Allams Clinical Examination - Dr. M. Allam (2020-2021) PDF

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CO NT EN TS
• ALLAM'S CLINICAL EXAMINATION
1 General
1 .............................................. General sheet
4 .......................... :·................... General Examination
4 .............................................. Pulse
9 ................................................. Temperature
11 ............................................... Blood Pressure
13 ............................................... Respiraory Rate
14 ............................................... Complexions
19 ............................................... Neck Veins
25 ............................................... Regional Examination
33 ............................................... Generalized Lymphadenopathy
35 Cardiology
35 .............................................. Introduction
36 ............................................... Cardiology sheet
37 ........................................ ....... Symptoms of Cardiology
43 ............................................... General examination
45 ............................................... Local examination
46 ............................................... inspection& palpation
49 ............................................... Percussion
51 ............................................... Auscultation
58 ............................................... investigations in cardiology
59 ............................................... Treatment in cardiology
60 ............................................... Valvular Heart Diseases
60 .............................................. Mitra! stenosis
62 ............................................... Mitra! Regurge
63 ............................................... Aortic Stenosis
64 ................................................. Aortic Regurge V
65 ............................................... Marfan's syndrome
66 ............................................... Aortic Regurge
67 ............................................... Congenital Heart Diseases
69 ............................................... Long Cardiology Case
70 Chest
71 .............................................. Introduction
73 ............................................... Chest sheet
74 ............................................... Symptoms of Chest
82 ............................................... Local examination
83 ............................................... inspection
85 ............................................... palpation
88 ............................................... Percussion
91 ............................................... Auscultation
94 ............................................... investigations in Chest
95 ............................................... COPD
97 ............................................... Lung Abscess
99 .............................................. Bronchiectasis
101 ............................................. Interstitial Lung Disease
102 ............................................. Long Chest Case
103 Abdomen
104 .............................................. Introduction
104 ............................................... Abdominal sheet
106 ............................................... Symptoms of GIT
Allam·s Clinical Examination

116 ............................................... Local examina tion
116 ............................................... inspecti on
119 ............................................... palpatio n
121 .............................. ................. palpatio n of liver
122 ............................................... palpatio n of spleen
125 ............................................... palpatio n of Kidney
126 ............................................... palpatio n of Gall Bladder
127 ............................................... palpatio n of Urinary Bladder & colon
128 ............................................... palpatio n of Abdomi nal masses
129 ............................................... Percussion
131 ............................................... Auscult ation
132 ............................................... Long Abdomi nal Case
134 Neur ology

135 .............................................. Introdu ction
139 ............................................... Neurological sheet
140 ............................................... Sympto ms of CNS
146 ............................................... Neurological examina tion
148 ............................................... inspect ion
149 ............................................... palpatio n
150 .............................................. Percussion
150 ............................................... Power
153 ............................................... Coordin ation
154 ............................................... Reflexes
158 ............................................... Sensory sensation
165 .............................................. Cranial Nerves
174 ............................................... Summa ry of CNS sheet
176 ............................................... Paraplegia
179 .................................................Hemiple gla
181 ............................................... Diabetic PN
182 ............................................... Cauda Equina
184 ............................................... Ataxia
186 ............................................... Myopathy
189 ............................................... Multiple sclerosis & Parkinson ism
190 ............................................... Chorea
l 92 ................................................. Neurolo gy long case
191 Rheu mato logy

194 .............................................. Introdu ction
195 ............................................... Rheumatological sheet
197 ............................................... Rheumatological examination
207 ............................................. Examination of the Hand
208 ............................................... Rheumatoid Arthritis
210 ............................................... SLE
211 ............................................... Ankylos ing Spondylitis
212 ............................................... Psoriatic Arthritis, Scleroderma
214 ............................................... Other C.T disorders
213 Misce llaneo us

216 ............................................... Hemato logy
l.__/ 221 ............................................... Renal
223 ............................................... Endocrine
Allam s Clinica l Exami nation

ALLAM'S CLINICAL EXAMINATION ► GENERAL:
GENERAL SHEET
1- History:
2- Examination:
3- Investigations.
7=
- - - - - - - - - r - - Personal history.
General
Complaint.
History of present illness:
Past history
4- Diagnosis . Local
Family history.
5- Treatme nt.
HISTORY
► Personal History: NASOM RH

1. Name: ( J'lti I"'"'~'> !4,!I cl;-""" I"'"'' • Farmers: bilharziasis - farmer's lung.
• To be familiar with the patient. • Medical staff: infection - X-ray irradiatio n (bone
• Sex identifica tion . marrow depression - sterility).
• False errors may occur when two patients with 5. Marital state: ~a:... ris •-= ~_,;...,1 ! rl.S fa~.,1 l!I.= !r;:.9.;:o
the same name have been under treatmen t in the Ask about
hospital simultaneously. 1. Duration of marriage.
• For follow up. 2. Number of children .
2. Age: ! a... ris l!I.= 3. The age of the youngest one.
Diseases common Diseases common

6. Residence: !! l!lia l!lp J¥1 .fo.!l.-.9 ~.,,,.. !! iJ':9 .:,51..,
in children May reflect socioeconomic condition and may
in old age
occasionally point to a certain disease e.g:
• Rheumatic fever. • Bronchogenic Carci-
• Country: Bilharziasis - exposure to animals
• T.B. noma.
(Brucellosis) - insectcides.
• Hemolyti c anemia. • Atherosclerosis and
• Towns: anxiety - hypertension - IHD.
• Acute leukemia. coronary artery dis-
• Sharkia: Filariasis!! !
• Poliomyelitis. ease.
• Duchenne myopathy. • Corpulmonale.
7. Special habits:
• Friedrich's ataxia. Special habit is a habit that makes the patient more
• Chronic lymphatic
susceptible than others to a certain disease
leukemia.
• Multiple myloma. !ofai/1 o.i.Ai J"il.7 ~ ~ !a... rlS
cll~ ! r~I ~ OJ~ !.p~ rtS
!4,!J opl tJ,i ~u½-,WI ~ ~9 .W...... 44!->6! !ulJJ.N .,; op y~
► N.B. Ask about number of cigarettes/day and duration + type

Tumors occur in children:
of smoking (pipe, cigarette)
• Wilm's tumor of the kidney.
• Smoking index= No. Of Cigs/day X duration in years
• Retinobalstoma.
• Mild ➔ < 100.
• Medulllob lastoma
• Moderat e ➔ 100 - 400.
• Heavy ➔ > 400.
3. Sex:
Diseases common in • Calculating pack years of smoking:
Diseases in female
20 cigarettes = 1 packet
male
Nomber of cigarettes smoked per day x nomber of
• I.H.D., Hemophilia, • S.L.E, Thyrotoxicosis
years smoking /20
Duchenne (X-linked) & Myxoedema. For example:
• Bronchogenic carci- • Chorea, Myasthenia.
A smoker of 10 cigarettes a day who has smoked for
noma
15 years would have smoked:
(10 x 15) + 20 = 7.5 pack years.
4. Occupa tion: ~4,!I~
• Ex Smokers means= he had stopped Smoking.
• lead worker: anemia - nephrop athy- peripheral
• ask your patient about shisha, Cannabis, Heroin or
neuropathy.
• Glass workers (Silicosis): interstitia l pulmona ry
any Drugs.
fibrosis (IPF).
• Asbestosis: IPF - bronchogenic carcinoma or me-
sothelioma.
•
► Hazards of Smoking :
C~ est C.V.s G.I.T. Other complications

• Chronic bronchitis, • Arrhythmia. • Peptic ulcer. • Cerebro- Vascular Stroke.
emphysema (COPD). • Hypertension. • Cancer lip and • Cancer bladder.
• Bronchial asthma. • I.H.D. tongue. • Tobacco amblyopia.
• Bronchogenic Carcinoma • Peripheral vascular disease. • Cancer esophagus • Intra uterine growth
• Post operative • Cancer stomach . retardation
pneumonia. (in smoker Pregnant Woman)
Qm:ffllffll -.J
Ask about the amount/ day. ._,,

