensory fibers
ed) are very closely packed in the internal
Absent May be capsule, its lesion gives rise to dense
Fascicu-
lations present hemiplegia and facial nerve palsy of the
opposite side (uncrossed hemiplegia).
Brain Stem
In brain stem lesions, there is crossed
hemiplegia, ie, cranial nerve palsy is on
* Neuronal shock: When there is sudden damage one side and hemiplegia is on the other
to the UMN system, as in brain hemorrhage, anterior
horn cells are depressed. Weakness is accompanied side. Lesion is on the side of cranial
by hypotonia and absent tendon reflexes; plantar is nerve palsy. Depending upon the cranial
usually upgoing. This is called neuronal (or spinal) nerve involvement lesion can be further
shock. Typical features of UMN lesion appear after a
few hours to days.
localized. For example:
PDFelement
+ If 3rd nerve is involved, lesion is in

the midbrain.
4 If 6th or 7th nerve is involved, lesion is
in the pons.
4 If 9th or 10th nerves is involved lesion
is in the medulla oblongata.
Spinal Cord
Upper motor neuron damage is usually
bilateral. If it is unilateral, lesion is on
Fig 5.83: Transverse section of the spinal cord;
the side of motor weakness.
shaded area indicating tracts involved in hemisection
4 If upper limbs are involved, lesion is
above the C5 spinal segment.
4 If all the abdominal reflexes are
absent, lesion is above the T8 spinal
segment.
4 If there is evidence of lower motor
involvement - like wasting - in the
segmental distribution, lesion is at
that segment.
4 If there is sensory loss in a
dermatome, lesion is at that spinal
segment.
4 If sensory tracts are involved, there
is sensory loss upto a certain level;
the actual site of lesion is a few
segments above that depicted by the
sensory level.
Hemisection of the spinal cord

(fig 5.83,5.84)
Below the level of the lesion there
is:
Ipsilateral UMN weakness and
loss of sense of position and
vibration
Contralateral loss of sense of
pain and temperature Fig 5.84: Manifestations of hemisection of the spinal
cord: Pyramidal signs and loss of position and
This is called Broum-Sequard vibration on the same side (blue shade); loss of pain
syndrome and temperature on the opposite side (pink shade)
PDFelement
NMNN
+ If anterior horn cells are involved,

Hemiplegia in a comatosed as in poliomyelitis or motor
patient neuron disease, manifestations
Detection of hemiplegia due to are widespread like monoparesis,
a recent stroke in a comatosed
paraparesis or quadriparesis.
patient may be difficult. Following
signs are helpful. + If a root is involved, the muscles
supplied by that root are paralyzed,
Look for hypotonia; this eg, If T1 root is damaged, there is
may be the only evidence of paralysis of all the small muscles of
hemiplegia. the hand.
Raise the arm of the patient + If a single peripheral nerve is
and let it fall. If it is paralyzed
it falls as if it did not belong to involved muscles supplied by that
the patient; it may even hit the nerve are affected, eg, in radial
face of the patient. The sound nerve paralysis there is weakness
arm does not fall in that way. of the extensors of the wrist
Deviation of the angle of the resulting in wrist drop. If multiple
mouth due to associated facial peripheral nerves are involved
nerve palsy can be detected as in neuropathy, muscles of distal
by applying pressure over the parts of the limbs are affected. In
supraorbital notch; the angle post infective polyneuritis (Guillain
deviates to the healthy side. Barre syndrome) there is paraplegia
Bilateral upgoing plantars in or quadriplegia.
a deeply comatosed patient
have no localizing value, but if Diseases of Muscles
plantar is upgoing only on one In diseases of muscles (myopathies)
side, it is the most useful sign weakness is more marked in the
of hemiplegia. proximal muscles, eg, muscles of
shoulder and pelvic girdles. Affected
muscles are usually wasted but
Lower Motor Neuron Lesion fasciculations are absent and reflexes
The cardinal signs of LMN damage are preserved. In Duchenne muscular
are wasting of muscles, hypotonia, dystrophy there is pseudohypertrophy.
diminished or absent reflexes and
downgoing plantar. Manifestations of In muscle diseases reflexes are
lesions at various sites along the course normal.
of LMN pathway are given below.
The site of lesion may be: In myotonic dystrophy relaxation of the
1. Nuclei of cranial nerves muscles is defective. Ask the patient
2. Anterior horn cells to grip your hand and then let it go
suddenly. He will only release the hand
3. Nerve roots
slowly. Strike the muscle lightly over
4. Nerves (cranial or peripheral) thenar eminence or tongue with the
+ If nuclei of cranial nerves are tendon hammer. A dimple of contraction
involved, as in local lesions of brain will appear which will disappear only
stem, there is paralysis of muscles slowly.
supplied by the affected nerves. In myasthenia gravis (a disease of
Manifestations are similar if cranial neuromuscular junction) extraocular
nerves themselves are involved and bulbar muscles are commonly
along their course.
PDFelement
involved. The weakness becomes more hundred; time taken for the last 50 will be
marked after repeated contractions of more than the time taken for the first 50.
muscles. Ask the patient to count till Another test is to ask the patient to look
un: ntosis will develop after sometime.
Hysterical paralysis
Hoover's sign: The patient should lie supine with legs extended. Place a hand
under one heel and ask him to lift the opposite leg against resistance. If the leg
with your hand under its heel is normal, it will be pressed downwards, but if
paralyzed, it will not be pressed. If paralysis is hysterical the leg will be pressed
down more strongly than when patient is asked to press down voluntarily.
Babinski's rising up sign: Patient should lie on the back. Ask him to sit up
without support of his arms. In organic spastic paralysis, paralyzed leg is
flexed at hip and is lifted from the bed while heel of the normal leg is pressed
down. This phenomenon does not occur in hysterical paralysis.
Differential Diagnosis of Motor Neuron Disease, Neuropathy and Myopathy
Features Motor Neuron Disease Neuropathy Myopathy
Wasting + It is marked 4 It is marked 4 It is marked. In

some varieties
there is
pseudohypert
rophy
Muscles 4 All groups of muscles 4 Distal muscles 4 Mainly proximal
involved are involved are involved muscles are
involved
Fascicula- 4 These are 4 These are absent 4 These are absent
tions characteristic of except in aCute
motor neuron disease neuropathy
Sensory 4 It is never present 4 It is almost 4 It is never
loss always present present
Reflexes 4 Diminished in 4 Diminished or 4 These are
progressive muscular absent normal
atrophy and brisk in
amyotrophic lateral
sclerosis
Plan tars 4 Downgoing in 4 Downgoing 4 Downgoing
progressive muscular
atrophy and upgoing
in amyotrophic
lateral sclerosis
PDFelement
Sensory System
Sensations are of two types; primary
and cortical. Primary sensations are
touch, pain, temperature, position,
passive movements and vibrations.
Cortical sensations are localization, two
point discrimination, stereognosis and
graphesthesia.
Primary Sensations
+ Expose the area to be examined.
+ Explain to the patient what you
are going to do and how he should
respond.
+ Apply stimulus to a possible normal
site like sternum so that he can
experience the normal sensation.
+ Compare two sides and ask the
patient whether sensations are equal
on both sides or not.
+ Don't duplicate the tests as repetition
results in loss of patient's cooperation,
and information obtained may be
conflicting and variable.
+ To map the area of abnormal
sensations, at first examine abnormal
area and then move towards normal
area.
4- The sites tested should cover the
territories of, both, peripheral nerves
as well as posterior nerve roots. These
are shown in fig 5.85 and 5.86.
Sensations may be completely lost
(anesthesia), impaired (hypoesthesia)
or heightened (dysesthesia). Sensory
symptoms are described on page 136.
PDFelement
BEDSIDE TECHNIQUES
Touch
Touch the skin with a small point of
cotton wool or a piece of paper (fig 5.87).
(Don't move the touching object over the
skin). In order to standardize quantity
of the stimulus a monofilament is used
nowadays which when pressed against
the skin transmits about 10 gram of
weight. Ask the patient to close his eyes,
and raise his finger, say yes or count
when he feels the touching object. He
should also tell whether sensations are
similar on both sides or different.
Fig 5.87: Testing touch in hand and foot
Pain
Use a disposable pin (or hypodermic
needle if pin is not available) to avoid
Fig 5.86: Sites to be tested posteriorly transmission of infections like hepatitis
PDFelement
B and C. At first, touch the patient with hot (not very hot) water and apply to a
both ends of the pin at a presumably healthy part so that patient experiences
normal site to make him experience the difference. Then apply these tubes
what you mean by 'sharp' and 'blunt'. in a random sequence to the skin of the
Then ask him to close the eyes, touch him part to be tested and ask him to indicate
with sharp and blunt ends of the pin in whether it is hot or cold (fig 5.89).
a random sequence and see whether he
can differentiate between the two or not
(fig 5.88). If patient can feel but cannot
distinguish between sharp and blunt, it
means his sense of touch is intact but
sense of pain is lost.
Deep Pain
Squeeze patient's muscles and tendons
and ask him to indicate when the
pressure becomes painful. You have to
decide whether the force applied could
be painful in a normal person or not.
Sense of Position and Passive
Movements
There are a number of ways of testing
sense of position and passive movements.
1. Ask the patient to close the eyes.
After random movements in
differetection, place patient's limb
in a particular position, making
sure that it does not touch the body,
and ask him to imitate it with the
other limb. If sense of position is
Fig 5.88: Testing pain in hand and foot intact, he will bring the other limb
in exactly the same position.
Temperature 2. At first, show the patient up and
Take two test tubes containing cold and down movements of the great
PDFelement
204 ■Ml
BEDSIDE TECHNIQUES
■M
toe. Then stabilize the proximal 3. Move a part of the body (toe or limb)
phalanx of the great toe by grasping and ask the patient to indicate as
it between thumb and index soon as he recognizes the movement.
finger of your left hand. Grasp the Note the angle through which part
terminal phalanx of the great toe has moved. Normally movement of
less than 10° can be recognized.
on its lateral sides between thumb
and index finger of your right Other features of impaired sense of
hand. It should not be in contact position
with the other toes. Ask the patient 1. Patient may complain of
to close the eyes. Move the terminal unsteadiness during darkness.
phalanx, gently and slowly, up and 2. Ask the patient to outstretch the
down in a random sequence so that arms and close the eyes; there are
patient cannot guess, and ask him to involuntary movements of the
identify the direction of movement. affected arm which disappear on
Repeat the test on contralateral side. opening the eyes.
In upper limb, terminal phalanx 3. Tests of coordination (page 192)
of index finger is used for this deteriorate on closing the eyes and
purpose. This is the most commonly Romberg's sign (page 194) is positive.
employed test (fig 5.90). Sense of Vibration
Take a tuning fork with frequency of
128 cycles per seconds. For setting it into
vibration, either strike it on a rubber pad
or side of your knee. At first, place the
base of vibrating and still tuning fork
on a proximal bony prominence like
forehead so that patient can experience
vibrations. Then ask the patient to
close the eyes, place tuning fork on the
dorsum of the terminal phalanx of a toe,
sometimes vibrating and sometimes still,
and ask him to indicate when vibrations
are felt. If sense of vibration is impaired,
test proximal parts by placing tuning
fork on the lateral malleolus, shin, tibial
tuberosity, iliac crest and costal margins.
In the upper limbs tuning fork is placed
on the terminal phalanx, wrist and
elbow (fig 5.91).
You can also compare patient's response
with your own. Place vibrating tuning
fork on patient's bony prominence.
Soon after he stops feeling vibrations,
place it on your corresponding bony
prominence; if you can still feel the
vibrations, patient's sense of vibration is
impaired.
PDFelement
cortical sensory function make sure that

patient is mentally normal, and speech
and primary sensations are intact.
Before testing for cortical

sensations make sure that
patient is mentally alert, has
normal speech and his primary
sensations are intact.
Sense of Localization
Touch a part of patient's body with his
eyes closed. Then ask him to open the
eyes and place his finger on that part.
Two Point Discrimination
Special calibrated divider is used for this
purpose. Open the divider and touch the
patient with one or both points; ask the
patient at how many sites he is being
touched. Change the width to determine
minimum distance at which patient can
identify two points as separate stimuli.
Normally it varies from 2 mm (on the
pulp of fingers) to 100 mm (in the legs).
Fig 5.91: Testing sense of vibration in hand and foot
If this distance is more than 5 mm on the
pulp of fingers, it is abnormal (fig 5.92).
Barber's chair sign
Ask the patient to touch the
chest with his chin rapidly. If
patient feels electric shock like
sensations radiating down the
arm, along the spine or down the
legs, sign is positive. This is seen
in lesions of the mid-cervical
region of the spinal cord. Causes
include multiple sclerosis, cervical
spondylosis, syringomyelia and B12
deficiency.
Cortical Sensations
When sensory cortex is damaged,
primary sensations remain intact but
there is loss of sense of localization,
two point discrimination, stereognosis
and graphesthesia. Perceptual rivalry
Fig 5.92: Testing two point discrimination
is another feature. Before testing for
PDFelement
Stereognosis 2. Sensory root

Ask the patient to close the eyes. Give him 3. Spinal cord
a suitable object like coin, key or pencil 4. Brain stem
and ask him to identify it after careful 5. Thalamus
palpation. A normal person can do so by
appreciating the size, shape and texture 6. Internal capsule
of the object. It is called stereognosis. 7. Sensory cortex
This ability is lost in sensory cortex Peripheral Nerves
lesion and is called astereognosis.
Sensory loss due to disease of peripheral
Graphesthesia nerves is of two types:
Draw a number on patient's palm with a 4 If a single nerve is involved, sensory
blunt object while his eyes are closed’. A loss is in the distribution of that
normal person can recognize it but this nerve, eg, if ulnar nerve is damaged
ability is lost in sensory cortex lesion. there is sensory loss over the
medial one and a half fingers, both,
Perceptual Rivalry anteriorly and posteriorly.
Patient's eyes closed, touch corresponding 4 If there is peripheral neuropathy,
parts of the body on both sides the sensory loss is over the distal
separately. If patient can appreciate,
parts of limbs, in glove and stocking
touch both sides simultaneously. In
distribution.
sensory cortex lesion, patient will feel on
only one side and the side opposite that Sensory Root
of parietal lobe damage will be ignored. Sensory loss is in the distribution of the
This is also called sensory extinction or
affected dermatome.
sensory inattention. It is usually found
alongwith visual inattention (page 155). Spinal Cord
When spinothalamic tract is involved,
Agnosia there is loss of sense of pain and
temperature below the level of the lesion
It means inability to recognize
on the contralateral side of the body.
familiar objects.
If posterior column is involved, there is loss
Visual agnosia: It means
of sense of position and vibration below
inability to recognize known
the level of the lesion on the same side.
objects while vision is normal.
Dissociated anesthesia: Some
Tactile agnosia: It means
modalities are affected while others are
inability to recognize objects by
intact. Usually pain and temperature are
palpation with both hands. It is
lost and touch, position and vibration
bilateral astereognosis. Lesion is in
are intact. This occurs in syringomyelia.
the parietal lobe.
Brain Stem
4 In lower brain stem lesion, there is
Localization of Sensory Lesion loss of pain and temperature on the
The sensory loss could be due to lesion of: same side of the face and opposite side
1. Peripheral nerves of the body (alternating analgesia).
PDFelement
CH 5 NERVOUS SYSTEM
+ If lesion is above the pons, there is Sensory loss is over the lateral two
hemianesthesia of the opposite side. and a half fingers and thumb, and
corresponding part of the palm
Thalamus anteriorly. Posteriorly it extends over
+ In thalamic lesion, touch is lost and the distal phalanges of the same fingers
there is unpleasant pain on. -the (fig 5.94).
contralateral side. Threshold of the
pain is increased, but when it occurs
it is severe.
Internal Capsule/ Sensory Cortex
There is loss of cortical sensations. Touch,
pain and temperature are intact.
Manifestations of peripheral
nerve lesions
Nerves of upper limb are commonly
involved and manifestations of their
lesions are given below.
Radial nerve
There is weakness of the extensors of the Ulnar nerve
wrist resulting in wrist drop. There is paralysis of small muscles of
Sensory loss is limited to a part of the the hand; patient develops claw hand
dorsum of the hand due to overlap from deformity - there is extension of the
other nerves (fig 5.93). proximal phalanges, flexion of the
distal phalanges and slight separation of
fingers.
Sensory loss is over the medial one
and a half fingers and corresponding
parts of the hand, both, anteriorly and
posteriorly (fig 5.95).
Fig 5.93: Area of sensory loss in lesion of radial

nerve
Median nerve
There is wasting of the thenar eminence
and weakness of the abductor pollicis
brevis and opponens pollicis.
PDFelement
Cerebellar Signs antagonists doesn't occur and patient

Cerebellum consists of midline vermis hits himself. This is called rebound
and lateral cerebellar hemispheres. The phenomenon. (The direction of pull of
vermis is important in the maintenance the forearm should not be towards the
of body posture and equilibrium. The patient's face.)
cerebellar hemispheres are important Pendular Knee Jerk
in smoothing and synchronizing the
timing of muscle contraction and Ask the patient to sit at the edge of the
relaxation when the limbs are moved. bed, legs swinging freely off the ground.
Elicit knee jerk. Normally leg moves
Following are the signs of cerebellar only once or twice and then settles to
dysfunction. its original position. But in cerebellar
1. Nystagmus dysfunction it oscillates several times
2. Scanning speech before settling. This is called pendular
3. Intention tremors knee jerk.
4. Incoordination Hypotonia
5. Dysdiadochokinesia Tone is decreased.
6. Rebound phenomenon
Ataxia
7. Pendular knee jerk
Ask the patient, at first, to stand with
8. Hypotonia
feet close together and eyes opened, and
9. Ataxia then, to walk on a straight line; he will
10. Drunken gait be unsteady and will tend to fall towards
the side of lesion.
Nystagmus (page 163)
Drunken Gait
Scanning Speech (page 146)
Patient walks on a broad base as if drunk.
Intention Tremors (page 195)
Interpretation
Incoordination (page 192) Lesion of the vermis: there is truncal
and gait ataxia. Gait is broad based and
Dysdiadochokinesia patient may fall when attempting
Patient is unable to perform rapidly tandem walking (page 193). If the patient
alternating movements. To test for it, is only examined in bed such sign will
ask the patient to flex the elbows at right be missed.
angle and supinate and pronate forearms Lesion of the cerebellar hemispheres:
rapidly or slap back of each hand with Finger nose test, finger to finger test
the other hand alternately and rapidly;
and heel knee test are abnormal. There
movements will be slow and clumsy.
is nystagmus towards the side of lesion.
Rebound Phenomenon Intention tremors are present and there
Ask the patient to flex the forearm is dysdiadochokinesia.
and pull it towards himself while you Miscellaneous Tests
resist. Release the resistance suddenly.
Normally antagonists (triceps in this Signs of Meningeal Irritation
situation) contract immediately and
patient is saved from hitting himself. But
These signs become positive when
in cerebellar dysfunction contraction of there is root irritation as a result of
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CH 5 NERVOUS SYSTEM
inflammation of the meninges or blood

in the subarachnoid space. Patient feels
pain and stiffness in the concerned
muscles when these roots are stretched.
Signs are:
1. Neck rigidity
2. Kernig's sign
3. Brudzinski's sign
Neck rigidity: Flex the neck so that
chin touches the chest. Normally it is
possible but if meningeal irritation is
present, neck becomes stiff and rigid;
flexion is not possible and causes pain
(fig 5.96). Fig 5.97: Looking for Kernig’s sign
Fig 5.98: Looking for Brudzinski’s sign
Fig 5.96: Checking neck rigidity Causes

1. Meningitis
Kernig's sign: Patient should be lying 2. Subarachnoid hemorrhage
flat with legs fully extended. At first,
3. Meningism (page 237)
flex the leg to be tested at the hip and
knee. Then keep the hip flexed and Signs of Root Irritation
extend the knee. If patient feels pain Irritation of sciatic nerve roots occurs due
in the hamstring muscles (and there is to slipped lumbosacral intervertebral
spasm of these muscles), Kernig's sign is discs resulting in pain starting from
positive (fig 5.97). back radiating along back of the leg (it
Brudzinski's sign: Patient should lie
is called sciatica). Root irritation can be
detected by Straight Leg Raising (SLR)
supine. Flex the neck; if both knees test. Ask the patient to lie flat. Flex the
become flexed, sign is positive. Another leg at the hip, keeping the knee fully
method is to flex one leg at the hip extended. Normally hip can be flexed to
and knee; if other leg becomes flexed 90°. If patient feels pain in the hamstring
automatically, sign is positive (fig 5.98). muscles before the leg is flexed to 90°,
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root irritation is present and straight leg Auscultation of Neck and Cranium
raising test is positive. Note the angle to Neck and skull should be auscultated for
which leg can be flexed without pain bruit (page 64) as a part of assessment
(fig 5.99 A). of nervous system as well because
Sometimes limitation of flexion may be vascular disease is an important cause
due to disease of the hip joint. In order of brain dysfunction. Carotid artery
to differentiate it from root irritation, bifurcation is the most common site
first achieve the limit of leg flexion, and for stenosis and its bruit is heard at the
then dorsiflex the ankle: if patient feels angle of jaw. Bruit due to vertebral or
pain in the back of the thigh, he has root subclavian artery stenosis is best heard
irritation, not the disease of the hip joint at the supraclavicular fossa. Bruit due
(fig 5.99B). to common carotid artery stenosis is
heard along the anterior border of
sternomastoid. Absence of bruit doesn't
exclude a significant stenotic lesion. If
one common carotid artery is completely
occluded, bruit may be audible on the
opposite side due to increased flow of
blood. For differential diagnosis of bruit
in the neck see page 64.
Bruit due to cerebral AV malformation
is best heard by placing bell over gently
closed eyelid because orbits acts as an
acoustic window; it may also be heard
Fig 5.99: Straight leg raising test: (A) leg movement over the cranium.
limited by tension of root over prolapsed disc (B)
Tetany
tension further increased by dorsiflexion of foot
When serum ionized calcium falls -
Differential diagnosis of L5 and Si which may be due to hypocalcemia
root lesions per se or alkalosis - the excitability
of the nerves increases and patient
develops carpopedal spasm: there is
L5 si opposition of the thumb, extension of
+ Dorsiflexion + Plantarflexion the interphalangeal and flexion of the
is weak is weak metacarpophalangeal joints; toes may be
similarly affected.
+ Patient has 4- Patient has
difficulty in difficulty in
Tetany may be latent and spasm may
not be present when patient comes to
walking on walking on the the doctor. Following signs are helpful
the heel toes in this situation.
+ Ankle jerk is + Ankle jerk is Trousseau’s sign
normal diminished or
Apply the sphygmomanometer cuff to
absent
the arm and inflate it to a level above the
+ Sensory loss + Sensory loss systolic pressure. In latent tetany carpal
is in the L5 is in the SI spasm occurs within 4 minutes.
dermatome dermatome Chvostek’s sign
(page 141) (page 141) Tap the facial nerve 3 - 5 cm in front
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and below the ear. If there are brief pressure again after 1 and 3 minutes.
contractions of facial muscles, sign is Normally blood pressure doesn't fall
more than 10 mmHg. If fall is more
than 20 mmHg, it is called postural
hypotension, and this is a feature of
autonomic dysfunction.
6. Ask the patient to perform Valsalva
maneuver (forcible exhalation
effort against a closed glottis).
Normally pulse rate falls but not in
autonomic dysfunction.
Summary of Examination of
the Nervous System
Higher mental function
4 Note appearance and behavior,
evidence of delusions or
hallucinations
4 Assess orientation in time and place,
Examination of Autonomic Nervous
and conscious level
System
+ Evaluate memory and general
Diabetes mellitus is the most common intelligence
cause of autonomic dysfunction in 4 Check for released reflexes if there is
daily practice. Patient may complain of any evidence of brain damage
dizziness on sudden change of posture,
dry skin, nocturnal diarrhea and Speech
impotence. 4 Listen to the spontaneous speech
Following are the simple bedside tests attentively
for checking the autonomic nervous + Test articulation
system.
4 If there is a disturbance of speech,
1. Check light reflex and decide whether it is dysphasia,
accommodation reflex (page 159).
dysarthria or dysphonia
2. Check the skin for sweating; lack of
+ Determine the level of the lesion in
sweating is a feature of autonomic
the nervous system responsible for
dysfunction.
the speech disorder
3. Check the pulse rate; resting
tachycardia is a feature of Cranial nerves
autonomic dysfunction. Sense of smell and taste, color vision,
4. Ask the patient to take deep visual fields by perimetry, positional
inspiration and check the pulse rate. nystagmus and gag reflex are usually
Normally there is a rise in the pulse not tested except when there is strong
rate with deep inspiration. This is suspicion of involvement of concerned
absent in autonomic dysfunction. nerves. For example:
5. Ask the patient to lie quietly on the 4 Sense of smell is tested when disease
couch and check the blood pressure of anterior cranial fossa is suspected.
after about 15 minutes. Then ask 4 Color vision is tested in individuals
him to stand and check the blood engaged in professions in which color
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differentiation is vital, eg, train drivers. to be the cause of the facial nerve
+ Perimetry for visual fields is done, palsy.
either to confirm a defect detected + Positional nystagmus is tested when
by the confrontation method or lesion of the vestibular nerve is
if suspected defect is difficult to suspected.
detect by confrontation method, eg,
constriction of visual field. + Gag reflex is tested when lower
+ Sense of taste is tested when disease cranial nerves are involved.
of the middle ear cavity is suspected Tests for cranial nerves are given below.
I Sense of smell in each nostril separately
II Visual acuity (near and far vision)
Color vision
Visual fields
Fundus
III Size of palpebral fissure (ptosis)
Pupil (size, shape, light reflex - direct and consensual - accommodation
reflex)
Eye movements
IV Downwards movement of the eye when it is adducted
VI Lateral movement of the eye
V Sensory-
Sensations over the face and cranium
Conjunctival and corneal reflex
Motor
Clenching of teeth while you feel masseter and temporalis
Movements of the jaw - side to side and downwards - against resistance
Jaw jerk
VII Motor
Wrinkling of the forehead
Closure of the eyelid
Nasolabial folds
Inflation of the cheek
Showing the teeth to detect deviation of the angle of the mouth
Whistling
Hearing (hyperacusis)
Taste of anterior two thirds of the tongue
VIII Hearing
Whisper and watch test
Tuning fork tests
Audiometery
Vestibular function
Positional nystagmus
IX Gag and palatal reflex (taste and sensations of posterior one third of the
tongue are difficult to test)
X Movements of the soft palate, posterior pharyngeal wall, vocal cords
phonation
XI Position of the scapula; shrugging of the shoulder
Movements of the head, laterally and downwards
XII Shape of the tongue, fasciculations
Movements of the tongue
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Motor system the parts indicated by the patient as site

Examine the following and compare of abnormal sensations and outline the
two sides. areas with abnormal sensations.
Bulk and nutrition of muscles: Look Primary Sensations: Test for:
for wasting or hypertrophy. Touch using cotton wool or a piece of
Tone of muscles: Perform passive paper (don't move the touching object
movements at major joints and assess over the skin)
whether tone is normal, increased or Pain using a disposable pin or needle
decreased. Temperature using test tubes
Power of muscles: Routinely, test containing cold and hot water
movements of the major joints only. . Deep pain by squeezing the muscles
Upper limb: Hand grip, flexion and and tendons
extension of wrist, flexion and extension Sense of position and passive
of elbow, abduction, adduction, flexion movements by moving the big toe
and extension of shoulder. passively
Lower h’mfo:Plantar and dorsiflexion of Sense of vibration by using a tuning
toes and ankle, flexion and extension of fork
knee, abduction, adduction, flexion and Cortical Sensations: Test for:
extension of hip.
Localization, two point discrimination,
Reflexes: Test ankle jerk, knee jerk, stereognosis, graphesthesia and
biceps jerk, triceps jerk, brachioradialis perceptual rivalry
jerk, plantar reflex, abdominal reflexes
and, if necessary, cremasteric reflex. Test Cerebellar signs
for ankle and patellar clonus if reflexes Look for following signs:
are brisk.
4 Nystagmus (note type and direction)
Coordination of movements: In the
+ Scanning speech
upper limb perform finger nose test and
finger to finger test; in the lower limb 4 Intention tremors
carry out heel knee test. 4 Incoordination
Involuntary movements: If present, 4 Dysdiadochokinesia
note the type of involuntary movements 4 Rebound phenomenon
and part of the body involved. 4 Pendular knee jerk
Gait: Ask the patient to walk and note 4 Hypotonia
type of gait.
4 Ataxia (Romberg's sign to
Sensory system differentiate between sensory and
Cortical sensory functions are not tested cerebellar ataxia)
in a routine sensory examination, but 4 Drunken gait
they must be tested when situation
demand their performance. Test over the Miscellaneous tests
sites so that all the dermatomes and areas These tests should be performed if
supplied by the important cutaneous history suggests possibility of relevant
nerves are covered. But concentrate on disturbance.
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Signs of meningeal irritation: Neck and watch test. Positional nystagmus is