10 gm alcohol = 30 ml of whisky= 100 ml wine = 250 ml bear.
Excessive alcohol intake: ..._,,
Male consumes> 21 unit/ week & female consumes> 14 unit /week.
► Hazards of Alcohol :
GIT CNS CVS

• Mallory-weiss syndrome • Wernicke's - Korsakoff syndrome (Opthalmoplegia + • cardiomyopathy
• Alcoholic fatty liver ataxia+Confusion +amnesia + confabulation).
• Alcoholic hepatitis then • Polyneuropathy.
cirrhosis. • Proximal myopathy.
• Acute hemorrhagic • Optic atrophy.
pancreatitis. • Hallucination - delirium and coma.
► N.B.
Familial tremors are Improved in small amount of alcohol
Please Write Personal History in a single paragraph as:

Male Patient XX X, 45 year old, driver, born in Zagazig but he is living now in Abbasia Cairo, Married 20
Years ago and has 3 living offsprings, the youngest one is 3 year old, he is a cigarette smoker, 20 cigarette/
day for 15 years and there is no other special habits of medical importance.
► Menstrual History :
In female added as a part of personal history:
• Date of Menarche and menopause.
• Menstrual cycle (rhythm, length, duration of the flow, amount and color) .
• Dysmenorrhea.
• Contraception ( current use ) . '--"
• Example: Her menarche at age of 13, 4 days of moderate amount of bleeding every 28 days without use of
Contraceptive pills and no dysmenorrhea.
► N.B. In neurological sheet add handedness to personal history
► Complaint: C/O + Duration

• By the patient own words; No medical terms.
• As short as possible (one complaint is enough) .
• Don't get confused by the patient words, take the most recent and agonizing complaint
Example: the patient is complaining of shortness of breathing of 1 week duration
....__,
► History of present illness (H.P. I):
1. Analysis of complaint. HPI should be:
2. Symptoms of the related system. (If present • As long as possible and Contains medical terms.
3. Systemic Review. • In chronological arrangement.
4. Investigation & treatment (related diseases). • In the form of a story.
5. Diabetes Mellitus and Hypertension (if present).
Analysis Of The Compla int:

For analysis of any complain t in chest as usual (8) + 3 variants+ 3 for any excreta.
& if not present: No
8 as usual:
• Onset - course - duration. 1 u½~ Jc,~ 3 1l J~ 3 i 1:,,-!t...1 i.s..1.o iJ.; ~ ~J..:.!½ u~ .;,1_,.•.i,111
3 "-:!! ~1 ~ ~9 o~ u~ i.sµ1
• Association. l o~Y.,.. i:,~ ~ ,).JI '½,)WI .;,1.,...~1~:;;9 ~~ 4-!~ .:..;IS JJl>
• What increase and what decrease . l ~ <fll 4:>.!.9 lo~ J,yi)I ~3~ .,.u1 "-:!!
• Effect of treatmen t. 1 '-?.'> Lo ~j ~ ~3 ~ .;,1.,...~1 ct'ila!I ~~ 1.1, JJl> m ~ t'ila!I ~b
• Date of last attack. l i?! i:,IS " o~ .;,_,.,.;1 ~! J~9 " J,yi)I cll~ o_,... _p-1
+ 3 variants + 3 for any excreta: + 3 for any pain:

• Postural.1 ~ ~ 9 J ~~ F ,!I~ • Amount. • Site
• Diurnal. l ~ ~3 1 ~1 J -I.!~ o~ J,yi)l • Content - Color - Consistency. • Character
• Seasonal.1 u.,__p- ~3 1:,,-!J 1 .~ ~3 '-'½-" ~ 3 i ~~
• Odour. • Radiation
► Past history:
Disease Operative ' Drugs

• D.M. ( if-ve) • Date. Drugs of chronic use as:
• Hyperten sion. ( if -ve) • Site. • Long acting penicillin (Rh. F).
• T.B. • Outcome . • Corticost eroid.
• I.H.D. • Blood transfusio n. • Contrace ptive pills.
• Anti T.B.
• Anti hyperten sive .
. Talk about the following in any disease in the past history:
Duration , Manifest ed, Investiga ted. Treated & Complic ated or not
► Family History:
• Consanguinity.
• Similar condition s.
• Chronic diseases: - DM /hyperte nsion/ TB/ IHD.
• If not present: write irreleven t
► Socioeconomical state:
• High social class: Hyperten sion - I.H.D - irritable bowel disease
• Low social class: malnutrit ion - infections .
Don't Rush to examination before making a

really good history, Always remember;
GOOD DOC TOR ....

GOOD HISTORY...
•
GENERAL EXAM INATION
1. Vital Signs: 3. Regions:

1. Pulse 1. Head & face examination
2. Temperature 2. Neck Examination
3. Blood Pressure 3. Upper Limb Examination
4. Respiratory rate 4. Lower Limb Examination
2. General Overview: 5. Back
1. Appearance & Attachment as canula, catheter & 4. Other Systems Except that of local examination
ECG monitor .. etc
2. Built
3. Consciousness
4. Decubitus
5. Facial Expression
~l.9; l Vitals: E
Other method for General Examination:
0 pulse
Blood pressure
Respiratory rate
Temperature.
__,
0 ilt: Over built, average built or under built
.._
G C.Omplexion: pallor, jaundice and cyanosis:
G Decubitus or position see pictures later in inspectio_n section
Neck vein (H & N)

0
0
E Clubbing (upper limb) & Flapping tremors in respiratory failure (CO2 retention)
Lower limb edema (lower limb)
.,S..s Mentality, Face + general lock.
Pulse
Definition:
A pressure wave transmitted from ventriclar ejection of blood to be palpated in superficial artery against bone
Manuver of examining radial pulse (most commonly used): -..._/
Encircling the wrist & palpating the radial artery by the middle 3 fingers (index &
ring fingers for slight compression & the middle finger for palpation). the artery is
between the radial styloid process and the tendon of flexor carbi radials. make sure
that the patient elbow is semiflexed to avoid streach of the brachia I artery by the
fascia in the cubital fossa.
Comment on:
1. Rate 6. Condition of the blood vessels
2. Rhythm 7. Peripheral pulsations.
3. Volume 8. Force.
4. Equality (in volume) on both sides. 9. Tension.
5. Special character.
lki 4
ldialy count rate in one minute, if pulse is regular you may count in 30
sec. and multiply by 2, or in 15 sec. and
multiply by 4.
Normal HR: 60 - 100 beat/ min under complet e physical & mental
rest.
Tachycardia: ( Rate> 100 / min)
Bradycardia: (Rate< 60 /min.)
► N.B.
Examine pulse in the followin g order:
Rhythm » Rate» Volum e» Equalit y» Special charachters » Vessel
wall » Peripheral pulse.
Examine rhythm before rate if regular count in 15 or 30 sec. if irregula

r you must count in comlete minute .
.---- - - - - - - - - - - -- Rhythm
Regular .....--- - - - - - - - - - Irregular

Normal
Irregular Irregula rity Regular Irregularity
1. A.F. (complete irregula rity) Pulsus bigeminy
2. Multiple extra systol es (occasional irregula rity) Pulsus trigemin us
3. Ventricular fibrillati on
4. Ht. Block with changeable degree of block.
5. A. flutter with changeable degree of A-V block.
Extra systole Atrial Fibirilation

(with S. tachycardia)
Pulse
Rhythm Occasional irregula rity marked irregula rity (I can't count 4
or 5 regular successive beats)
Rate According to sinus usually rapid e.g. 100- 150/min
Carotid massage
slowing of pulse
Exercise May Decrease irregula rity increased irregula rity
Pulse deficit (see below) <10 beats/m in >10 beats/m in
Res. sinus rhythm Positive negative
markedly irregula r
► N.B.
Slow AF may occur in treatme nt with digitalis, Beta blockers, associat
ed Heart block or lone AF
•
ALLAM 'S CLINICAL EXAMINATION ► GENERAL:
3. Volume:
Pulse pressure (Volume or Amplitude) = Systolic blood pressure - Diastolic blood pressure e.g. 20 - 60 mm Hg.
Judged by the movement of the palpating finger produced by the arrival of the pulse wave.
Big pulse pressure:
• Pulse pressure> .1/2 systolic blood pressure
• or Pulse pressure> diastole. Or roughly pulse pressure> 60 mmHg
Small Pulse volume Big Pulse volume Variable Pulse volume