rigidity, Kernig's sign, Brudzinski's sign absent.
Signs of root irritation: Straight Leg X: Movements of the soft palate, posterior
Raising (SLR) test pharyngeal wall and vocal cords are
Signs of latent tetany: Trousseau's and normal. Phonation is normal.
Chvostek's sign XI: Shrugging of the shoulder and
movements of the head, laterally and
Examination of autonomic
downwards are normal.
nervous system
XII: Shape of the tongue is normal.
Look for following:
Fasciculations are absent. Movements of
Light and accommodation reflex
the tongue are normal.
Skin for sweating
Pulse rate; affect of respiration and Motor system
Valsalva maneuver on pulse rate Bulk and nutrition of muscles are
Postural hypotension normal. Tone of muscles is normal.
Power in all the groups of muscles in
Writing out Routine Examination upper and lower limbs is normal. Deep
and superficial reflexes are intact.
Higher mental function Coordination of movements is intact.
Patient is fully conscious; well orientated Involuntary movements are absent. Gait
in time and place. Behavior is normal. is normal.
There are no delusions or hallucinations.
Memory is good and general intelligence Sensory system
is normal. Touch, pain, temperature, position,
Speech is normal passive movements, and vibration are
intact.
Cranial nerves
II: Visual acuity, visual fields and fundus Cerebellar signs: Nystagmus is absent.
are normal. Speech is normal. There are no tremors.
Ill, IV, VI: There is no ptosis. Pupils
Coordination is intact. Repetitive
are normal in size and shape. Light and movements are normal. Gait is normal.
accommodation reflexes are present. Eye Signs of meningeal irritation are
movements are normal. absent.
V: Sensations on the face and head are There is no postural drop in blood
intact. Conjunctival and corneal reflexes pressure
are present. Masseter, temporalis and
pterygoids are normal. Jaw jerk is absent. LUMBAR PUNCTURE
VII: Wrinkling of the forehead, closure A needle is introduced into the
of the eyelids, nasolabial folds and subarachnoid space between L3 and L4
inflation of thetheeks are normal. Angle vertebrae, usually to obtain a sample
of the mouth is not deviated. Patient can of CSF for diagnostic purpose. This
whistle. There is no hyperacusis. procedure must be learned by every
VIII: Hearing is normal by whisper doctor.
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MM*
Indications 3. Hypotension
Lumbar puncture is performed, both, for 4. Bleeding/clotting disorders
diagnosis and treatment.
Complications
Diagnostic 1. Introduction of infection
1. Signs of meningeal irritation with 2. Transtentorial or tonsillar
or without fever (meningitis, herniation
subarachnoid hemorrhage)
3. Low pressure headache
2. Fever with disturbed consciousness
3. Unexplained coma
4. Suspected: Difference between traumatic
lumbar puncture and
a. Guillain Barre syndrome
subarachnoid hemorrhage.
b. Acoustic neuroma
1. If CSF is hemorrhagic, collect
c. Multiple sclerosis it in three separate vials. In
d. Nervous system involvement in subarachnoid hemorrhage
lymphomas, leukemias the color of the CSF will be
e. Transverse myelitis the same in all the three vials
5. Myelography while in traumatic lumbar
puncture CSF will be clearer
Therapeutic in the third vial compared
1. Spinal anesthesia with the first vial.
2. Intrathecal methotrexate in acute 2. Centrifuge the CSF. If color
lymphoblastic leukemia of the supernatant is yellow
compared with that of water,
Contraindications it is called xanthochromia**
1. Papilledema** which is a feature of
2. Local sepsis (another site can be subarachnoid hemorrhage.
used)
* * If meningitis is strongly suspected, lumbar

puncture must be done even in the presence of
papilledema with following precautions (cisternal
puncture should be preferred if an experienced
person is available):
1. Alert the neurosurgical team in case patient
develops brain herniation.
2. Rapidly infuse mannitol (200 nil of 20%) to lower
the intracranial pressure.
3. Raise the foot end.
4. Use a thin bore needle. Don't remove the stylet
completely so that CSF comes out in drops rather
than jet. Remove only minimum quantity of CSF
necessary for diagnostic purpose.
5. Repeat mannitol infusion.
6. Keep the patient in lateral position with foot end ** ** ** Yellow discoloration occurs du
elevated for 4-6 hours. to breakdown products of hemoglobin.
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Chapter ■■H
g I PEDIATRIC CLINICAL
EXAMINATION
Pediatrics is the doctoring of children. It other family members may help to
is a specialty bound by age and not by complete it. If child is not accompanied
system. (Although thre are paediatric by one of the adult family members
sub specialities with experise in different looking after him, one of them should
body systems) The dividing line be requested to come. History obtained
between children and adults is usually from relatives not looking after the
at 15 years of age. In Pakistan Pediatric child may not be reliable.
units usually deal with patients less Supplementary questions are often
than 12 years of age. needed during history taking. Terms
Pediatric age group is further divided used by the relatives may also need to be
into various subgroups: further elaborated. Many a times parents
Neonatal period First month of life volunteer their own interpretation of
child's symptom which may not be true,
Infancy First year of life
eg, mother often attributes undue crying
Pre school child 1-5 years of the baby to abdominal pain while
School child 5-15 years actual problem may be somewhere else.
Adolescent 12-18 years The older children may give an accurate
and detailed account of their illness
Children less than 15 years and should be encouraged to tell their
constitute 45% of total symptoms.
population in our country. In The pattern of writing the history is
this chapter child less than the same as in adults with additional
three years of age is reffered as information about birth, feeding,
"young Child". development and immunization.
HISTORY PRESENTING COMPLAINTS/

The pediatric diagnosis relies mainly CHIEF COMPLAINTS
on a well-taken history and thorough A list of main complaints of the child
physical examination. should be made in the chronological
Mothers are very good observers, obtain order of appearance. Include all
the history from them wherever possible; complaints whether they have been
216
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CH 6 PEDIATRIC CLINICAL EXAMINATION
volunteered by the parents or or became symptom of disease in childhood and

apparent on your questioning. infections - localized or generalized -
are the most common cause. Ask about
HISTORY OF PRESENT ILLNESS duration of fever, intensity (low or high
Ask details of all the symptoms listed grade), pattern, and any other associated
under presenting complaints, one by symptoms. In a child with no localizing
one. features of infection malaria, UTI and
enteric fever are the likely possibilities.
For the present illness of your patient,
Do not forget to examine the throat of a
record the details of treatment given
febrile child.
till then including the doses of drugs
which may be inadequate. Inquire about Feeding
traditional treatment and treatment Ask about any change in milk intake (in
taken from alternate medicine case of young child) or food and water
practitioners (Homeopaths, Hakims). intake (in case of older child) since
A worried anxious mother may forget or illness started. Infants have difficulty in
ignore a symptom or detail of it: to avoid feeding if their nose is blocked or mouth
missing significant information about is sore. Refusal to feed is an important
the child's illness, ask questions about all symptom in children and indicates the
the important symptoms in the form of severity of illness. Inability to feed or
systemic inquiry, after the mother has drink anything may be due to severe
finished her narration. respiratory distress, persistent vomiting
or unconsciousness.
Symptomatology
Main symptoms of diseases in children Vomiting
are discussed below (see adult section It is very common in sick children.
for the description of symptoms in older Vomiting and diarrhea together - due
children). to gastrointestinal infections - are one of
Remember in a young child common the most common pediatric problems in
symptoms like crying, poor feeding, third world countries. Vomiting is often
lethargy, vomiting, fever may be due to associated with sore throat fever or
many different illnesses. cough. Persistent vomiting accompanied
by distension of abdomen suggests
Symptoms of serious illness intestinal obstruction or paralytic ileus.
The following are considered indicators Ask about following details:
of a serious illness (or signs of danger) in 4 Frequency and force of vomiting.
children.
4 Relationship of vomiting’ with
+ Inability to feed or drink feeding.
+ Vomiting everything 4 Color and contents of vomitus.
4- Lethargy or unconsciousness Remember that effortless regurgitation
4 Convulsions of milk is common in normal newborns
and infants, and should not be confused
Fever with true vomiting.
Fever is perhaps the most common
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Bowel Habits 4 Is it worse at a particular time of

Normal bowel habits of an infant may the day (late night or early morning
vary from 5 or 6 times a day to once in a cough may be due to asthma)?
couple of days. Breastfed babies usually 4 Is there any relation with feeding
pass stool after every feed (gastrocolic (cough during feeding may indicate
reflex). inflamed throat or incompetent
Diarrhea is very common in infancy. swallowing)?
Often there is associated vomiting 4 Is it accompanied by wheeze or
or fever. In Pakistan, infections of fever?
gastrointestinal tract are the most Difficult Breathing (Respiratory
common cause of diarrhea. Other Distress)
common causes include infection
Difficult breathing may be acute ( of
anywhere else in the body, inappropriate
recent onset), or recurrent over a period
feeding, drugs etc. Ask questions about:
of time. Sometimes it may be chronic
4 Duration of diarrhea. and persistent.
4 Frequency, quantity, consistency, Pneumonia, asthma and heart disease
color, odour and contents of stools, (congenital or rheumatic) - are the
particularly the presence of any important causes of respiratory distress
blood or mucus in the stools. in children. Ask about:
Crying 4 Age of onset.
Infants cry when they are hungry, 4 Duration.
thirsty, wet, warm, cold or lonely. 4 Relation with activity.
(Mothers usually can recognise these 4 Relation with feeding in young
physiological cries of their infants). infant.
Crying more than normal and without 4 Presence of cough, stridor, wheeze
any obvious reason should be taken as a or cyanosis.
symptoms of disease. On the other hand,
a severely ill infant may be too weak to Rashes
cry. Skin rashes are frequent in children.
Common causes of generalized rashes
Cough are exanthematous fevers (eg, measles,
Respiratory tract infections are very chickenpox, rubella). Localized rashes
common in children and cough is an may be due to eczema, scabies, allergy
important presenting symptom. Cough and drugs. Find out:
may be due to common cold, pharyngitis, 4 Duration.
tracheobronchitis or pneumonia.
4 Site and distribution.
Long bouts of cough associated with
a whoop, cyanosis, apnea or vomiting 4 Type (macular, papular, vesicular,
may indicate whooping cough. Ask the pustular, purpuric).
following questions about cough: 4 Presence of itching.
4 Is it dry or wet (children usually 4 Purpuric rashes are due to bleeding
swallow the sputum)? disorders eg, thrombocytopenia.
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CH 6 PEDIATRIC CLINICAL EXAMINATION 219
Cyanosis the duration and specific problems with:

It is bluish discoloration of skin and + Neck holding and sitting.
mucous membrane due to excess of 4 Standing and walking.
reduced hemoglobin (page 26). In
4 Usual body movements.
children it is, either due to congenital
cyanotic heart disease or a severe Involuntary Movements
respiratory disease. Ask about: Get full description of involuntary
+ Age of onset. movements from parents or patient if he
+ Duration. is old enough. Obtain information about:
4 Episodic or persistent. + Age of onset.
4 Associated symptoms (eg, respiratory 4 Duration.
distress). 4 Any relation with febrile illness.
Jaundice 4 Progress since onset.
In older children viral hepatitis is Convulsions (Fits or Seizures)
the most common cause. Jaundice These can be of recent onset, associated
developing after birth is a different with other symptoms eg fever or can
entity. It occurs in more than 50 percent be recurrent. If doctor himself has not
of newborns. In case of neonatal jaundice
observed the convulsions (or fits), detailed
the time of onset after the birth is
description by an observer is the main
very important. Jaundice developing on
information on which the diagnosis is
the first day after the birth may be due to
based (see page 135). True convulsions
hemolytic disease of the newborn while
should be differentiated from
that appearing on the second or third
day is usually physiological. If jaundice restlessness, jerkiness, hysterical
persists beyond 2nd week of age, consider psychoneurosis, tics, involuntary
the possibility of pro longed p hys io Iogica I movements and breath-holding
jaundice, neonatal hepatitis or biliary spells. Febrile convulsions - associated
obstruction. with high grade fever - are common in
children between six months and five
Lethargy and Unconsciousness years of age; there may be previous
Lethargy is a sign of severity of history of such convulsions in the child
disease, particularly in acute illness. or in the family. Meningitis (pyogenic or
Unconsciousness is usually due to tuberculous) and cerebral malaria are
neurologic or metabolic disorders the two disease which must be suspected
like meningitis, encephalitis, cerebral and excluded in any child with acute
malaria, severe dehydration, renal onset of fits.
failure, hepatic encephalopathy or
hypoglycemia. Hearing
Hearing defects are frequent in children.
Posture and Gait
Ask whether child responds (by turning
Rickets, polio, cerebral palsy, muscular his face) to any voice out of his field of
dystrophies, hemiplegia, paraparesis and vision, and whether he has difficulty in
congenital abnormalities can affect the understanding your commands. Hearing
children's gait and posture. Ask about problem can be congenital or acquired
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(usually due to recurrent/persistent 4 Feeding difficulty in neonatal

middle ear disease). period.
4 Jaundice, cyanosis, fits, fever or any
HISTORY OF BIRTH other symptom during neonatal
It is particularly important in newborn period.
and in children with congenital
anomalies or neurological disorders. It is FEEDING HISTORY
divided into three periods: It is particularly significant in children
less than two years of age; and in those
Antenatal suffering from anemia, malnutrition or
Inquire about health of mother during other nutritional disorders. Find out:
pregnancy; ask about history of:
4 Time between the birth and the first
+ Diabetes mellitus. feed.
4 Hypertension. 4 Type of feeding (breast feeding or
4 Swelling of feet. formula feeding - type of milk).
4 Fits. 4 Frequency of feeding; quantity and
4 Infections (tuberculosis, rubella). dilution of bottle feeds.
4 Drug intake (dose, duration and time 4 Progress in feeding during first
of gestation). months of life.
4 X-rays. 4 Age at which solids were started and
their nature, amount and frequency.
Natal 4 Current feeding practices before
Ask about: present illness.
4 Duration of gestation. 4 Any change in food intake during
4 Place of delivery (in the hospital illness.
or at home; carried out by dai, lady
health visitor or doctor). IMMUNIZATION
4 Duration of labor. Check the vaccination card if available;
4 Mode of delivery (spontaneous, otherwise ask about:
assisted, cesarean section). 4 Visit to vaccination center.
4 Complications during delivery. 4 Type of vaccination.
Newborn (Postnatal) 4 When and given by whom.

4 Complete or incomplete.
Information should be obtained about:
4 First cry - immediate or delayed. 4 Boosters.
4 Time of onset of respiration after

delivery (delay of 5 minutes or DEVELOPMENTAL HISTORY
more indicates birth asphyxia); any Mother should be asked when did the
resuscitation given. child first:
4 Birth weight. 4 Smile?
4 Birth injury. 4 Hold his neck?
PDFelement
4 Roll over? SOCIAL HISTORY

4 Start responding to voices? Find out:
4 Sit up with support and without 4 Parent's education and occupation.
support? 4 Family income.
4 Crawl? 4 Persons living in the house.
4 Start to walk with and without
support? PERSONAL HISTORY
4 Talk; single words, sentences? Inquire about:
4 Run? 4 Particular habits of the child.
4 Start feeding with hands? 4 Details of class, school and interest in
4 Indicate toilet needs; became dry by studies.
day/by night? 4 Behavior of the child at school and
relationship with other children.
PAST HISTORY
Details of birth, feeding, development
ENVIRONMENTALHISTORY
and vaccination are also a part of past Inquire about:
history. In addition, inquire about 4 Size of the house and number of
all significant illnesses in the past, occupants.
particularly diarrhea, respiratory 4 Cleanliness and general hygienic
infections, fevers, fits, jaundice etc. conditions.
FAMILY HISTORY 4 Source of drinking water.
Ask about the following: EXAMINATION

4 Age of mother and father. Before examining the abnormal, it is
4 Parent's health (present and past). important to know the limits of the
4 Siblings: normal. For this purpose students are
• Age and sex. advised to examine a large number of
normal children of different ages. Such
• Illnesses. normal children can be found among
• Any death (cause if known their own relatives, in their neighborhood
or symptoms of illness before and in out-patient vaccination clinics.
death). Examination of children demands
• Stillbirths, miscarriages. patience and a friendly and caring
4 Grand parent's health (particularly attitude. Unfortunately, the deplorable
if living with the family). practice of giving unnecessary injections
4 If an inherited disorder is suspected, to the children has created in them fear
obtain information about health of of doctor's clinics. So be patient, and try
uncles, aunts and their children. to remove child's fear by talking to his
parents softly and by offering the child
4 Consanguinity (blood realtion
toys suitable for his age.
between parents): cousin marriage,
second cousin marriage. Children, generally, don't like their
PDFelement
clothes to be removed; so exposure should

MEASUREMENTS
be limited to minimum necessary. Measure weight, height and head
Posture of examination varies with age. circumference routinely during
Children between the ages of six months general examination of child and
compare with standard values for
and three years are better examined .on his age. Charts giving standard
the mother's lap because they are too values for these measurements
afraid to leave her. Those below this age at all ages are available and can
can be examined on the couch and those be used, but you should try to
above this age can be examined while remember important milestones
sitting or standing. Older children can of growth. Upto 7 years of age,
there is little difference between
be requested to lie on the couch if they both sexes.
agree. WEIGHT
Observation (inspection) constitutes the It is an important parameter of
growth and should be measured
most important method of examination regularly. Below 5 years of age
in children. It should start during history weight for age is a very good
taking and should be supplemented screening test for nutritional
by few minutes of keen observation status. Regular growth monitoring
just before actually touching the child. of children below 5 years of age
The principle in the technique of - by measuring their weight
and plotting on a growth chart
examination of children is STOP-LOOK...
- is recommended by WHO and
TOUCH. Small children do not like to be endorsed by the Government
examined for more than a few minutes, of Pakistan as a measure for
consequently the clinical examination early detection of faltering of
needs to be quick and thorough. Sequence growth and nutrition. Standard
of examination should be regional growth charts are available at
all Government health centers.
rather than systemic. You should be
Sometimes weight for height is
ready to change your routine and used to detect current (acute)
order of examination according to the malnutrition which is also called
circumstances and child's response. In wasting.
small children, it is useful to auscultate LENGTH OR HEIGHT
heart and lung - which needs a quiet child It is another parameter of growth.
It is measured as crown-heel
- before palpation or touching which
length in children less than two
may irritate the child. Frightening and years and as standing height in
painful procedures like examining the older children. Decreased height
throat should be postponed till the end. for age is called stunting. It is an
indicator of chronic or prolonged
Summary of examination is given below malnutrition in children below
while details have been discussed in the age of 5 years. Causes of
previous sections. Those aspects which inability to attain adequate height
are peculiar to the pediatric age group in older children include chronic
are given in boxes. diseases and endocrine disorders.
PDFelement
While considering adequacy General Physical Examination

of height in any child, height The General Physical Examination
of parents should also be taken (GPE) in children includes:
into account. Height velocity is
increase in height per year. It is 4 Observation (inspection)
maximum in first three years and'
increases again at puberty. + Palpation
HEAD SIZE
4 Recording vital signs - pulse, blood
Abnormal head size usually
indicates some disease of brain. pressure, respiratory rate and
Occipito-frontal circumference of temperature
the head is measured by placing
4 Measuring height, weight and head
a tape measure around the head
covering the occipital prominence circumference.
and above the eye brows, and Sequence of examination should be from
is compared with standard
tables of head circumference -at head to toe, but painful examination,
different ages. Small head size like throat and ear examination, should
(microcephaly) may be due to be left to the end.
inadequate brain growth (mostly
associated with mental handicap) General Appearance
while large size is usually due to (Observation)
hydrocephalus (fig 6.1).
TEMPERATURE Note the following:
In infants and children usually
temperature is taken by placing 4 Apparent age.
a thermometer in axilla for two
4 Built of the child.
minutes reading approximates
core/oral temperature of the body. + Degree of illness - mild, moderate or
There is no need to add anything severe.
to this reading.
4 Conscious level.
+ Posture.
FORMULA FOR EXPECTED
WEIGHT (Kg) 4 Nutritional status - normal, obese or
Birth = 3.2 undernourished
3-12 months = age in months +9
2 4 State of hydration.
1- 6 years = (age in years X 2) + 8 4 Behavior.
7-12 years = (age in years X 7) - 5
2 Dehydration is indicated by
FORMULA FOR AVERAGE presence of sunken eyes, dry
HEIGHT (cm) mucous membrane, sunken
Birth 150
fontanel, loss of skin turgor
1 year = 75
and rapid low volume pulse.
2- 12 years = age in years X 6 + 77
PDFelement
MMCS
Malnutrition in children Microcephaly (small head)

is manifested by weight loss,
thinness, thin shiny skin, loose skin indicates poor brain growth. It
folds, atrophy of subcutaneous is a sequalae of birth asphyxia,
fat, wasting of muscles, dull congenital (in utero) viral
hair, brittle nails, prominent - infections and chromosomal
bones, protuberant abdomen, flat
buttocks and hypotonia. disorders like Down's
Marasmus is severe wasting with syndrome.
loss of subcutaneous fat. Macrocephaly (large
Kawashiorkor is characterized
head) usually indicates
by the presence of edema with
hair changes and skin dermatosis. hydrocephalus.
Anterior fontanel usually
Skin closes by 12 months. Delayed
Look for:
+ Pallor, cyanosis, jaundice. closure occurs in rickets
+ Dehydration. and hydrocephalus. Raised
+ Edema. and tense fontanel indicates
+ Rash distribution; type(macular, meningitis, intracranial
papular, vesicular, pustular, scaly,
lichenified etc). hemorrhage or hydrocephalus
+ Purpuric spots. while depressed fontanel is
+ Scratch marks. seen in dehydration (fig 6.2).
+ Pigmentation (hypo or hyper).
Sutures of the skull are
separated during neonatal
Fever with rash, called period and are closed by 6
exanthematous fevers (eg, months of age. They may
measles, rubella, chickenpox) remain separated in raised
are common in children. intracranial pressure. Early
Pattern of rash is characteristic closure of sutures may occur
in each condition and a spot due to premature synostosis of
diagnosis can be made. skull bones (fig 6.2).
Pustules on palm and sole, groin Bossing of forehead is seen
or lower back are suggestive of in hemolytic anemias like
infected scabies. thalassemias or in rickets.
Cranium Lice are common in hair of
Note: children and their nits (eggs)
+ Head: size, shape, circumference, can be seen adherent to hair
bossing of forehead.
+ Fontanels: size, bulging or sunken, shafts. Fungal infection (tinea
closure (normal, early or late). capitis) causes local patchy loss
+ Sutures: separated or closed. of scalp hair with broken hair
4- Distribution of scalp hair. shafts.
4 Bruit.
PDFelement
joining outer angle of the eye to the

external occipital protuberance).
+ Auditory canal for inflammation.
+ Tympanic membrane for
congestion, perforation.
+ Mastoid for swelling and tenderness.
Ear infections are common and otoscopic
examination should be carried out if
suspected. Position of the child during
ear examination is shown in fig 6.3.
In infants pinna is pulled backward
and downward and in old children
it is pulled backward and upward to
Fig 6.1: Measuring head size
align the cartilaginous part of external
auditory canal with its bony part.
Fig 6.2: Sutures and fontenels
Ears
Like other painful procedures, leave this
examination to the end. Examine:
+ Pinna for deformities, low set ears
(it means ears are below the line Fig 6.3: Position of the child for examination of ear
PDFelement
BEDSIDE TECHNIQUES
Face Common Dysmorphic Features

Look for:
Skull abnormalities
4- Symmetry of the face.
- Slanting eyes, hypertelorism,
+ Movements of the face during (increased distance between
crying of the child. eyes)
+ Abnormal facial characteristics, like Depressed bridge of nose
those in mongolism, cretinism. Micrognathia (small chin)
Small chest
If face looks abnormal, compare Umbilical hernia
it with that of parents. - Small fingers, syndactyly,
polydactyly
Some diseases are characterized
by peculiar facial appearance, Simian crease (single
transverse palmer, crease)
eg Down's syndrome
(mongolism), cretinism or - Short stature
gargoylism. Hirsutism (increased hair
growth)
Down's syndrome (Trisomy
21) is the most common
chromosomal disor der.Features Eyes
are upward and outward
Look for:
slanting eyes, epicanthic folds,
+ Puffiness around the eyes.
hypertelorism, depressed
bridge of the nose, open 4- Mongolian slant (upward and
mouth, visible tongue, small outward).
head, single transverse palmar + Hypertelorism (increased distance
crease on hand, hypotonia and between the eyes).
mental retardation. + Epicanthic folds (skin folds covering
Dysmorphic feature is the inner canthus of eyes).
name given to abnormal + Lacrimation, discharge.
appearance of any body part + Exophthalmos, enophthalmos.
when present since birth eg, + Conjunctival pallor, redness, xerosis
slanting eyes, simian crease of (dryness).
hands.
+ Yellowness of sclera.
Syndrome is the name + Corneal opacity.
given to a specific collection
+ Squint.
of dysmorphic features eg,
Edward syndrome. + Cataract.
4- Eye movements, nystagmus.
PDFelement
4 Mucosa: color (cyanosis, pallor),

Watery discharge from ulcers, thrush, Koplik's spots (see
the eyes is common in early below).
infancy, and is due to delayed 4 Teeth: number, position, caries,
canalization of nasolacrimal mottling, discoloration, notching.
duct. 4 Gums: bleeding, swelling.
Eyes are sunken in dehydration 4 Tongue: size (tongue is enlarged in
and malnutrition. cretinism), surface, color (pallor,
Corneal opacities are due to cyanosis).
sequalae of corneal ulceration 4 Cleft palate.
associated with vitamin A
4 Tonsils: size, color, exudate on
deficiency. Congenital cataract
can be idiopathic, familial or
surface.
due to intrauterine rubella.
Purposeless eye movements
with little fixation are
seen in infants with visual
impairment.
Nose
Look for:
4 Shape.
+ Bridge of nose (normal or depressed).
4 Movements of alae nasi indicate
respiratory distress.
+ Patency of the nostrils.
4 Color of nasal mucosa.
4 Nasal discharge.
Mouth
Examination of mouth and throat is
important in all children. A young child
should be held by the mother. Throat
may be visible while he cries, otherwise
spoon or spatula should be used. Position
of a young child for examination of
throat is shown in fig 6.4. Older children
can be requested to open the mouth
widely. Look for:
4 Hare lip (cleft lip).
4 Fissure at the angle of the mouth
Fig 6.4: Position for examination of throat
(cheilosis).
PDFelement
Teeth: Twenty milk teeth Small discrete cervical or

appear between 6 months and 2 inguinal lymph nodes are
years of age. These are replaced common in children. These
by permanent teeth between 6 indicate past infection and are
and 12 years of age. of no consequence.
Thrush: This is patchy Tuberculosis is a common
white coating of tongue and cause of enlarged cervical
buccal mucosa due to Candida glands which are tender and
infection. matted together. Child may
Tonsil: Size varies with have history of exposure
age. Lymphoid tissue shows to tuberculosis and may be
maximum growth around 6-8 debilitated. In long standing
years of age. cases cold abscesses can form
which ulcerate to produce
Koplik's spots: These are
sinuses.
greyish-white spots like grains
of sand with a red margin
opposite the molar teeth. These Spine and Back
are seen in measles one day Look for:
before the generalized skin + Kyphosis, scoliosis, lordosis, gibbus.
rash appears.
+ Spina bifida (usually there is a tuft
Vesicles and ulcers in the of hair or a sinus at that site).
oral cavity of young children
+ Meningocele or meningomyelocele
are commonly due to viral
(a midline sac of produded meninges
infections (measles, herpes
covered by skin or membrane).
simplex) or aphthous ulcers.
+ Tenderness.
Neck
Look for: Gibbus is a local kyphosis
of spine caused by vertebral
+ Webbing of neck (it is seen in
Turner's syndrome). collapse; usual cause is
tuberculosis of spine.
4- Retraction (it indicates meningitis
or tetanus). Thorax and Abdomen
+ Movements of the neck. Look for:
4- Neck rigidity (page 209). 4 General contour.
4 Lymph nodes (page 23).
4 Position of nipples.
4 Thyroid (page 21).
+ Any deformity of thorax.
4 Any other swelling, eg cystic
hygroma. 4 Abdominal protuberance.
+ Neck veins. 4 Umbilicus.