• Small stroke v. (low COP) • A.I. - P.D.A. - AV fistula • A.F.
• Shock: Thready pulse; weak & rapid • Arteriosclerosis of the aorta • V. Tachycardia.
• Bradycardia in C.H.B. • 3rd H.B.
-
• Tachycardia
• Hyperkinetic state (3H3P3A) • Pulsus alternans
Hyperkinetic state:
4H: Hypoxia, Hyperthyroidism, Hepatic Faliur & Hyperthermia
3B: Pregnancy, Beri Beri & Paget's
3A : Anemia, AV fistula & Anxiety
4. Equality:
Encircle both hands and feel the both radial arteries,
Both radial arteries must be examined at the same
time for equality as regard volume.
Causes of unequal pulse:
A. Compressing from outside B. Causes in the arterial wall C. Causes occluding the lumen
1. Cervical rib . • Aortic arch aneurysm • Thrombosis.
2. Cervical L. Ns. • Coarctation of the aorta (pre ductal) • Embolism .
3. Pancoast tumour • Aneurysm of subclavian a.
• Arteritis.
.......
► N.B. (on request)
Unequal pulse rate occurs in one rare situation: pulsus alternans with decreasing volume in one side as _,
pancost tumor
5. Special character:
-.._/
1. Water hammer pulse= collapsing pulse= bounding pulse :

Sharp ascending and sharp descending with high
amplitude
best examined by raising the arm to decrease the
diastolic BP and to maximise the gab between S &D
while palpating the forearm by the palm .
Causes: the same causes of high pulse P. (see volume)
2. Plateau pulse = pulsus tardus et parvus:

slow ascending and slow descending with low ... ....
~
amplitude .
Causes:
• A.S. ( moderate or severe cases)
• B blockers therapy
• L.V.F.
3. Pulsus paradoxus:
Marked drop in the systolic pulse during inspiration ► N.B.
(more than 10 mm Hg) Mechan ism of Pulsus Paradoxus:
Causes: • It's a wrong term because it's an exaggeration
• Pericardia!:- tampon ade, constrictive or effusion of normal not a reversal of normal
• Severe congestive H.F. • Norma lly during inspira tion the lungs expand
• COPD (especially severe asthma) and accomedate more blood that decrease
Detecti on: blood volume on left side ➔ ._l, systolic blood
by Palpation (marked drop) or sphygm omano metery pressure ➔ ._l, pulse volume
(mild drop) Measure B.P. during inspiration & during • But also during inspira tion venous return in-
expiration. creases, some compansation occur and the net
result is decreasing systolic BP and pulse vol-
4. Pulsus deficit: ume< 10 mmHg
Search for Pulsus Deficit in irregula r pulse • If venous return is decreased pulsus paradoxus
HR on apex> radial pulse occurs
Explain: Contraction of an empty ventric le (so some
weak beats are unable to reach the radial artery).
Causes:
• A.F >10 beats/m
• Extrasystoles < 10 beats/ m.
You can't count 2 things at the same time, but 2 doctors
can do pulsus deficit at the same minute , one countin g
apical pulse and the other countin g radial pulse; the
most acciptable tichniq ue is countin g the difference
betwee n apical beats (Sl) by stethoscope and radial
beats.
5. Pulsus bisferiens =bifid =double hump:

Best seen & felt at carotid artery
Causes:
• A.I. combined with A.S. (double A)
• Severe A.I.
• Hypert rophic obstruc tive cardiom yopath y
6. Pulsus alternans:
Alterna tion of strong & weak pulse waves with
Equidistance, as volume is reduced in every other
beat.
Causes: Severe L.V.F.
Mechan ism: Thers are a difference in refracto ry
period betwee n healthy and diseased fibers.
Strong beat means all ventric le contracts, Weak beat
means only healthy fibers contrac t
Detecti on: by palpation or by sphygm omano meter by
countin g pulse at time of high systole then countin g
again withou t using sphygm omano meter.
If douple d means pulsus alternans
7. Pulsus bigeminus, Pulsus trigem inus & pulsus

quadrigeminus:
Cardiac phenom enon characterized by groups of 2
beats close togethe r followe d by compansatory pause
Causes:
• Ventricular premat ure beats
• Digitalis toxicity
• Myocar ditis
•
• Myocardial infarcti on
► N.B. ► N.B.
Unequal Carotid Pulsations: Causes of absent or decreased pe ripheral pulsation :
• Atheroma of in nominate artery or common • Leriche's syndrome
carotid artery 1. Claudication of the buttocks and thigh
• Aortic aneurysm or dissecting aneurysm 2. Absent or decreased femoral pulsations
Special characters of pulse in aortic vulve diseases: 3. Impotence
• AS: Plateau pulse • Coarctation of aorta
• AR: water hummer pulse (Collapsing pulse) • Extenssive atherosclerosis
• Douple aorta: pulsus bisferiens • Peripheral embolism
• Thromboa ngitis oblitrans (Burger's disease)
Rolling maneuver :
distal and proximal occlusion of small segment of that artery by the index and ring
fingers, rolling of the middle finger.
Osier's maneuver :
occlude the brachia I a. by one hand (or by sphygmom anometer cuff) & palpate the
radial a. by the other hand .
Result: Normally the arterial wall is not felt (or felt & elastic)
Causes of palpable arterial wall :
• Systemic atherosclerosis.
• Focal arteriosclerosis.
• Polyarteritis nodosa: grape like along course of the artery. .
..._,,
Other peripheral arterial pulsations & capillary pulsation

)
Most commonly used one is dorsalis spedis artery {despite it's absent in 15% of normal population
Body map for superficial arteries that can be used for pulse exam ination:
Sup. Temporal Ant. & sup to tragus

-
Radial Lateral to the tendon of flexor ~ - - - superficial Temp. a.
carpiradialis . Facial & Maxillary a.
Brachia! At the elbow medial to the biceps ,..,- - - Carotids
tendon.
Subclavian Pressing downward above the middle
of clavicle .
Carotid Medial to the sternomas toid muscle
At the level of cricoid cartilage Brachia! - - f f.A
Against the transverse process of 6th Ulner

C. vertebrae. Radial
Femoral At the patient midpoint of inguinal
ligament while the thigh is flexed and
abducted.
Popliteal Middle of the popliteal fossa while
the patient lies supine with the knee
slightly flexed.
Posterior Behind the medial malleolus .
..;
tibial
Anterior Tibial Midway between medial and lateral
malloulus against ankle joint
Dorsalis pedis Lateral to the extensor hallucis longus
tendon against navicular bone on the
dorsum of the foot.In the 1st interos-
sus space (normally absent in 15% of
population ) .
0
► N.B. ► N.B.
Force = Systolic Bp Radio Femoral Delay
Least pressure needed to Means femoral artery is weaker and
occlude arterial pulsations delayed than radial artery in cases of:
Tention = Diastolic Bp • Coarctation of aorta
Least pressure needed to feel • Saddle shaped embolus at
arterial pulsations bifurcation of aorta
Example of normal pulse:

patient pulse is regular, 75 beats / minute, average volume, equal in both sides,
no special character, normal
vascular wall & intact periphera l pulsations with no radiofem oral delay.
ExampJe for aortic reguage:
patient pulse is regular, 75 beats / minute, big volume, equal in both sides, water
hummer pulse, normal
vascular wall & intact periphera l pulsation s with no radiofem oral delay.
Example for AF:
Patient pulse is irregular 95 beats / minute, variable volume, equal in both sides,
with pulse deficit> 10
beats / minute with intact periphera l pulsations and no radiofem oral dealy
Temperature
Using Mercuria l thermom eter
Oral temp: Under the tongue with closed lips for 3 min
Normal: 36.5 - 37.2 •c
• Terms:
•
False decrease: • Subnormal Temp. < 36.5 °C.
• Mouth breathing . • Fever> 37.2 °C. L Low grade :538.5
• Incomple te closure of mouth. High grade >38.5
• Putting thermom eter for too short time. • Hypothe rmia = :5 35 °C.
Conitions in which we can't measure tempera ture orally: • Hyperthe rmia = > 41 °C.
Child, Colvulsions, coma, dyspnea (mouth breather)
mentally retarded patient, persistent vomoting , painful oral ulcer, trismus of jaw
Rectal temp: Left for 2 min. (0.5 °C higher) .
Axillary temp:
Put in axilla for 3 min . (1/2 °C Lower).
e
ALL AM'S CLINICAL EXAMI NATION ► GENERAL:
e-ci.11 Temperature
► Types of fever :
Fluctuation
Base Continuous Remittent Intermittent Relapsing
1. Continuous: {Gram negative sepsis, CNS damage)