PDFelement
an
CARDIOVASCULAR SYSTEM
Protuberant abdomen is a
normal finding in children Pulse
less than three years of age. 4 Rate, rhythm, volume and character
should be noted. Pulses should be
Hands compared, particularly for radio
Look for: femoral delay.
+ Pallor. 4 In young babies it needs experience
4 Cyanosis. to palpate the pulse, in newborn
4 Clubbing. index finger can be used; in difficult
+ Koilonychia. cases heart rate can be determined
4 Splinter hemorrhages. by auscultation of the precordium.
4 Extra digits (polydactyly). 4 Heart rate varies with the age.
+ Syndactyly (fused fingers). Average normal values are given
below:
4 Simian crease on hands (single
transverse palmar crease). Age Heart rate per min.
Newborn 120 -160
Simian crease of hands is Infants 110 -150
typically seen in Down's
Pre school child 80 -120
syndrome; can be present in
other genetic syndrome or in School child 70 -110
normal persons.
Extremities Easily palpable foot pulses in

Look for: infants indicate wide pulse
4 Lymph nodes: axillary, inguinal. pressure.
4 Legs: deformities like bowleg, Variation in pulse rate with
knock-knee. respiration (sinus arrhythmia)
4 Joints: swelling, redness, is common in children.
movements. Most common causes of
tachycardia in children are
Signs of rickets include fever and anemia.
widening of ends of long bones
(most evident at wrist), rickety
rosary (prominent costochondral Blood Pressure
junctions), bow legs (tibial In children measuring the blood pressure
bowing) and genu valgus (knock should be left to the end of examination
knees). as it is an annoying procedure. Various
sizes of cuffs are used according to the
length of the arm. A blood pressure cuff
Feet
which covers two-thirds of the length of
4 Deformities, eg, club foot (talipes the upper arm should be used. Four cuff
equinovarus). sizes area generally available; newborn
4 Edema feet. = 1.5 inches, infant = 2.5 inches, young
PDFelement
child = 4 inches, older child = adult size. Palpation

In very young babies both palpatory and Palpate the precordium for:
auscultatory methods can be used with 4- Apex beat; site, character.
patience. Flush method is unreliable. 4 Left parasternal heave.
Doppler ultrasound gives the most
4 Palpable sounds.
reliable measurement. Average normal
values are: 4 Thrill.
Age Blood pressure(mmHg) Normal apex beat in young
Newborn 70/40 children is in the 4th intercostal
Infants 80/55 space at midclavicular line.
Preschool child 90/60
Percussion
School child iOQ/yo
Percuss for:
4 Area of cardiac dullness.
Formula for normal blood 4 In routine examination it is usually
pressure in children omitted.
Systolic pressure at 6 years of
Auscultation
Auscultate for:
age is 100 mmHg and rises 2.5
mmHg per year thereafter. 4 Heart sounds: intensity, splitting.
Diastolic pressure is calculated 4 Added sounds: 3rd and 4th heart
by 60 + age in years. sounds, clicks, opening snap.
Hypertension in children 4 Murmurs.
is usually due to secondary 4 Pericardial rub.
causes, most commonly renal
diseases.
Quietness of the child is
essential for auscultation of
Neck Veins the heart. A sleeping child
These are difficult to see in infants but gives an opportune moment
can be examined in older children in the for this purpose. Auscultation
same way as in adults (page 45). should be performed in
the beginning of clinical
Examination of the Precordium examination in young children
Examination of the precordium needs before they are distr ubed.
a quiet child. It consists of inspection,
palpation, percussion and auscultation. Splitting of 2nd heart
sound is usual in children,
Inspection third heart sound can
Inspect the precordium for: normally be present.
4 Bulging. Congenital heart diseases
4 Apex beat. are more common in small
children, rheumatic heart
+ Pulsations.
diseases are seen in children
4 Scar of surgical operations.
PDFelement
+ Expiratory grunting, stridor or

more than 5 years of age. wheeze (bring your ear near the
Clinical features of congestive child).
heart failure in infants are + Type of cough (dry, wet, croupy).
tachycardia, tachypnea, + Intercostal and subcostal retraction.
breathlessness after feeding,--
+ Lower chest wall indrawing.
sweating and hepatomegaly.
Innocent murmurs are Respiratory rate varies with the
heard in many children. These age and average normal values are
are usually mid systolic, soft, as follows:
localized and not associated Age Respiratory rate per min.
with other signs of heart
disease. Flow murmurs are
commonly heard in anemic Average Upper
children. limit
Important signs of two Less than 2 months 40 60
common congenital heart 2-12 months 30 50
diseases are: 1-5 years 25 40
Fallot's tetralogy: cyanosis, 5-10 years 20 30
single S2 and ejection systolic
murmur at pulmonary area
Ventricular septal defect: Lower chest wall indrawing:
pansystolic murmur at left Normally, during inspiratory
lower parasternal border, phase, all parts of chest wall
no cyanosis and abdomen move out. Lower
chest wall indrawing is inwards
movement of lower chest wall
RESPIRATORY SYSTEM during inspiration. This abnormal
Examination of respiratory system movement is a sign of respiratory
needs a quiet child. Chest indrawing, distress in children less than 5
repiratory count and auscultation are years of age. This may be seen in
especially unrealible in crying child. severe pneumonia, acute severe
asthma, bronchiolitis, airway
Inspection obstruction, cardiac failure and
Inspection is the most important step in severe dehydration.
examination of respiratory system in
children.
Note: Respiration in children of both
sexes is abdomino-thoracic
+ Shape and symmetry of the chest.
+ Deformities like Harrison's sulcus,
Antero-posterior diameter and
pigeon shaped chest, funnel shaped transverse diameter are equal
chest, rickety rosary, kyphoscoliosis. in infants and chest is almost
circular. In older children, like
+ Movements of the chest.
adults, it is elliptical.
+ Respiratory rate.
PDFelement
Palpation
Normal premature newborns Palpate for:
may have periodic breathing
4 Position of trachea and apex beat.
with periods of apnea in
between normal respiration. + Tenderness.
This apnea may last for upto' 4 Chest movements.
20 seconds but should not be 4 Chest expansion (measured with a
accompanied by cyanosis. tape measure).
Chest indrawing (in children 4 Vocal fremitus.
less than 5 years of age) or 4 Any palpable sound.
indrawing of intercostal
and subcostal areas (in all
age groups) is frequently seen - Trachea is more mobile in
in children suffering from children and its deviation is
bronchiolitis in infancy less significant.
pneumonia Crepitus or ronchus may be
asthma palpable.
congestive heart failure - Spindle shaped swelling of
costochondral junctions may
respiratory obstruction, as
be visible or palpable in rickets
in diphtheria
(rickety rosary).
metabolic acidosis with
Palpation of chest
acidotic breathing
movements with hands
Stridor (harsh inspiratory
in young children is not as
sound) can result from:
reliable as in adults.
foreign body in larynx or
Vocal fremitus is not of
trachea
much importance in children.
laryngeal diphtheria
viral Percussion
laryngotracheobronchitis Percuss for:
acute epiglottitis 4 Upper border of the liver (usually in
infantile (soft, collapsible) 4th intercostal space; pushed down in
larynx (in infants) hyperexpanded lungs).
Laryngeal congestion/ 4 Type of note over all parts of the
edema lungs.
Wheezing (musical expiratory
sound) can be due to: Normal percussion note is
asthma more resonant in children
bronchiolitis than in adults. Differences like
acute bronchitis impaired, dull, stony dull are
bronchopneumonia (some more difficult to appreciate in
cases) children as compared adults.
PDFelement
■OMMMHa
Auscultation + Prominent veins; direction of flow

of blood in them.
Auscultate for:
+ Umbilicus.
+ Breath sounds; type and intensity.
4 Hernial orifices.
4 Added sounds; crepitations, ronchi,
pleural rub. Palpation
4 Vocal resonance. Palpate for:
4 Rigidity of abdominal wall.
Babies are usually frightened 4 Tenderness and rebound tenderness.

by stethoscope. They should be 4 Liver, spleen, kidneys, urinary
encouraged to play with it for bladder.
some time. 4 Any abnormal masses.
Auscultation is unreliable if 4 Fluid thrill.
the child is crying. Crying can
be helpful for determination
of vocal resonance in young
children who would be shy of
speaking on request.
Breath sounds are clear and
intensity is more in young
children. Breath sounds are
bronchovesicular in infants.
Breath sounds are widely
transmitted in the chest of
infants and young children, so
it may be difficult to localize
the disease.
Fig 6.5: Palpation for pyloric tumor
Transmitted sounds
(conducted sounds) due to
secretions in the throat are
Abdomen is normally quite
common in young children. protuberant in young children.
Peristalsis may be visible in
ABDOMEN the epigastrium in congenital
pyloric stenosis. Inspect from
Inspection the left side while baby is
Inspect for: being fed and look for gastirc
peristalsis moving from the
+ Size and shape of abdomen.
left to the right across the
4 Movements with respiration.
4 Peristalsic movements.
PDFelement
imaenaBraananaBKBi
Percussion
It is difficult to palpate while Percuss for:
the child is crying. All attempts 4 Shifting dullness.
should be made to calm him. If 4 Enlargement of liver, spleen, urinary
the child does not pacify, then bladder.
carry out limited palpation
Auscultation
during the few seconds he Auscultate for:
stops crying to inspire, but this + Bowel sounds.
is unreliable. 4 Bruit.
Pyloric tumor may be
palpable in congenital PERINEUM AND GENITALIA
hypertrophic pyloric stenosis. Examine:
Palpate from the left side (fig 4 Urethral meatal opening.
6.5). Place fingers of the left + Testes: size, site.
hand below the liver edge and 4 Scrotum: hydrocele, hernia.
lateral to the right rectus. Press 4 Enlargement of clitoris.
the fingers gently. Tumor 4 Anus and rectum (rectal
may be palpable only when examination may be performed in
contracted and that may cases of acute abdomen, intestinal
happen once in 10 -15 minutes; obstruction, chronic constipation
and rectal bleeding).
continue palpation for that
long.
Liver is palpable not only Congenital anomalies
when enlarged, but also when in perineal area include
pushed down. In infants, liver undescended testes, displaced
edge is palpable normally. or imperforate anus,
Spleen may be palpable in 10
hypospadiasis and ambiguous
genitalia.
percent of healthy children.
In female infants, the clitoris
The direction of enlargement
may be enlarged in congenital
of spleen in young children is adrenal hyperplasia.
usually towards left iliac fossa. Perianal dermatitis may
A sausage shaped mass may be be present in severe acute
palpable around the umbilicus diarrhea.
in intussusception. Rash in the groin may be
Fecal masses are commonly due to inadequate cleaning,
candidiasis or allergy.
palpable in unconscious or
Rectal prolapse may be seen.
immobile children.
In Hirschspring's disease, on
Common tumor masses in rectal examination there may
ab domen of children are Wilm's be gripping of the finger by
tumor (nephroblastoma) and the narrowed rectal segment
non Hodgkin's lymphoma. and flatus may be released
when finger is withdrawn.
PDFelement
NERVOUS SYSTEM Head Circumference

Examination of older children is similar Cranial cavity grows with the growth
to that of adults (page 135). In infants and of brain. Head growth is measured as
young children usual assessment of tone, occipito-frontal head circumference.
power, reflexes, sensations etc. should be Causes of microcephaly (small head) and
preceded by close observation of activity, macrocephaly (large head) are given on
spontaneous limb movements, behavior page 224.
and interaction with surroundings. This
will provide invaluable information Average occipito-frontal head
about muscle tone power and circumference
coordination. Birth and development Birth 35 cm
history is very important in children
3 months 40 cm
with neurological disorders.
6 months 44 cm
Conscious Level 9 months 46 cm
Child may be irritable, drowsy or deeply 1 year 47 cm
unconscious. Use Glasgow coma scale (page
2 years 49 cm
144) for assessment of conscious level.
3 years 50 cm
Behavior
Assess behavior of the child and Fontanel (page 224)
determine its appropriateness for his age.
Cranial Nerves
Voice and Speech + In older children cranial nerves
Listen to the child's voice and assess his can be examined in the same way
speech. Evaluate range of his vocabulary, as in adults (page 152). In younger
considering the age. It should be children note the following points
remembered that many speech defects + Visual fixation and following
are due to hearing abnormalities. (2nd cranial nerve): Observe
whether infant or child is able to
fix his eyes on human face or on
First words are usually bright colored objects. Note whether
spoken by one year of age. he follows the movements of face or
Speech may be delayed, eg, in objects. Newborn can momentarily
deafness or mental retardation. focus their eyes. Ability to focus and
Hoarseness may be due to follow objects develops in the first
laryngitis or cretinism. month of life. By 3 months of age
Nasal speech may be due to eyes can follow objects or mother's
cleft palate. face through 180°. Fundoscopy can
be done at all ages, but requires
Speech may be unintelligible,
experience. Accurate visual fields
as in cerebral palsy.
testing is only possible after 5 years.
Other speech defects eg,
4- Eye movements (3rd, 4th, and 6th
stammering may be present.
cranial nerves): Eye movements
PDFelement
BEDSIDE TECHNIQUES
in all directions mean 3rd, 4th and hypotonic cerebral palsy), cerebeller
6th cranial nerves are normal. lesions (eg, dysgenesis), hypocalcemia
Strabismus (squint) is common in (eg, rickets) or hypokalemia (eg
infancy Usually it is non-paralytic. diarrhea, malnutrition).
If it persists beyond infancy, 4 In hypertonia muscles are firm
opinion of ophthalmologist should and passive movements are stiff.
be obtained. Common causes are cerebral
+ Rooting and sucking reflexes palsy, cerebral infections and
(page 237-238) check trigeminal and cerebrovascular accidents.
facial (5th, 7th) nerve function.
4- Facial palsy can be detected during
Power
crying of the infant. Usual facial 4 Observe spontaneous movements of
movements which occur during the child before touching him.
crying (depression of the corners + Younger children can be encouraged
of the mouth, closure of eyes) are to move the limbs by offering toys
absent on affected side. or by tickling the palms and soles.
4 Hearing (8th nerve) can be assessed They will move weaker limb less or
by determining child's response to not at all compared with the healthy
a sound stimulus which is about 18 limb.
inches away from him at ear level, + Older children can be requested
and is out of his visual field. It can to walk, run or jump. If these acts
be checked in newborn by startle are performed easily without any
reflex (page 238). abnormality, muscle power is
4 Swallowing and gag reflexes (9th normal in lower limbs.
and 10th cranial nerves): observe 4 If the child is old enough to cooperate,
feeding of the infant. muscle power can be tested by
+ Movements of tongue are observed conventional method (page 179).
to test the 12th cranial nerve.
Tendon jerks and superficial
Motor System reflexes (page 186)
Observation of posture and spontaneous 4 Relaxation needed for eliciting
or stimulated movements of newborns tendon jerks may be difficult to
and infants gives information about achieve in an apprehensive child.
tone and power of muscles. 4 Tendon jerks in newborns and
Tone young infants are better, elicited
with a finger than with a patellar
+ In hypotonia muscles are soft,
hammer.
passive movements of the joints are
lax and child is floppy on handling. 4 Plantar reflex may be normally
Limbs may be seen lying on bed in extensor in infancy (upto 2 years of
Frog posture. Generalized hypotonia age).
can be due to weak muscles (eg 4 Anal reflex may be absent in cases
myopathies), cerebral disorders (eg of spina bifida.
PDFelement
Coordination Signs of Meningeal Irritation

4 In young infants incoordination Neck Rigidity (page 209): In children
may be obvious while they play meningitis (pyogenic, tuberculous, viral)
with toys. is the major reason of developing neck
4 After first few months of age child
rigidity. However, sometimes it may be
can be shown a toy to catch and
due to infections other than meningitis
like tonsillitis, otitis media and
coordination assessed.
pneumonia. This is called meningism.
4 In older children, in addition to usual
methods (page 192), coordination can Kernig's Sign (page 209): It is a late sign
be tested by asking them to walk on of meningitis in children and is not
straight line, hop on one foot and helpful in children below 3 years of age.
stand on one leg. Brudzinski's Sign: When head is flexed,
thighs and knees become flexed.
Gait
Bulging anterior fontanel: It is a
4 Independent walking is achieved sign of raised intracranial pressure and
usually between 10 months and is very helpful to detect meningitis in
18 months of age. Common causes infants and younger children in whom
of delayed walking include classical signs of meningeal irritation
cerebral palsy, mental handicap, might be absent. Fontenel may also be
muscle disease, rickets and severe bulging in intracranial hemorrhage and
malnutrition. hydrocephalus.
4 Abnormalities of the gait should be
observed if child can walk (page 196). Neonatal and Infantile Reflexes
These reflexes - also called primitive
Abnormal movements reflexes - are peculiar to infants, and
4 Look for any abnormal movements disappear with maturation of nervous
like tremor, chorea, athetosis, system. The following reflexes should be
myoclonus and convulsions. checked in all newborns.
Sensory System Sucking and swallowing reflex
4 In older cooperative children These are present in all the newborns
examination of sensory system is and are needed for feeding. They can be
carried out as in adults (page 201). assessed during normal feeding process.
4 Infants and young children respond Sucking can be checked by placing a
to touch by withdrawal and to pain clean finger the babies mouth. '
by crying.
Cerebellar Signs Moro reflex
Buttocks, back and shoulders of the
4 Infants and young children show
infant are supported on one hand and
tremor and incoordination on
arm (or on bed), and head on the other.
spontaneous movements.
If head is lowered for an inch or so, arms
4 Examination in older children is
and legs are abducted first and then
carried out as in adults.
PDFelement
238 nooaass
BEDSIDE TECHNIQUES
adducted. This reflex can also be elicited and joints. Inspect before palpating.
by thumping the bed or making a loud + Watch the baby or child while sitting
sudden noise, which is called startle and moving (crawling, walking).
reflex. It disappears at 2 - 3 months.
+ Inspect and palpate the joints first.
Grasp reflex 4- In case of older child, first encourage
For palmar grasp reflex place a finger or him to perform active movements
pencil on infant's palm between thumb and then perform passive
and forefinger; he reflexly grasps it. movements yourself.
For plantar grasp reflex press heads + In a newborn baby look for any
of metatarsals; there is flexion of toes. congenital abnormality including
Grasp reflex disappears at 2 - 3 months. congenitally dislocated hips.
Rooting reflex + A limping child may have a joint or
a bone disease, or even a soft tissue
If light contact is made with the infant's
problem (injury or inflammation).
cheek near the angle of mouth, he turns
He may be suffering from
his lips towards that side.
neurological or muscular weakness.
Tonic neck reflex + In Duchenne's muscular dystrophy,
Baby should lie in supine position. When child climbs up his legs if asked to
head is rotated to one side, there is partial rise from a sitting position (Gower's
extension of the arm and leg of that sign).
side and its tone is increased. Flexion of
contralateral leg may occur. This reflex NEONATAL EXAMINATION
disappears at 4 - 6 months.
Newborn baby should be examined soon
after birth, during first 24 hours and
Moro reflex, grasp reflex, rooting
then at 4-6 weeks.
reflex , sucking reflex and tonic
neck reflex: Newborn at Delivery
May be absent if there is birth First examination of newborn is
asphyxia and hypoxic brain due at the time of birth to rule out
injury or there is cerebral major developmental anomalies
dysgenesis and to determine general condition.
Determination of Apgar score (a
May persist beyond the time
combination of five factors: Heart rate,
at which they normally
respiratory effort, color, body tone and
disappear in cerebral palsy
response to stimuli) is a useful measure
and mental retardation
to assess condition of the baby. It is
usually done at 1 minute, 5 minutes, and
Musculo-Skeletal System 20 minutes of age. Persistently low score
Examination of musculo-skeletal system inspite of resuscitation efforts, indicates
includes examination of muscles, bones poor prognosis.
PDFelement
Apgar Score
Sign Score
0 1 2
Heart rate absent <100 >100
Respiratory effort absent slow irregular good strong cry
Color blue pink trunk, blue pink all over
extremities
Tone limp some limb flex active move
ion ment
Response to stim none Grimace cry
uli
Interpretation 7 -10 = good score

4 - 6 = moderate score
1 - 3 = low score
Newborn during First Week of tissue and resolves in a few days.
Life + Cephalhematoma is soft swelling,
Another detailed examination of usually on one of the parietal bones,
newborn should be carried out during bounded by bone edges. It consists
first 24 hours of life to detect anatomical of subperiosteal hemorrhage and
variations, to assess physiological resolves in 1 - 2 months.
functions, and to find out any problem in
+ Facial palsy may result from forceps
adjusting to extrauterine environment.
delivery. It is usually transient.
The sequence of examination is from
head to toe. 4 Central cyanosis at this age is
usually due to respiratory disorders.
Skin
Eyes
+ Erythematous rash is common
during first few days and is called 4 Eyes may show . conjunctival
erythema toxicum. hemorrhage or (rarely) congenital
cataract.
4 Physiological jaundice is seen in
more than 50 percent of all the + Baby opens the eyes if held upright.
newborns. It appears by day 2-3 and 4 Accumulation of lacrimal'f luid with
disappears by day 7-10 of life. secondary infection (conjunctivitis)
is commonly due to incomplete
Head and Face drainage from nasolacrimal duct.
4 Caput succedaneum is the baggy
swelling of the presenting part of Chest
the scalp developed during labor. It 4 Normal respiratory rate is 40 - 60
consists of edema of subcutaneous per minute.
PDFelement
+ Severe Chest indrawing (subcostal Frog posture with fully abducted

recession) indicates a respiratory hips indicates hypotonia.
problem. Mild subcostal recession is 4- Elicit tendon jerks using finger tip.
normal. 4 Primitive reflexes are present in
+ Normal heart rate varies from 120 the newborn and disappear at the
to 160 beats per minute. age of 6 months (page 237).
+ Systolic murmurs can be heard + To test hearing make a loud noise;
during first few days of life; infant will startle.
evaluation for congenital heart 4 For testing vision make the infant
disease may be required in such to look at you from a distance of 20
cases. cm; he will fix and follow with the
Abdomen eyes.
+ Respiration is abdominal. Gestational Age
+ Umbilicus is a common source of Gestational age of the newborn (varying
infection in newborn, it should be from 20 to 40 weeks) can be assessed
kept clean. from the maternal history and physical
+ Liver edge is usually palpable by 2 - and neurological signs in the newborn.
3 cm below the costal margin.
Prematurity
+ Urinary bladder may be palpable
in the hypogastrium. A preterm newborn (less than 37 weeks
of gestation) shows small size, shiny
+ Look for any abnormality of thin skin, matted hair, incompeletly
genitalia.
curved, inelastic pinna, small size nipple,
light (pink) colored genitalia, absent
Extremities
transverse sole creases, incomplete Moro,
+ Gently look for dislocatable hips** rooting, sucking and swallowing reflexes
+ There may be talipes equinovarus and hypotonia. Increasing intensity
(club foot) deformity of feet. of these clinical signs indicates lower
gestational age.
Central Nervous System
Observation is the most useful method Newborn at Four to Six Weeks
of examination. This examination is intended to assess
+ Note the posture. Examine tone feeding and growth. Baby is examined
and power of muscles by checking while lying on the couch.
recoil of flexed extremities. Posture is
usually flexor with good body tone.
General Observation
Look at the skin for rashes, birth marks
* * Place the baby supine, legs pointing towards and color. Observe respiration and
you. Mold each thigh in such a way that your thumb
is over the lesser trochanter and index finger is over
behavior. Note limb movements. Look
the greater trochanter. Flex hips and knees to the for evidence of malnutrition (page 223).
right angle and then abduct both hips simultaneously
until knees touch the examining table. If hips are Head and Face
dislocated, a click is felt - and sometimes heard -
during this maneuver. + Check anterior fontanel.
PDFelement
+ Get the baby fix .his eyes at your face 1. Posture and locomotion
from a distance of 20 cm and give a 2. Vision and manipulation
smile. A normal baby should smile 3. Hearing and speech
in return.
4. Social behavior
4- Look for discharge from the eyes.
Watery discharge may be due to However, usually these are
blockage of nasolacrimal duct. interdependent and complementary
rather than isolated.
+ Look for thrush on the tongue and
mucous membrane of oral cavity. For developmental examination child
should be healthy, quiet and at ease.
Chest, Abdomen, Nervous System Disease, fear and non-stimulating
Chest and abdomen should be examined surroundings may not allow the child to
as described before. For nervous perform upto his potential.
system examination check tone, limb
movements, primitive reflexes, baby's Milestones
response to sound and his ability to Some of the milestones achieved at an
momentarily hold the head while pulled early age are given below.
from lying to sitting position.
Six Weeks
DEVELOPMENTAL + Holds his head momentarily in
sitting position when pulled up from
EXAMINATION
lying.
Assessment of neurological development + Fixes on a human face and follows it
of the child is an integral part of sideways.
Pediatrics. Gross evaluation should be
+ Hands begin to open.
made at each visit. Appropriate ages
for detailed developmental assessment + Vocalizes.
are six weeks, six months, nine or ten + Smiles in response.
months, two years and four or five years.
Three Months
Development in a child is characterized
by functional maturity and gain of 4-Keeps head steady and erect (neck
positive skills that parallel with growth, holding).
myelinization and development of + Hands reach out.
connections in the brain. Development + Eyes can converge.
is a continuous process, however, on this + Is alert and responsive; responds to
road of development certain milestones
sound and babbles.
can be recognized (eg, sitting, walking).
These milestones of development are Six Months
achieved in the same sequence by + Sits with support, rolls over, can
all the children while rate of normal extend arms and lift the chest in
development can vary within certain prone position.
limits.
+ Reaches out and picks up small
For descriptive purposes, development objects and transfers them to the
can be divided into four different areas:
PDFelement
other hand or takes them to the Eighteen Months

mouth. + Walks, may run.
+ Eyes move in all directions. 4- Points to distant objects.
+ Turns to the sound made at a distance + May speak upto 20 words.
of 50 cm at the level of ear.
+ Drinks from cup without spilling.
+ Laughs and babbles. Takes
everything to the mouth.
THE ACUTELY ILL INFANT
Nine Months
Infants become ill very quickly.
+ Sits alone, can support weight when
Common serious diseases like
made to stand.
pneumonia, malaria, meningitis, severe
+ Very observant. Holds small objects
malnutrition, septicemia, gastroenteritis,
in thumb and side of finger.
urinary tract infection and peritonitis
+ May know and turn to his name.
may present in similar way. Common
+ Holds and bites piece of bread. presenting symptoms of these conditions
Twelve Months are irritability or lethargy, refusal to
+ Crawls, stands with or without feed, vomiting, labored breathing and
support; some begin to walk. convulsions. First of all assess degree of
+ Holds objects in thumb and index illness, and state of airway, breathing,
finger (pincer grasp). circulation (ABC) and hydration and
+ Can speak 2 - 3 words.
nutrition. Then record vital signs and
perform appropriate examination as
+ Is fearful of strangers and clings to
required.
the mother.
PDFelement
C h a pte r ■
7’ HOW TO PRESENT
A CASE!
Method of presenting history and and has to sleep propped up against four
examination findings is a little different to five pillows.
from the way it is recorded in history There is no history of edema feet. There
books or patient's notes. Following are is no cough except which occurs if he
few examples. lies flat. There is no history of allergy,
vomiting, diarrhea, loss of weight,
HISTORY NO. 1: DYSPNEA urinary complaints, headache, fits or
Muhammad Aslam, 55 years old male, motor weakness.
businessman from 11-B Gulgasht Multan In the past he was operated for
presented with shortness of breath on appendicitis thirty years ago. He was
exertion for the last two months and admitted to Cardiology Ward two years
shortness of breath on lying flat for the ago with chest pain and was diagnosed as
last one month. a case of acute myocardial infarction. He
History of present illness: Patient used to get chest pain on exertion after
was all right two months ago when he discharge from the hospital. This was
noticed shortness of breath on exertion. relieved by rest and sublingual tablets.
Initially, it occurred on moderate to There is no history of hypertension,
severe exertion like walking fast or diabetes mellitus, tuberculosis or
going upstairs but it progressed and rheumatic fever.
now he cannot walk even a few steps He is an ex-smoker. He smoked 20 - 30
without becoming breathless. It was cigarettes for thirty five years but
accompanied by chest pain, palpitation gave up after episode of infarction. His
and sweating. appetite has decreased for the last one
For the last one month he cannot sleep month and sleep is disturbed. He is a
flat. Initially, he used to wake up after cloth merchant and makes reasonable
midnight due to breathlessness which living.
used to get better on sitting up and His father died twelve years ago due to
sometimes on walking to the window. stroke. Mother is alive and suffers from
It was also accompanied by cough osteoarthritis. He has one sister who is
productive of frothy sputum. Now he healthy. He is married with two sons
cannot lie flat even for a few minutes and one daughter; all are healthy. There
PDFelement
is no family history of hypertension, is central; vocal fremitus is normal and

diabetes mellitus, ischemic heart disease equal on both sides. Chest movements
or tuberculosis. are equal on both sides. Chest expansion
He is taking elantan 20 one tablet twice is 3 cm. Percussion note is normal and
daily, losartan potassium 12.5 mg and equal on both sides. On auscultation
loprin 75mg once daily but compliance breath sounds are of normal intensity
is not good. and vesicular. There are bilateral end
inspiratory crepitations on the back
On general physical examination a
upto mid zone. Vocal resonance is equal
middle aged man lying propped up in
on both sides.
the bed. Pulse 115/minute, regular; blood
pressure 114/72; temperature 98.6°F, In GIT orodental hygiene is satisfactory.
respiratory rate 28/minute. He looks On inspection shape of abdomen is
pale. There is no cyanosis, jaundice, normal. There are no prominent veins.
clubbing or koilonychia. There are There is a scar in the right iliac fossa. On
no Osier's nodes, Heberden's nodes or palpation there is no tenderness, no mass
splinter hemorrhages. There is no palmar or viscera is palpable. On percussion
erythema. Lymph nodes and thyroid are note is resonant all over. On auscultation
not palpable. JVP is not raised. Ankle bowel sounds are audible 3 - 5 / minute,
and sacral edema is absent. of normal character. No bruit is audible.
In cardiovascular system, pulse is In nervous system higher mental
115/minute, regular, low volume, of functions are normal. Speech is normal.
no special character, all pulsations Cranial nerves are intact. Motor and
palpable, vessel wall is not palpable. sensory systems were not examined
Blood pressure is 114/72. On inspection in detail as patient was too sick but he
of precordium apex beat is visible below can move all the four limbs and can
and lateral to the nipple. There are no appreciate touch and pain. Signs of
other visible pulsations, prominent meningeal irritation are absent.
veins, pigmentation or scar. On Provisional diagnosis
palpation apex beat is palpable in 6th
intercostal space in anterior axillary Left ventricular failure due to old
line; no special character. No left sternal myocardial infarction.
heave, thrill or any other palpable Differential diagnosis
sound. On auscultation 1st heart sound
COPD.
is diminished in intensity. Second heart
sound is normal in intensity; no splitting. Anemia.
Third heart sound is audible at apex. Plan of investigations
A pansystolic murmur is audible with
maximum intensity at apex, radiating Complete blood examination, urinalysis,
to the axilla; intensity is 3/6; it is loud urea, creatinine, serum sodium,
during expiration. potassium, blood gases, ECG, chest x-ray,
In respiratory system on inspection echocardiography. Exercise tolerance test
shape of the chest is normal. Movements and coronary angiography to be decided
are equal on both sides. There is no after results of above investigations are
deformity or scar. On palpation trachea available.
PDFelement
CH 7 HOW TO PRESENT A CASE?
HISTORY NO. 2: PAIN tablet for his joint pain. Names are not
known. There is no prescription or drug
EPIGASTRIUM specimen available.
Nazir Ahmad 43 years old male laborer On general physical examination a
by occupation from Shareef Pura Multan middle aged man of normal built, lying
presented with pain epigastrium for~the comfortably in the bed. Pulse is 56/
last five months. minute regular; blood pressure 136/82;
History of present illness: Patient temperature 98.2°F; respiratory rate 17/
started having pain in the epigastrium minute. He is pale. There is no cyanosis,
about five months ago. It is moderate jaundice, clubbing or koilonychia.
to severe in intensity, occurs one a half There are no Osier's or Heberden's nodes;
to two hours after meals and is relieved no splinter hemorrhages or palmar
by food and milk. It is also relieved erythema. Two small submandibular
by taking white Medicine (perhaps lymph nodes are palpable which are
antacids). Patient usually wakes up at discrete, mobile and non tender. Left
night due to pain. It is localized. There lobe of thyroid is moderately enlarged.
is history of pain free intervals varying It is non tender and surface is smooth.
form 2 - 3 weeks in duration. There is There is no bruit over it. J VP is not raised.
no history of vomiting or black colored There is no sacral or ankle edema.
stools. Appetite is good. Patient has In GIT orodental hygiene is poor. On
gained some weight. inspection abdomen is of normal shape.
There is no history of dyspnea, chest pain, There are no veins or scar. It is moving
cough, hemoptysis urinary complaints, with respiration. On palpation there is
headache, fits or motor weakness. marked tenderness in the epigastrium,
Past history: Patient has pain in the to the right of midline. No mass or
right knee joint for the last two years viscera is palpable. On percussion note is
and takes pain killers regularly. There resonant all over. On auscultation bowel
is no history of hypertension, diabetes sounds are audible 4-6 per minute. No
mellitus, ischemic heart disease or other sound is audible.
tuberculosis. In cardiovascular system pulse is 56/
Personal and social history: He is minute regular, of normal volume,
laborer. He smokes Hukka. His sleep no special character; all the pulses are
is disturbed due to pain. His house is palpable; vessel wall is not palpable.
rented and is small and of poor quality. Blood pressure is 136/82. On inspection
Surroundings are also poor hygienically. of precordium apex beat is not visible.
Family history: Both parents are dead;
There are no pulsations, prominent
cause not known. He had three brothers veins or scar. On palpation apex beat is
and two sisters. One elder brother died palpable in 5th intercostal space medial to
of a febrile illness, others are healthy. midclavicular line, of normal character.
He has two sons and four daughters. One No other sound, thrill or left parasternal
son died of gastroenteritis in infancy. heave is palpable. On auscultation 1st and
2nd heart sounds are of normal intensity.
Treatment history: He takes a white
No other sound or murmur is audible.
medicine for pain abdomen and a
PDFelement
In respiratory system on inspection started having fever about ten days ago
shape of the chest is normal. Movements which was high grade without rigors or
are equal on both sides. There is no chills. It is continuous. It is accompanied
deformity or scar. On palpation trachea by body aches and pains. For the last
is central; vocal fremitus is normal and four days patient is passing loose stools
equal on both sides. Chest movements 6 - 7 per day and 1-2 per night without
are equal on both sides. Chest expansion blood and mucus. There is no history of
is 4 cm. Percussion note is normal and headache, vomiting, ear discharge, sore
equal on both sides. On auscultation throat, cough, chest pain or burning
breath sounds are of normal intensity micturition.
and vesicular. There are no added sounds. Past history: There is no history
Vocal resonance is equal on both sides. . of hypertension, diabetes mellitus,
In nervous system higher mental tuberculosis, operations or admission to
functions are normal. Speech is normal. the hospital.
Cranial nerves are intact. Motor and Personal and social history: She is a
sensory systems are intact. There are housewife. No habits or addiction. No pets
no extrapyramidal signs. Signs of at home. Sleep is normal. Appetite has
meningeal irritation are absent. been good before this illness but now it
In locomotor system right knee joints is decreased. Husband is a school teacher.
movements are painful but full. There is House surroundings are satisfactory.
no swelling, Crepitus is palpable. Other Family history: Both parents are alive
joints are normal. and healthy. She has two brothers and
three sisters; all are healthy, she has two
Provisional diagnosis
sons and one daughter. All are healthy.
Peptic ulcer
Treatment history: She has taken
Osteoarthritis right knee treatment from local doctors in the form
Differential diagnosis of injections, tablets and syrups but no
benefits. One of the prescription shows
Gastritis
that she was given septran, nivaquine
Cholecystitis and ponstan.
Worm infestation On general physical examination a young
Plan of investigations lady of normal built, lying comfortably
in the bed. Pulse is 86/minute regular;
Complete blood examination, stool blood pressure 118/66; temperature
for ova and occult blood, abdominal 101.2’F; respiratory rate 22/minute. She
ultrasound, Upper GI endoscopy looks pale. There is no cyanosis, jaundice,
clubbing or koilonychia. There are no
HISTORY NO. 3: FEVER Osier's or Heberden's nodes; no splinter
Tahira, 32 years old female, a housewife hemorrhages or palmar erythema. No
from Chak no. 234 GB tehsil Khanewal lymph nodes are palpable Thyroid is
presented with fever for the last ten mildly enlarged. It is non tender and
days. surface is smooth. There is no bruit over
History of present illness: Patient it. JVP is not raised. There is no sacral or
PDFelement
CH 7 HOW TO PRESENT A CASE?

247
ankle edema. Throat is not congested. kidneys and urinary bladder are not
In cardiovascular system pulse is 86/ palpable. No other mass is palpable.
minute regular, of normal volume, On percussion note is resonant all over
no special character; all the pulses are except in the right hypochondrium
palpable; vessel wall is not palpable. over the enlarged liver. On auscultation
Blood pressure is 118/66. Inspection of bowel sounds are audible 4-6 per minute.
precordium not done. On palpation No other sound is audible.
apex beat is palpable in 5th intercostal In nervous system higher mental
space medial to midclavicular line, of functions are normal. Speech is normal.
normal character. No other sound, thrill Cranial nerves are intact. Motor and
or left parasternal heave is palpable. On sensory systems are intact. There are
auscultation 1st and 2nd heart sounds are no extrapyramidal signs. Signs of
of normal intensity. No other sound or meningeal irritation are absent.
murmur is audible.
In respiratory system on inspection Provisional diagnosis
shape of the chest is normal. Movements Enteric fever
are equal on both sides. There is no
deformity. On palpation trachea is Differential diagnosis
central; vocal fremitus is normal and Malaria
equal on both sides. Chest movements
Tuberculosis
are equal on both sides. Chest expansion
is 2.5 cm. Percussion note is normal and Brucellosis
equal on both sides. On auscultation UTI
breath sounds are of normal intensity
and vesicular. There are no added sounds.
Plan of investigations
Vocal resonance is equal on both sides. Complete blood examination, urinalysis,
blood, stool and urine culture, typhidot
In GIT orodental hygiene is poor.
test, chest x-ray, slide for malarial
Inspection of abdomen not done. On
parasite, agglutination test for brucella,
palpation there is no tenderness. Liver is
palpable 3 cm below the costal margins; tuberculin test, liver function tests.
it is smooth and non tender; upper Antinuclear factor and bone marrow to
border of the liver is in 5th intercostal be done if above tests don't diagnose the
space. Spleen is just palpable. Gallbladder cause of fever.
PDFelement
I INDEX
posterior spinal 142 Brudzinski's sign loud SI 57
Abdomen Articulation 147 in children 237 lymph nodes enlarge
auscultation of Ascites Bruit ment 24
in children 234 tapping 134 aortic 130 murmur 63
hernial orifices 115 Athetoid movements hepatic 130 early diastolic 62
in children 228 195 renal 130 pansystolic 178
in newborn 240 Auscultation Bullae 28 palpable kidney 125
palpation of of abdomen pleural effusion 105
for the spleen 122 in children 234 reduced chest move
in children 233 of precordium Cafe au lait spots 27 ments 89
percussion of in children 230 Campbell de Morgan respiratory failure
in children 234 Austin Flint murmur 71 spots 28 type I 106
pubic hair 115 Cannon waves 48 type II 106
veins, prominent Caput succedaneum 239 reverse splitting of
direction of flow of Babinski’s rising up sign Carcinoma S2 58
blood 115 200 gall bladder 122 right ventricular
Abducent nerve Behavior head of pancreas 122 heave 52
examination of 160 in children 235 Cardiovascular system ronchi 98
Accommodation reflex Bilirubin 27 33 soft A2 57
159 Blood pressure examination of soft both heart sounds
Added sounds in children 229 in children 229 57
respiratory 98 flush method 230 summary of 80 soft P2 57
Adductor pollicis brevis normal level 230 writing out 82 soft SI 57
180 Blood supply symptoms of 33 tachycardia 37
Aegophony 100 of spinal cord 142 Carry-Coomb's murmur thrill 52
Albinism 27 Bowel habits 71 usual splitting of S2 58
Alimentary system in children 218 Causes of variable intensity of
examination of Bowel sounds bradycardia 37 SI 57
summary of 132 in paralytic ileus 130 relative 37 whispering pectorilo
writing out 133 Bradilalia 147 chest wall bulging 88 quy 100
Anemia 26 Bradycardia 36 chest wall flattening Celsius scale 8
Anomic dysphasia 146 causes of 37 89 Cephalhematoma 239
Anus relative 36 cough 83 Cerebellar signs 208
imperforate 234 causes of 37 crepitations 99 in children 237
Aortic Brain stem cyanosis Chest
ejection systolic click lesion of 197 central 26 added sounds 98
60 Breathlessness 10 peripheral 26 deformity of
Apex beat 49 in children 218 deep venous thrombo bulging 88
Apgar score 238 Breath sounds sis 82 flattening 89
Appearance and behav bronchovesicular 98 edema 25 in newborn 239
ior 143 vesicular ejection systolic clicks movements 89
Appetite 10 with prolonged expi 60 abnormal 89
Apraxia 196 ration 98 hematemesis 108 due to extra respira
Arcuate fasciculus 146 BrocaCs hemoptysis 84 tory muscles 89
Arterial system 81 dysphasia 150 left parasternal heave inward 90
Artery Bronchophony 100 52 paradoxical 90
anterior spinal 142 Bronchovesicular loud A2 57 reduced 89
of Adamkiewicz 143 breathing 98 loud P2 57 palpation of 90
248
PDFelement
INDEX 249
pulsations 89 hemorrhage 215 non-fluent 145 of nervous system 143

scar 89 Cyanosis 26 receptive 145 summary of 211
veins, prominent 89 central 26 sensory 145,149 of precordium 49
Chest indrawing causes of 26 transcortical motor in children 230
in newborn 240 in newborn 239 146,150 of respiratory system
Chorea in children 219 transcortical sensory writingout 104
Huntington's 195 peripheral 26 146,149 of respiratory system
rheumatic 195 causes of 26 WernickeOs 149 summary of 103
Sydenham's 195 Dysphonia 147 of speech 147
Choreiform movements
195
■■■■■■■■■■ Dyspnea 10
at rest 11
of taste 168
of trochlear nerve 160
Deep venous thrombo
Chvostek's sign 210 sis 82 exertional 10 pediatric 216,221
Circle of Willis 142 signs of 82 in children 218 Expressive dysphasia
Claudication, intermit symptoms of 82 orthopnea 10 145
tent 81 Dehydration 25 paroxysmal noctur Extremities
Click Delusions 143 nal 10 in children 229
ejection systolic 60 Diarrhea 11 Dystonic movements in newborn 240
aortic 60 Differential diagnosis of 196 Eyes
causes of 60 abdominal pain 9 in newborn 239
pulmonary 60 ascites and ovarian ■■■■■■■■■■I
Clitoris cyst 130 Ecchymosis 28
enlargement of 234 ascitic fluid 134 ’ Echolalia 147 Face
Coin test 100 hemoptysis and he- Edema 10,24 in newborn 239
Complications matemesis 109 causes of 25 Facial nerve
of lumbar puncture L5 and SI root lesions non-pitting 25 examination of
215 210 pitting 25 motor function 168
Conduction dysphasia left kidney and spleen Eisenmenger’s syn interpretation of 169
146,150 126 drome 71 paralysis of
Congenital cataract 239 motor neuron disease, Ejection systolic clicks LMN type 169
Congenital heart disease neuropathy and 60 UMN type 169
230 myopathy 200 aortic 60 Facial palsy
Conjunctival hemor pansystolic murmur causes of 60 in children 236
rhage 239 72 pulmonary 60 in newborn 239
Conscious level 144 pleural fluid 105 Emphysema Fahrenheit scale 8
in children 235 pleural rub and crepi subcutaneous 27 Fallot's tetralogy 71
Constipation 12 tations 99 Enteric fever Fasciculations 178
Contraindications upper motor neuron sample history of 246 Fecal masses
of lumbar puncture paralysis and Erythema in children 234
215 lower motor neu marginatum 28 Feeding 217
Convulsions 13 ron paralysis 197 nodosum 28 Feet 24
in children 219 Diplegia Examination in children 229
Coordination definition of 179 general physical Fever 8
in children 237 Divarication of the recti summary of 29 associated symptoms 8
Cough 11 116 writingout 32 continuous 8
causes of 83 Dysarthria 146 neonatal 238 grade 8
in children 218 Dyslexia 149 of abducent nerve 160 in children 217
types of 83 Dysphagia 12,108 of alimentary system intermittent 8
Cranial nerves 152 globus hystericus 108 writingout 133 mode of onset 8
in children 235 in esophageal stricture of alimentary system pattern 8
list of 152 108 summary of 132 quartan 8
nuclei of 152 in neuromuscular of autonomic nervous quotidian 8
Crepitations 99 disorders 108 system 211 relapsing 8
causes of 99 Dysphasia of cardiovascular remittent 8
Crusts 28 anomic 146 system rigors or chills 8
Crying BrocaDs 150 in children 229 tertian 8
in children 218 conduction 146,150 writingout 82 Fits 13
CSF expressive 145 of cardiovascular in children 219
difference between fluent 145 system Fluent dysphasia 145
traumatic lum global 146,150 summary of 80 Fluid thrill 129
bar puncture and isolation 146,151 of facial nerve Fontanel
subarachnoid motor 145,150 motor function 168 anterior
PDFelement
BEDSIDE TECHNIQUES
bulging 237 A2 no. 3 246 in children 219

Forced expiratory time palpable 52 occupational 6 Ischemia
100 first of birth 220 acute 82
Forced expiratory palpable 52 antenatal 220 chronic, signs of 81
volume in one fourth natal 220 Isolation dysphasia 146,
second 104 palpable 52 newborn 220 151
Forced vital capacity P2 postnatal 220
104 palpable 52 of feeding 220
Friction sounds, in abdo second of immunization 220 Jaundice 12,27
men 131 splitting of of present illness in children 219
fixed 58 in children 217 physiological 239
reverse 58 past 5,221 Joint
Gait 196 third personal 6,221 pain in 14
drunken 196 in children 230 social 6, 221 Jugular venous pulse
festinant 196 palpable 52 treatment 5 cannon waves 48
hemiplegic 196 Heart sounds Hoarseness rapid 'y' descent 48
high stepping 196 palpable 52 in children 235 ventricularization of
in children 219,237 Heave Hoover's sign 200 venous pulse 48
parkinsonian 196 right ventricular 51 Hum, venous
shuffling 196 causes of 52 in the abdomen 130
spastic 196 Height 222 Hydration 25
waddling 196 Hematemesis 108- Hyperpyrexia 8 Kernig's sign
Gall bladder differential diagnosis Hypertension in children 237
mucocele 122 of 109 in children 230 kidneys
Ganglion Hematoma 28 Hypertonia 179 palpable, causes of 125
geniculate 169 Hematuria 12 in children 236 Koplik's spots 228
Geniculate ganglion 169 Hemianopia Hypertrophic obstruc Kussmaul sign 48
Genitalia binasal 156 tive cardiomyo Kyphoscoliosis
examination of 131 Hemiballismus 195 pathy 71 thoracic 88
in children 234 Hemiplegia 13 Hypertrophy 178
in newborn 240 crossed Hypospadiasis 234 ■■■■■■■■■■
Gestational age 240 definition of 179 Hypothermia 8 Left parasternal heave
Global dysphasia 146, definition of 179 Hypotonia 179 causes of 52
150 uncrossed in children 236 Left ventricular failure
Globus hystericus 108 definition of 179 Hysterical paralysis 200 sample history of 243
Gower’s sign 238 Hemoptysis 84 Length 222
Graham Steel murmur causes of 84 Lethargy
71 differential diagnosis Illusions 143 in children 219
Groin of 109 Indications Light reflex 159
examination of 131 types of 84 of lumbar puncture Liver
Hernia 215 in children 234
epigastric 116 diagnostic 215 in newborn 240
Habit spasms 195 paraumbilical 116 therapeutic 215 Localization of lesion
Hair umbilical 116 Infancy 216 in motor system 197
distribution 27 Hernial orifices 115 Infant Lumbar puncture 214
pubic 115 Higher mental function acutely ill 242 complications of 215
Hallucinations 143 143 Inspection contraindications of
Hand Hips of precordium 49 215
in children 229 dislocatable 240 in children 230 difference between
Harrison's sulcus 88 Hirschspring's disease Intercostal spaces traumatic lum
Headache 13 234 indrawing of bar puncture and
cluster 13 History in newborn 240 subarachnoid
psychogenic 13 developmental 220 Internal capsule hemorrhage 215
Head growth 235 environmental 221 lesion of 197 indications of 215
Head in newborn 239 example no. 1 243 Interpretation diagnostic 215
Hearing family 6,221 of 3rd, 4th, 6th nerves therapeutic 215
in children 219,236 in children 216 lesions 160 Lumbricals 180
Heart rate information from an of facial nerve lesion Lung function tests 104
in children 229 other person 5 169 in obstructive lung
in newborn 240 menstrual 5 Intussusception 234 diseases 104
Heart sound no. 2 245 Involuntary movements in restrictive lung
PDFelement
INDEX
MWMNmnt
diseases 104 retraction 228 special times of occur Precordium

Lymph nodes webbing 228 rence 7 auscultation of
axillary 23 Neck rigidity Palilalia 147 in children 230
drainage area 24 in children 237 Pallor 26 bulging of 49
of groin 24 Neck veins Palpation examination of 49
in children 230 of abdomen in children 230
Neonatal examination in children 233 inspection of 49
Macules 28 238 of chest 90 in children 230
Mass 10 Neonatal period 216 of precordium 49 palpation of 49
in rectum 131 Nerves in children 230 in children 230
Measurement cranial, see cranial of spleen 122 percussion of
of the circumference nerves of trachea 90 in children 230
of limbs 177 in children 235 Palpitation 11 prominent veins 49
Measurements Nervous system Papules 28 pulsation 49
in children 222 autonomic Paralysis 13 scars 49
Memory 144 examination of 211 of seventh cranial Pre school child 216
Meningeal irritation examination of 14’3 nerve Presenting complaints
signs of in children 235 LMN type 169 in children 216
in children 237 in newborn 240 UMN type 169 Prostate 131
Meningism 237 Neuronal shock 197 Paralytic ileus 130 Pseudohypertrophy 178
Methemoglobin 26 Newborn Paraplegia 13 Pulmonary
Migraine 13 at delivery 238 , definition of 179 ejection systolic click
Milestones 241 at six weeks 240 Pareses 13 60
eighteen months 242 during first week of Peak expiratory flow regurgitation 69
nine months 242 life 239 rate 104 Pulse
six months 241 Nodules 28 Pectus excavatum 88 characteristics of 40
six weeks 241 Non-fluent dysphasia Pediatric examination in children 229
three months 241 145 216 posterior tibial 36
twelvemonths 242 Nose Peptic ulcer rate 36
Monoplegia 13 in children 227 sample history of 245 Purpura 28
definition of 179 Percussion Pustules 28
Motor cortex for ovarian cyst 129 Pyloric stenosis 233
lesion of 197 Odors of abdomen Pyloric tumor 234
Motor dysphasia 145,150 abnormal 27 in children 234
Motor system Optic chiasma of precordium
in children 236 visual field defects, in children 230 Quadriplegia
Movements due to lesion of Percussion note definition of 179
in children 237 156 dull 96
Murmur Oral cavity hyper resonant 95 I 1°:
Austin Flint 71 in children 227 impaired 96 Ramsay Hunt syndrome
Carry-Coomb's 71 Orientation 144 resonant 95 169
causes of 63 Orthopnea 10 stony dull 96 Rash
early diastolic Ovarian cyst tympanitic 95 in children 218
causes of 62 percussion for 129 types of 95,96 Raynaud's phenomenon
grades of 63 Perianal dermatitis 234 82
Graham Steel 71 Pericardial knock 60 Receptive dysphasia 145
in newborn 240 Pain 6 Perineum Rectal examination 131
intensity of 63 aggravating factors 7 in children 234 Rectal prolapse 234
pansystolic associated phenom Perisylvian area 146 Reflex
causes of 178 enon 7 Petechiae 28 accommodation 159
Murphy's sign 122 character 7 Pigmentation 27 grasp 238
Musculo-skeletal system duration 7 Pleural effusion palmar 238
238 frequency 7 aspiration of 104 plantar 238
Myasthenia gravis 199 intensity 6 causes of 105 light 159
Myoclonus 195 in the joint 14 Pleural rub 99 Moro 237
Myopathies 199 periodicity 7 Polyuria 12 plantar
Myotonic dystrophy 199 radiation 6 Posture in children 236
referred 7 in children 219 rooting 238
relieving factors 7 Power of muscles 179 sucking 237
Neck shift of 7 grades of 180 swallowing 237
in children 228 site 6 in children 236 tonic neck 238
PDFelement
Reflexes Sounds alimentary system 4 Unconsciousness 144

infantile 237 abnormal 27 cardiovascular system in children 219
neonatal 237 Spasticity 179 4 Upper motor neuron
root value of 186 clasp knife type 179 endocrine 5 lesion 197
superficial Speech general 4 Urinary bladder
in children 236 articulation 147 immediate attention 4 in newborn 240
Respiration delayed 235 locomotor system 5
in newborn 240 disorders, miscellane nervous system 5
Respiratory failure 106 ous 147 respiratory system 4 Venous hum
type I 106 disturbances 149 skin 5 in the abdomen 130
causes of 106 examination of 147 urinary system 4 Venous system 82
type II 106 in children 235 Systemic Inquiry 4 Ventricularization of
causes of 106 nasal venous pulse 48
Respiratory rate 25 in children 235 Vesicles 28
in newborn 239 scanning 146 Tachycardia 36 Vesicular breathing
Respiratory system slurring 146 causes of 37 with prolonged expira
examination of Spider nevi 28 Taste tion 98
summary of 103 Spina bifida 228 examination of 168 Vessel wall
writing out 104 Spinal cord Teeth condition of 40
Right ventricular heave hemisection of 198 in children 228 Vision
51 lesion of 198 Telangiectases 28 in children 235
causes of 52 Spine Temperature 25 Visual field defects
Rigidity 179 in children 228 diurnal variation 25 due to optic chiasma
cog-wheel type 179 Spirometry 104 Tendon jerks 156
hysterical 179 Spleen in children 236 Vitiligo 27
lead pipe type 179 in children 234 Testes Vocal resonance 99
Ronchi 98 palpation of 122 undescended 234 Voice
causes of 98 Splitting of S2 Tetraplegia in children 235
Root irritation fixed 58 definition of 179 Vomiting 11,108
signs of 209 in children 230 Thorax in children 217
Rub reverse 58 in children 228
pleural 99 Sputum 84 Thrill 52
Squint causes of 52 Walking
in children 236 Thrombosis independent
Scales 28 Stammering 147 deep venous 82
School child 216 Strabismus Thrush 228 in children 237
Seizures in children 236 Tics 195 Wasting 177
in children 219 Stridor 99 Titubations 195 Weakness 13
Sensory dysphasia 145, Succussion splash Tone of muscles 178 Weight 222
149 in abdomen 130 in children 236 loss of 10
Sensory system inchest 100 Tonsil 228 WernickeDs
in children 237 Sulfhemoglobin 26 Torsion spasms 196 dysphasia 149
Sign Summary Torticollis, spasmodic Wheals 28
Babinski's rising up of examination 196 Whispering pectorilo
200 general physical 29 Tracheal tug 90 quy 100
Brudzinski’s 237 of alimentary sys Transcortical motor dys causes of 100
Chvostek's 210 tem 132 phasia 146,150 Word blindness 146,151
Gower's 238 of cardiovascular Transcortical sensory Word deafness 146,151
Hoover's 200 system 80 dysphasia 146,
Kernig’s 237 of respiratory sys 149
Kussmaul 48 tem 103 Tremors Xanthochromia 215
Trousseau's 210 symptoms 4-33 flapping 195
Signs of Symptoms intention 195
chronic ischemia 81 in children 217 parkinsonian 195
deep venous thrombo of cardiovascular sys Trochlear nerve
sis 82 tem 33 examination of 160
root irritation 209 of deep venous throm Trousseau's sign 210
Skin bosis 82
in newborn 239 routine questions &■■■■■■■
lesions, definitions about 6 Umbilicus
of 28 Systemic inquiry in newborn 240
PDFelement
TREATMENT
GUIDE
■
e,
param0l!,]t
pubUsbi»9
Enterprise
treatment
TREA i
1 •‘“Sunt .s»
GUIDE
d NasU-
Muhan,n,‘
1
PDFelement
BEDSIDE
TECHNIQUES
Methods of Clinical Examination
About the Book

Bedside Techniques: Methods of Clinical Examination is a distinguished book, explaining the
1462 relevant signs and symptoms correlating to the disease. Clinical judgement and
assessment is an integral part of medical knowledge, diagnosis and management of patients.
This book provides, all essential to the need and knowledge of undergraduate (third, fourth
and final year MBBS) and postgraduate (MCPS and FCPS) students.
About the Author

Dr. Muhammad Inayatullah is a graduate, and now, a professor of Medicine at Nishtar Medical
College, Multan. He is also a Fellow of Royal College of Physicians, London.
This ambitious and talented author has penned two other books, ^ Essentials of
Differential Diagnois and Treatment Guide 2013.
9789694949208

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Remove Watermark Wondershare

A book for medical students and doctors

Shabbir Ahmed Nasir

Paramount Books (Pvt.) Ltd.

©Paramount Books (Pvt) Ltd.

All Rights Reserved

.Paramount Books (Pvt.) Ltd.

Introduction................................ 1 Summary of Examination... 80

Writing Out Routine 6. Pediatric Clinical Examination.. 216

Dr. Abdul Rauf Ahmad (late)

PREFACE TO THE FIRST EDITION

Muhammad Inayatullah MRCP (UK)

PREFACE TO THE FOURTH EDITION

Muhammad Inayatullah FRCP (LONDON)

Remove Watermark Wondershare

Remember: far from the truth. Laboratory tests are

the interview is over and before Sex

or. unimportant/unrelated to present

oliguria, nocturia, passage of gravel in + History of admission to hospital,

with the main site, eg, pain of cholecystitis 7. Dull

other symptoms may be present, like Pattern of Fever

HISTORY TAKING AND PHYSICAL EXAMINATION

4 Sore throat. 4 Pressure symptoms (eg, dyspnea or

+ Tenesmus (sense of incomplete Jaundice

burning micturition; pain in the + Onset: sudden or gradual.

Posture and Attitude

proximal part of the nail which is

Cyanosis: It means bluish discoloration

+ Finally, due to overall swelling,

+ Schamroth's sign is present. (When two Gastrointestinal tract disease

Splinter hemorrhages: These are

Fig 1.9: Splinter hemorrhages

Leuco nychia: These are white patches

Fig 1.11: Nodes in the fingers (A) Heberden’s (B)

is seen in some normal subjects. It

Fig 1.14: Rheumatoid arthritis (A) button-hole and

Sweating: Excessive sweating on the

Blood Pressure General appearance: There are certain

Fig 1.17: Palpation of thyroid from behind

Retrosternal thyroid. Thyroid can

+ Pre and postauricular. + Size.

Fig 1.19: palpation of supraclavicular lymph nodes

Note the following features if lymph

For palpation of anterior group, hold Lymph Nodes of Groin

When a group of lymph node is

generalized anasarca.and pitting can be State of Hydration

Pallor Peripheral cyanosis

1. Respiratory failure (page 106)

In cirrhosis, the pubic hair distribution

Definitions of Skin Lesions Ecchymosis: These are large reddish

SUMMARY OF GENERAL PHYSICAL EXAMINATION

Pulse Rate and rhythm

WRITING OUT ROUTINE EXAMINATION

leaning forward and may get worse on

Fig 2,2: Palpation of carotid pulse

Femoral pulse: Press with the thumb/

Fig 2.1: Palpation of (A) radial pulse (B) brachial

Brachial pulse: Flex the patient's arm

Causes of abnormal heart rate

Causes of atrial fibrillation

v________________________________________ y Volume of Pulse

In younger people it reflects stroke cause, but it can also occur in

Fig 2.13: Jerky pulse

Fig 2.11: Collapsing pulse