Fluctuation: <1 •c & >baseline.
2. Remittent: (Viral, TB)
Fluctuation: >1 ·c & >baseline.
3. Intermittent (Hectic): {Abscess- malaria)
Fluctuation: >1 ·c & may reach the base line within hours
4. Relapsing (cyclic, periodic): (Collagenosis, lymphoma, brucellosis, IMN & FMF)
Days of fever and days of normal
► Temperature - Pu lse relationship:
• Synchronization between rise in body temperature and pulse rate documented as:
Each 1' 1 ·c ➔ 1' 10 -15 beats/m in HR
• • •
Relative Tachycardia Relative bradycardia
HR more than expected for body temperature as HR less than expected for body temperature as
Myocarditis {Rh. F/Diphtheria). typhoid F/ menin itis.
► Temperature - Respiration relationship :

Each 1' 1 ·c ➔ 1' 4 cycle/m
Causes of Hypothermia: Causes of hyperthermia:
• Hypothalamic lesion • Heat stroke ._,.
• Myxedema • thyrotoxecosis
• shock
• Starvation
•
Blood pressure
Introduction:
Factors affecting blood pressure: Classification of blood pressure measurements:
Systolic Diastolic Category Systolic BP Diastolic BP
C.O.P (Lt. V. systolic P. & • Peripheral resistance • Optim al < 120 < 80
stroke volume ). (vascu lar tone) & intact • Norma l <130 < 85
aortic valve. • High norma l 130--139 85-89
• Elastic ity of Aorta .
Hyper tensio n
• Bl. Volum e.
• mild (Stage I) 140-15 9 90-99
• Bl. Viscos ity.
• Moder ate (Stage II) 160-17 9 100-1 09
• Severe(Stage Ill) > = 180 > = 110
For meas urem ent of blood pressure you have to do:

1. Palpatory and auscultatory 3. Upper limb and Lowe limb
2. Right and Left 4. Laying flat and on standing
1. Palpatory and Auscultatory :
Patient : The doctor:

• Put the patien t's arm at the same level of heart
• Palpate the patien t's radial pulse and inflate the
with the same level of sphyg moma nomet er
cuff until you feel the exact point when the pulse
• Make sure that they do not have any tight clothin g
disapp ears (estim ated systolic pressu re).
which may constr ict their arm
• Place the stetho scope over the brachia I artery
• Under compl ete menta l and physical rest
and inflate the cuff 30 mmHg above the estima ted
Apply blood pressure cuff:
systolic pressure.
• The bladde r of the cuff should encircl e 80% of the
• Release the pressu re slowly, no greate r than 5
arm/ not tight nor loose.
mm Hg per second.
• The centre of the cuff bladde r should be placed
• The level at which you consis tently hear beats is
over the line of the brachia I artery.
the systoli c pressu re.
• Appro ximate ly 2 cm above the anticu bital fold.
• Contin ue to lower the pressu re until the sounds
disappear. This is the diastol ic pressu re.
Lastly: Remove the cuff.
Palpatory Auscultatory
' Advantage avoida nce of auscul tatory gap.
1--- ---- =--- ---+ -- __; . . . . , = . . - ' - - - - -Can detect Diasto lic Bp
Disadvantage can't detect diasto lic B.P.
+---- --- -~- --- --- -1
Presense Auscu ltatory Gap
•
Auscultatory Gap: (Silent gap)

Defenition: Period during measuring blood pressure by auscultation in which no sound can be heard but
blood passes and can be felt; Present with unknown mechanism, and some hypertensive patient leads to
false measurement
Kortakoff phases: ll'"
• 1st sound heard.
• Sounds markedly decreased or may disappear (mistaken for D).
• Sounds reappear (mistaken for S).
• Sudden muffl ing of the sounds.
• Total disappearance of the sounds.
2. Measure right and left :

,,
Noramlly there is a difference less than 10 mm Hg between both sides
If more than 10 mmHg, that means unequal blood pressure (the same cause of unequal pulse)
3. upper limb and lower limb :

• Blood pressure in lower limbs> blood pressure in upper limbs by less than 20 mmHg which is normal and
called "Hills phenomena" due to:
• True increase : as arteries in lower limbs are in line with aorta .
• False increase : as arteries in lower limbs are surrounded by bulky muscles,, so muscle need high pressure -
in bag to occlude the artery.
• If blood pressure in lower limb> blood pressure in upper limb by > 60 mmHg it is called : "Hills sign" in AR. '--•
• If blood pressure in lower limb< blood pressure in upper limb it is called: "reversal of Hills" and occur in
coarctation of aorta. "
Measurement of B.P In the LL:
• Pt. is lying in prone position. -_.-
• Apply the cuff around the lower 1/3 ofthe thigh above popliteal fossa .
• Auscultate (or palpate) popliteal artery.
• Continues as in U.L.
4. Measure blood pressure on laying flat and standing :

Measure blood pressure on supine position and then ask the patient to stand up and remeasure again after 1-2
minutes
• if Systolic Bp decreased > 20 mm Hg or diastolic BP > 10 mm Hg that means postural hypotension
• In postural hypotension (orthostatic hypotension = orthostatic syncope}
During Standing there is large fall in both systolic & diastolic B.P. (Normally there is a slight fall in systolic B.
P. < 20 mm Hg and increase in diastolic B. P. < I0mmHg).
► Orthostatic Hypotention: ► N.B.

• Autonomic neuropathy, e.g. Diabetes. B.P. in obese arm :
• Sympatholytic drugs, e.g. ganglion blockers • Use wider cuff that can encircle the arm
• Lumbar sympathoectomy. completely, or
• Hyponathremia . • The cuff wrapped around the upper 1/3 of
• Prolonged recumbency. the forearm & diaphragm of stethoscope is
• Elderly patient. positioned over the radial artery.
• Huge varicose veins.
• Hypovolaemia. e.g.: Haemorrhage or Aneroid
dehydration.
• Weakness of the muscles of the lower limbs
(muscle pump) .
Types of sphygmomanometer:
• Mercurial : old but accurate
Mercurial
• Aneroid: no fluids, may be used
• Electronic (Digital) : recent but less accurate
ALLAM'S CLI NICAL EXAMINATION GENERAL:
Uses of sphygm omano meter:

1. B.P. & pulse changes: 3. Diagnostic tests:
• Measur ement of B.P. • Capillary fracilty test (Hess test)
• Determi nation of pulse pressure (S-D) • DVT: application of low pressur e will came se-
• Detection of pulsus alternans: if pressure is vere pain in diseased leg
between weak beat & strong beat the radial • Diagnosis of tetany: Trousseau's test (carpo-
pulse will drop by half as, the weak beats will be pedal spasm).
abolished. • Wallrer"s test fur diagnosis of Myaslhenia gram.
• Detection of pulsus paradoxus: systolic B. P. will
drop during inspirati on (more than 10 mm Hg.) 4. Others:
• Detection of unequa lity of pulse in both sides • Tourniquet in venesection.
(differen t blood pressure in Rt. & Lt limb). • Haemos tasis.
2. In some valvular disorder s:

• In coarctation of aorta: B.P. in arms more than
B.P. in legs by more than 60 mm Hg (reversal of
Hill's).
• In A.I. : B.P. in leg is more than B.P. in arm by
more than 60 mm by (Hill's sign)
Respiratory rate
Resp. rate: 12 - 20 cycles/m in
Count respirat ory rate while you are simulati ng counting pulse to distrad
your patient
Type:
• Male: abdomi no thoracic
• Female: thoraco abdomin al
For more details see chest
Built
-
Over bui lt average built under built Dwarfism
Determi ned by noting the weight and height in relation to: Age & Sex.
humb le.sl In Marfa n's S
• Height
f-,
• Dwarf (stunted growth) : as in
•
• Familial
• Congenital cyanotic Heart Diseases:- Fallot tetrology.
• other details in endocrin ology
• Tall: as in
• Marfan's syndrome (tall, arachnodactyly, pes cavus, high arched palate,
ectopic lens, up ward sublaxation of lens and A.I.)
• Other details in endocrin ology
•
ALLAM 'S CLINICAL EXAMINATION ► GENERAL:
► N.B.
Built is usually by just inspection without measurment while weight is by measurment
• Weight
It can be determined by
1. body mass index (BMI): which is derived from the 3. Waist/ hip ratio {in male <0.95 in female <0.85}
formula Wt (Kg)/ Ht (m 2 ) Apple shaped persons with a greater waist-hip
2
• Normally it is "18-25 l<g\M " (average Weight). ratio have
• Under built: < 18. an increased risk of cardiovascular disease
Feature
• Overbuilt: 25-29.
• Obesity: 30-39. L • Class 1 (30-35) • The height and span are almost equal.
• Height: distance from the occiput to the heels in
• class 2 {35 - 40)
• Morbid obesity: 40 or more . upright position.
• Span : distance between the tip of the fingers
2. Obesity c.an be assessed by the thickness of skin with outstretched hands.
folds e.g., • Lower and upper segments are usually equal
• Lateral aspect of the arm 0.9 -1.1 cm. • L. segment= distance between symphysis pubis
• Abdomen = 1.5 cm. and floor
• Buttocks= 1.5-2.5 cm. • U. segment= distance between occiput and
symphysis pubis
kl~ fo ld oi ar m
C
"O
"O
(0
-,
':E0
(0
-,
Vl
(0
OQ
3
(0
:::J
r-t
. - .
Complexion (colors)
Pallor, Jaundice, Cyanosis, Pigmentations & Skin rashes
QWIMI
Definition: Diffeciency of colour or decrease visability
of oxyhemoglobin . ► N.B. ...,,
Site of examination: • The degree of pallor depends on the state of
1. Inner aspect of lips (pull the lower lip outward capillaries, amount of blood within the capillaries,
gently) Hb, pigmentation & thickness of the skin.
2. Tongue • Examination of the mucous membranes may help
3. Skin of the face. 5. Palm creases. to distinguish pallor of anemia from that of other
4. Nails. 6. Conjunctiva causes.
Never examine pallor in Conjunctiva because
of endemic trachoma in Egypt that healed by
•
cicatrization
ALLAM' S CLINICAL EXAMINATION ► GENERAL:
► Q: Causes of pallor?
• Anemia
• Causes of pallor with normal CBC:
• Shock or .J, COP.
• Toxemia e.g. infective endocarditis.
• Edema of the face e.g. nephro tic syndrome.
• Racial pallor (Far East).
• Albinism
• Myxedema
• Lymphedema
► Jaundice:
Def.: yellow discoloration of skin & mucous membranes due

to increase level of bilirubi n > 2.5 mg%.
Sub clinical Jaundice: Serum bilirubi n == 1- 2.5 mg/di.
Site of examination: In sclera of lower fornix in the day light & soft
palate
(why sclera?): Because sclera is elastic tissue that has high afinity
to bilirubi n
Unilateral Jaundice: jaundice in a patient with one artificial Eye
& it may be an unusual finding ~
Types:
1. Hepatocellular J :- e.g.:- Viral hepatitis, cirrhosis: Orange
yellow ± L.C. F. Manifestations Liver is enlarged
& tender, later it may become firm and shrunken .
2. Hemolytic J. : Lemon yellow J. ± pallor
3. Obstruction J. : Olive green J. + pruritus, bradycardia & frothy
urine.
For more details see hepatology
► N.B.:
• It is best appreciated in fair-skinned individuals in
natural daylight.
• Jaundice should not be confused with carotenemia,
which also causes a yellow discoloration of the
skin, but the sclera remain white.
• During the examination, expose the sclera by
gently holding down the lower lid and asking the
patient to look upward. It is importa nt that the
examiner consider the possibility that in patients
with black or brown skin, hyperpigmented areas
on the sclera are often nonpathological and are
associated with the presence of melanin in the
tissue of the sclera .
DD of yellow discoloration of skin & sclera:

• Racial in nigros
• Atebrin
• Hypercaroteinaemia (not in sclera)
• Picric a. toxicity
• Uraem ia & Myxoedema
• xanthomatosis.
ALL AM'S CLINI CAL EXAMINATI ON ► GENERAL:
► Cyanosis:
Definition:
it is bluish discolouration of skin & m.ms, due to presence of more than 5 gm% reduced Hb.
Cyanosis is aggravated with ploycythaemia.
Site of exam:
• tongue, lips, hands; nails.
• Examination in daylight is essential.
Types:
1. Central. 3. Chemical (False)
2. Peripheral. 4. Differential
_,,
Cyanotic lung disease : Generalized decreased blood Flow :

• Asphyxia . • Polycythaemia: increased viscosity.
• High altitude. • Marked decrease in C.0.P.
• Pulmonary A-V fistula. • systemic venous congestion : (RVF& cardiac
• Lung diseases:- COPD, fibrosis, collapse, Massive con- Tamponade)
solidation, Pneumothorax or Pulmonary embolism • Shock
Cardiovascular system : Localized decrease in blood flow :
• Fallot's tetralogy • Cold temp.
• Eisenminger's (right to left shunt) • Peripheral circulation disturbance (Raynaud's,
Ploycythaemia (increase reduced haemoglobin) Burger's, venous thrombosis & Arterial occlu-
sion)
All the body: Skin of peripheral parts:

site Skin, conjunctiva, inner lips & tongue Tip of fingers, hands, tip of nose, ears, outer lips
~ d as in peripheral) (Tongue is normal)
Hand Warm (peripheral V.D.) Cold (peripheral V.C)
-- -
-i
warming No effect Cyanosis improved
Improves cyanosis No effect
0 xygen
---
(in pulmonary causes only)
Decreased arterial and venocapillary
-Decreased in venocapillary but normal in arterial
p02
blood blood
-- -ve
±
Clubbing
p loycythaemia
-
- -- - stimulate
+ (hypoxia erythropoisis)
- -ve
► N.B.: • Examination of under surface of tongue is better

• Why Tongue? than dorsum Due to:
• Has no autonomic (VC) fibers • Presence of viens on the undersurface
• Highly vascular • Presence of Papilae, Pigmentations or coat on
• Continuous exercise the dorsum
• Warm site
• Central and Peripheral cyanosis occur in one dis-
• Blu , on ~ µtril. , ral
0 . nosis occur in: ease: Polycythemia:
• Lingual vien thrombosis • Central: 1' Reduced Haemoglobin relativly
• SVC obstruction • Peripheral: stagnation by slow circularion
&J!!
_ _ , _.2-._ ! n· ra Cyano::.i ~ • Never to diagnose anemia (marked pallor) and
In differential cyanosis (see later) central cyanosis in the same patient
•
ALLAM'S CLINICAL EXAMIN:',TION ► GENERAL:
3. Chemical (False} cyanosis: Abdnorma l haemoglob in simulating reduced Hb & presented as central
cyanosis &
diagnosed only by spectroscopy
• Met-Hbaem ia: cong. / nitrites
• Sulph-Hbaemia: sulphonam ide treatment or bacteria
4. Differential central cyanosis: in the lower half of the body only:
• PDA with reversed shunt.
• PDA with coarctation of aorta (Preductal infantile aortic coarcetation)
Pigmenta tions:
• Haemochromatosis. • Malar rash in MS with PH++ due to:

• Addison's. • lry biliary cirrhosis • Reflex VD
• RF • Pituitary cushing • Compression of sympathat ic chain by Lt. Atrium
• Myxedema, Cushiong & Alcoholics
• Discoid: spare nasolabial fold in SLE
• Brown:
• Pellagra
• Pregnancy (Chloasma Gravidarum)
► N.B.:
Blue sclera in:
• Familial
• Gong. Glucoma
• Osteogenesis
imperfecta
• TB
► Skin Rash:
• Erythema marginatum: redness of the skin or mucous membrane s It is found primarily
on extensor surfac-
es; associated with bradykinin has been proposed in the case of hereditary angioedema
• Erythema nodosum: an inflammat ory condition characterised by inflammati on of the fat
cells under the
skin, resulting in tender red nodules or lumps that are usually seen on both shins. resolves spontaneo
usly
• Erythema multiformis: type of erythema follows an infection or drug exposure.
• Spider Nevi: and it's DD, See abdomen
rythema Mar lnatMm rythema Nadosum ~ •
•
ALLAM S CLINICAL EXAMINATION ► GENERAL:
Decubitus
Decubitus: Position of the patient in bed in relation to certain disease as Lat. Decubitus
Position: Position perfered by patient during siting as squating position
Attitude: Position taken by the patient on standing as flexion attitude.
Gait: Walk style of the patient as circumduction gait in hemiplegia
• Orthopnea: Semi setting position

• Heart: Lt. Sided H.F.& Pericardia! effusion.
• Chest: Br. Asthma & Emphysema
• Increased intra abdominal pressure e.g. massive ascites & Marked obesity. .-
• Platypnea: dyspnea in the erect position relieved by recumbency In huge apical lung tumors or
hepatopulmonary syndrome. -~
• Trepopnea (Lateral Decubitus): Patient prefer to lie on one side and dyspnea occur on the opposite side as
in pleurisy or lung abscess
• Squatting position: In Falott's tetralogy to increase blood volume & BP to the most important areas (heart &
brain) by squezing on peripheral BV
• The praying Muslim position (leaning forword position): pericardia! effusion, mediastinal syndrome &
acute pancreatitis.
• Opisthotonus: (high arched back) meningitis, tetanus or strychnine poisoning.
• Flexion attitude
• Passive in abdominal colic. • Or Rigid in peritonitis. • Parkinsonism
emislnnp PO'iition eanin forward oslt,r,n
oiSthotonus
•
ALlAM'S CLINICAL EXAMINATION ► GENERAL:
...
Neck Veins
Value: reflects pressure ch anges in sid e t he ri gh t atriu m as in t erna l jugu lar vien is con ne cted to Ri gh· at ri um
via
Superior Vena Cava without any va lves in betwe en.
Th e venou s pressure is measured most accu ratel y by manometrv.
Internal jugular vein is preferred:
. Internal jugular vein - ~...... . External jugular vein

• Valvless • may contain valves.
- - - ·--------i--- --- - ·----
• Dosen ' t pierce deep facia of the neck. • pierce deep fascia of the neck so easily occluded.
• Straight Course. • Tortous Course
• Straight line from the angle of the jaw to the medial • Line drawn from angle of mandible to mid clavicular
end of the clavicle deep to stenomastoi d & platysma point
muscles.
► N,B.
Right sided pulsation~ are preferred:
• Lt. lnnominate vein(= brachioceph alic) may be
compressed by the arch of the aorta lead ing to
congestion of left Jugular.
• Right int. Jugular vein indirect continuation with
the right atrium.
It is venous or arterial ?
Lower Lateral (LL) to stemomasto id in Medial &upper to stemomasto id in ant.

Sterno mastoid post. Triangle. Triangle.
----- --+-- ----- ----- ----~ _j --- ---
Better seen than felt - - - - - ~ ~ : Better felt than seen
Character Wavy: more than one wave Have an upper h
level One wave as no upper 1eve 1
A Synchronise with heart beats. Synchronise with heart beats.

Respiration Changed with inspi ration (empyting)
Position changed by position I not affect~
not changed.
------------t
Pressure oblitarated by pressure. ~ not oblitarated_b~ pressure.
Hepato•
jugular Reflux
+ve ( increase Pressure ) Ino effect
► N.B.
Hepato Jugular Reflux = one minute abdominal Compression test.
mild pressure on liver or abdomen leads to elevation of upper level of vien and dosen 't affect artery .
•
Comment on neck veins:

1. Waves (J.V. pulse).
2. Pressure (column elevation =congestion).
To know the relation between neck veins and cardiac cycle you have to remember at first cardiac cycle
Sl S2 51
Systole diastole
03sec. 0.5sec.
1. lso metric contraction phase. 1. lso metric relaxation phase. .../
2. Ejection phase. 2. Passive filling 70%.

3. Atrial contraction 30 %.
• Consists of three positives (A, C and V) and two negatives (X and V).
• The A wave is normally the highest wave.
• The X wave is usually deeper than the V wave.
• Radial pulsation is preferred for timing of the venous pulsations.
Elevation of the tricuspid valve at the start of ventricular contraction

CWave
or/ Transmitted pulsation of carotid artery.
X (Systolic
Right atrial relaxation. Systolic
collapse)
Accumulation of venous blood in the right
VWave Systolic
atrium during ventricular systole.
Y Wave: Descend of blood from atrium to ventricle
Diastolic
(70 %) passively.
• A wave: • Deep X:
• Large or giant A waves: T.S. / P.S. PH++ • Pericardia! effusion
• Absent A: Atrial fibrillation. • Constrictive Pericarditis.
• Cannon A wave: Nodular rhythm /V. tachycardia / 3rd HB • Deep V:
• Prominent V wave (systolic expansion} • Pericardia! Effusion
1. T.R. • Constrictive Pericarditis.
2. Right sided heart failure
3. AF.
a
4. Cannon waves
-
Definition:
it is the vertical height between the top of venous pulse & angle of
Louis when the Pt. is lying at an angle of 45.
Measurement:
I
• The Pt. is positioned at about 45° to the horizontal plane with Good Lightening.
• The head is supported by a pillow & the neck is slightly flexed to allow the skin &
muscles overtying the vein to relax, also the face is directed to the left side to relax
stemomastoid.
• The jugular V. pressure is measured as ''The vertical distance bet. the manubrio-
stemal angle & the top of the venous column
AL LAM'<; CLIN ICAL EXAMINATION GENERAL:
Norma l jugula r venou s pressu re :

• The angle of louis is about 5cm above Rt. A. at 45.
C.V.P.= J.V. pressure (---1 + 5cm = (---1 cm H20
• Norma l jugular venous pressure not more than 2 cm H20.
• Norma l pressure in Rt. A. (centra l venous pressure) less than
7 cm H20
Conge sted neck veins
1. Congested pulsating neck veins: 2.Congested non pu lsating neck veins:
• Right sided heart failure. • S.V.C. thromb osis causing comple te obstruc tion.
• Tricuspid valve disease as T.I. & T.S.
• Medias tinal syndro me causing comple te obstruc -
• Pericardia! (effusio n - Constri ctive pericar ditis).
tion.
• Increased intratho racic pressure (Massive pleural • Severe late constri ctive pericar ditis & pericar dia!
effusio n\ Tension Pneum othorax / Emphysema).
effusion
• Increased intra-ab domina l pressure (Tense ascites /
Pregna ncy/ Huge abdom inal swellin g). .B.
• Over transfu sion = hyperv olaemia Any severe congestion may appear as congested
• Hyperd ynamic circulat ion. non pulsating.
► N.B.
Neck vein & respi ration;
• lnsp. ➔ emptyi ng (norma l).
• lnsp. ➔ no change
• Congestive H.F. or,
• S.V.C. obstruc tion.
• lnsp. ➔ filling in pericar dia! disease "Kaussmaul's
sign".
• Exp. ➔ filling in emphys ema.
Examples to comme nt on neck viens:

1- if normal : non Congested neck veins with normal waves (Systoli
c collapse and normal inspira tory empytin g).
CVP < 7 Cm water.
2- in AF : Congested pulsatin g neck viens with normal inspira tory
empyti ng with systolic expansion (promi nant V)
and absent A wave. CVP > 7 Cm water.
•
ALLAM S CLINICAL C:XAMINAT!ON /> GENERAL:
Clubbing
Definition: Proliferation of soft tissues at nail beds & terminal phalanges due to Chronic toxemia, hypoxia,
irritation or immune disease
Causes of clubbing:
1. Pale (toxaemic) 2. Blue (hypoxic/ cyanotic)
needs weeks to appear needs months to appear
Cardiac • Infective endocarditis. • cong. cyanotic heart: Fallot's &
• Lt. atria Myxoma Eisenminger's
Chest • Suppurative lung S. Cyanotic lung diseases:
• Bronchogenic carcinoma • lntestitial pulmonary fibrosis
• Mesotheliom a.
• COPD (if associated with bronchectasis or
bronchogenic carcinoma)
• Fibrinoid TB
Abdominal • Bilharzia! polyposis
• Cirrhosis especially lry biliary cirrhosis
• Ulcerative colitis .
• Crohn's Disease
• Steatorrhoea
3. Familial: 5% benign condition

4. Occupationa l: some fingers e.g. index & thumb (shoemakers & carpenter).
5.Thyroid Acropathy : occurs in 1% of patient of graves (Clubbing, Exophthalmos, pretibia myxodema)
6. Unilateral clubbing : causes of unequale pulse on both sides,
7. Differential clubbing tin L.L. only): causes of differential cyanosis
Causes of reversible clubbing:

{Empyema, mesotheliom a & endocarditis).
Grades of clubbing:
• Grade I: obliteration of the angle between nail and nail bed(+ ve fluctuation test at nail base).
• Grade II (parrot beak): I+ increase convexity of nails in its longitudinal curve.
• Grade Ill (Drum stick) : I+ II+ hypertrophy of terminal phalanx.
• Grade IV (hypertrophic osteoarthropathy): Ill+ "tender" Hypertrophy of distal ends of long bones at
wrist & ankle due to periosteal irritation & new bone formation.
Examination:
• Look at fingers in profiles.
• Window test (Schamroth's window test : patient
holds 2 index finger nails touching each together:
if normal, will show a diamond-shaped window) .
• Fluctuation test at the nail base as clubbing in-
creases vascularity and act as a cystic swelling ...
see the picture below
•
ALLAM S UN 1CAL E AMI NATION GENERAL:
DD of clubbing (causes of psudeo clubbing) :

Definition : Over curvature of the nails in both longitudinal
and transverse axes, with preservation of a normal
nail bed angle
Causes:
• Chronic paronychia • chronic renal failure
• subangular hematoma • sarcoidosis & scleroderma
Oedema
Definition: means abnormal accumulation of fluid in the intersti
tial tissue due to disturbed mechanisms of
formati on of intersti tial fluid .
Comme nt on:
• Unilateral or bilateral (Unilateral: local diseas, Bilateral : system
ic disease)
• Pitting or non pitting (Pitting if soft as heart failur or LCF, non
pitting if hard as lymphedema &
myxodema)
• level (extent) for example below knee or generalized .. . etc
• Tenderness (painful! in inflama tion or obstruc tion as DVT; painles
s if just acumm ulation of fluid as LCF)
• Examination of serous membranes ( Lower limb edema with
ascites, pleural and pericardia I effusion
means Generalized edema .
Examination of oedem a:
• Below the knee pressure for about ½ minute over bony
prominence (Posterior to medial malleolus,
dorsum of the foot and the chin of tibia)
• Pinching test over the thigh
• Pedou-orange over the anterio r abdominal wall.
• Examine back for sacral edema .
► D.D. of generalized edema :
1. Cardiac oedem a: with congested neck veins.

• Bilateral.
• Unequal oedema occurs in case of deep venous thromb osis
(DVT).
• It may be on one side in Pts. preferring to sleep on one side.
• Painless.
• Pitting.
• Depend ant: appears in the depend ant parts of the body:
• Ankle oedema: in ambula nt Pt.
• Sacral oedema: in recumb ent (or bed ridden) Pt. (When oedem
a is very great; it may affect whole LL,
genitalia, abdomen, chest and even the face "generalized anasarc
a")
• Before ascites: always L.L oedema precedes ascites except
in 2 conditions where ascites precedes (asci-
tes precox):
• pericardia! effusion & constrictive pericarditis.
• T.R. or T.S. due to marked congestion of liver
Q: Pathogenesis of cardiac oedema ?
Al LAM'S CLINIC.AL EXAMINATION GENERAL;
2. Renal oedema: Occurs firstly in eye lids, generalized, pitting marked in the morning.
Nephritic: in acute nephritis Nephrotic: _
• Oliguria • Heavy albumlnurici
• Hypertension (Na & water ret) • Hypoproteinaemia
• Haematuria • Generalized oedema
• Epith & red casts in urine • increased cholesterol
3. Hepatic oedema: In advanced liver cirrhosis+ other signs of L.C.F.

4. Nutritional oedema: + other signs of nutritional deficiencies.
• Sever malnutrition.
• Sever malabsorption.
• Sever anaemia.
5. Angioneuroti c oedema: allergic.
• Non pitting, Acute, Localized (lips, eye lids, larynx) or generalized
• History of other allergic manifestation: eczema., asthma.
• Family history of allergy.
• Rapid response to anti allergic measures.
► localized edema :
1. D.V.T.
2. Lymphedema: ( non pitting) Filariasis - Post mastectomy. ..___,
3. Varicose veins: Mainly in LL.+ signs of varicosities.
4. Orthostatic edema: Mainly in LL+ diurnal variation ± Occupational Factors '-...../
5. Angioneurotic edema: Affecting the face (lips) asymmetrically, with history of allergy. Of sudden onset, self
limited
• Causes of edema in one UL or one ~.L.: DVT, cellulltis, lymphedema trauma

• Drugs causing oedema e.g. cortisone, pills, NSAID.
• Non pitting edema occurs in Lymphedema, myxoedema and Angioneurotic edema.
• Occ::ult Oedema: Up to 3 liters of excess fluid may be retained in the interstitial tissue without apparent oede-
ma Pitting oedema is usually demonstrated if accumulating exceeds this amount (3 liters).
Menta lity & Appearance

Mentali ty: Consciousness, orientat ion (Time, Place and Person mood
(emotio nal state), memory intelligence and
behavior.
Appearance: Healthy, ill, toxic, cachectic, irritable , Depressed ..... etc
► Example:
The patient is fully conscious, oriented with time, place & persons, emotion
ally stable with intact memory
as regard near & far events of average intelligence & behavio ur normally
.
'
Regional Examination
Face Examination :
Specific facial appereance and expressions can diagnose certain diasess
from the first Look.
hown:'M ongoloi d face+
....__
-L~~~ette~-~~r~.
• Toxic look: Infective endocarditis

• Mitra! face (malar flush): peripheral cyanosis of cheeks (low C.O),
Dilated
capillaries, lips may be cyanosed.
• Tricuspid face: tinge of jaundic e+ peripheral cyanosis of the lips.
• Congenital syphilis: Square like bulldog
• Uremia: Earthy look
• Homer's syndrome: See neuro
• Myopat hic face: Expressionless, protrude d lower lip
► NB: Mogolo id face:

• Down Syndrome: + epicanthal fold, flat philtrum , Low setted ear &
thin
upper lip
• Thalassemia.
ALLAN ~ LIN IC:AL E.l<AMIN Tl N GENERAL:
Head Examination:
,1@11
• Large Skull in acromegaly and chronic Hemolytic 7. Conjunctiva :
anemia . • Pallor: conjunctiva is not reliable to diagnose pallor.
• Hydrocephalus and Paget's. • Sub conjunctival hemorrhage: as in
• Microcephaly and craniostenosis. • hemorrahgic blood disease • trauma
• Enlarged supraorbital ridges: acromegally (forntal • cough • server hypertension
sinuses) • Infective endocarditis (Micro-embolization)
• Tender temporal artery: Giant cell arteritis. It usually has an upper limit to be differentiated from
• Bruit: on intracranial arteriovenous malformation or conjunctiva! congestion.
big cerebral aneurysm. • Conjunctivitis: C\P: photophobia, lacrimation and
• hair and it's pattern of distribution as silky hair in LCF. a sticky discharge).
• Vitamin deficiency: as Xerosis (Vit .A), Vascularization
( Vit.82 ).
1. Eyebrow: Loss of hair in outer 1/3 of eyebrow: • Pterygium patch of progressive fibrosis may encroach
(See page 32 picture E3)
upon the cornea.
• Myxodema. • Familial
• Leprosy. • Artificial ( the commonest) 8. Lens:
• Cataract occurs in:
2. Eye ball. • Cretinism.
• Diabetes mellitus.
,,- ~I 'Enophfhalmos i • Scleroderma
Exophthalmos 1
k ) I
• Mongolism
.
( •
sun en :eye • Hyperparathyroidism

• Myotonia atrophica.
• Thyrotoxicosis • Dehydration • Ectopic lens· in Marfan's syndrome
• cavernous sinus • Homer's syndrome
(pulsetile) ► .B.
• leukaemic deposits nuh l'
behind eye ball stigmas indicating maternal rubella infection:
• Con enital 1. Cataract 2.Mental defect 3.Nerve deafness
4. Associated with cardiac (PDA or P.S.)
3. Eye Lids. (See page 33 p ictu re El&6)
9. Iris and ocular tension:

• Congenital. • Chronic cough. • lritis is often a manifestation of systemic disease
• Hysterical. • Renal, nephrotic or e.g. ankylosing spondylitis and Behcet's disease.
• Mechanical. nephritic • The ocular tension can be tested digitally, it is
• Oculomotor nerve • Myxoedema . tested in patients with headache and diminished
paralysis • Lack of sleep or visual acuity.
• Myasthenia gravis excessive sleep 10. Xanthelasma: (See page 32 picture E2)
• Ectropion, Entropion • Angioneurotic It is a yellow eruption at inner side of the
• Blepharospasm • Raraly as a part of eyelids and peri-orbital skin associated with
generalized oedema hypercholesterolaemia .
(HF/ LCF)
4. Sciera.
• Blue Sciera
• Jaundice
5. Cornea (See page 32 picture E4&5)

• Arcus senilis in senile patients and young with hyper-
lipidaemia
• Opacitis due to trauma or infection.
• Kayser Fleisher ring Wilson's disease.
6. pupil
• Irregular: Argyll Robertson pupil
• Miotic: Homer's syndrome
• Mydriatic: 3rd er. N. paralysis/ opiate/ atropin
• ...,
ALLAM'S CLINICAL EXAMINATION GENERAL:
11. Fund us exam ination :

Nowdays it is one of general examina tion. GMnl
• Optic neuritis and its causes as Multiple Scl erosis and • Bleeding: Vitamin C deficiency, thrombo cytopen ia,
ethamb utol. chronic liver disease.
• Papilledema and its cause as Brain Tumors. • Hypertrophy: Epanutin, monocy tic leukemia.
• Diabetes M (Non proliferative and proliferative • Blue line: lead poisoning.
Retinopathy)
• Hypertensive retinopa thy :
•i-i,i41tM
The surface of the tongue normall y varies as regard
• Grade I: mild sclerosis ( narrowi ng ) of retinal arteries
colour and appearance.
1. Color:
• Grade II: Modera te to marked sclerosis with
• Black: iron therapy , Addison's.
compression of veins at crossing
• Brown: smoking.
• Grade Ill: flame like hges + fluffy cotton exudates
• Blue: cyanosis.
• Grade IV: Papilledema + as in Ill
• Pale: anemia.
• Infective endocaditis
2. Atrophy: (Glazed red tongue) (See page 32 picture T3)
• Central retinal art. Occlusion by embolism.
• With iron deficiency anaemia,
• Central spots: (due to vasculitis).
• Hypovitaminosis e.g. : B12, pellagra .
• Roth's spots. "Central pale spot surrounded by
3. Leucoplakia: (See page 32 picture T7)
hyperemic ring caused by micro-embolization.
• Due to chronic irritation , it is precancerous.
• SLE: hard exudates = cytoid bodies I hges.
4. Moistur e: (See page 32 picture TS)
• Capillary pulsations in A.R.
• Dry tongue (under surface )= dehydration.
Nose and Ear : 5. Strawberry tongue: (See page 32 picture T4) Scarlet fever.
• Redness of the tip of nose : alcoholism . 6. Macroglossia: (See page 32 picture TI)
• Depressed nasal bridge (saddle nose) (See page 32 picture • Myxoedema • hemangioma
NI) : congenital S, traumat ic or congenital or Wegner's • Acromegaly • Pseudomacroglossia: Down
granuloma. • Amyloidosis • Oedema : Angioneurotic
• Working ala nasi: - pneumonia or nervousness. 7. Neuro logical ex.
• Sulfur granules : B2 deficiency. • Tremors of the tongue
• Large nose: congenital - acromegaly • Thyrotoxicosis.
• gouty tophi on helix, discharge chalky materials • Parkinsonism.
..____.,, • F.B in the external meatus • Essential familial tremors .
• Spider nevi • Percussion or tap ping for : Fasciculation, Myoton ia .
• Lale ears: congenital, acromegaly & myxoedema. • Cranial nerve For 5th\ 7t h\ 9th\ 12th.
hiM?ii 8. Scrotal or fissured tongue (See page 32 picture T6)
• Down syndrome and acromegaly.
• Pale: anemia
9. white coated: typhoid F
• Red: S.L.E & Cushing disease.
10. Ptyalism (increased salivation)
• Malar flush: M .S.
• Neurosis
• Brownish pigmentation: pellagra.
'---' • Stomatitis
ma • Reflex from GIT diseases.
Buccal mucos a, palate, tonsils and pharyn x :
• Cheilitis: painful vertical fissures mainly of lower lip
caused by malnutr ition or with Crohn's disease. 1. Buccal mucosa:
• Angular stomatitis (angular cheilosis) also in Vit.B2 • Pigmentation (Addison's disease)
and Iron deficiency, also caused by candida . • Aphthus:- ulcers on the inner sides of the lips, the
• Pallor, cyanosis (See complexion) edge of the tongue and the inside of the check
• Angioedema, herpes labialis. (See page 32 picture Ml) • Koplik's spots
i@UM 2. Tonsillitis and pharyngitis
3. Palate:
• Discoloration: Tobacco, poor hygiene, lead poisoning • Jaundice appears early in the soft palate.
"-- • Loosing of teeth: D.M. • petechial spots in thrombo cytopen ic purpura and
• Wide spacing: (See page 32 picture M4) Acromegaly. leukemia.
'--' • Notch.ed: (See page 32 picture MS) congenital syphilis • Pin point petechial spots also in infectious mononu -
(Hutchinson's teeth) cleosis.
~ • Dental caries, tooth extraction. • High arched palate or cleft palate in congenital condi-
tions. (See page 32 picture M6)
• Palatal moveme nt, palatal & pharyngeal reflexes .
'-_.;
•
4. Breath:
• Aceton: diabetic ketoacidosis
Other Anatomical disorders
• Ammonical: uremia Congenital abnormalities (e.g. high arched palate,
• Foetor hepaticus: hepatic failure webbing of neck & fingers & toes, pectus carinatum or
• Foiled smell: suppurative lung disease (Halitosis) pectus excavatum, arachnodactyly or polydactyly, pes
• Other causes of halitosis: Bad oral hygiene, Sinusitis, cavus or flat foot, telangiectasia, neurofibromatosis)
Tonsillitis or Dyspepsia
Marfan ·s Syndrome
Parotid enlargement : (See page 32picture M2&3) 1. Head and Neck
• Stones or Tumor • Ectopic lens± cataract
• Mumps
• Hypoproteinaemia. • High arched palate.
• Sarcoidosis
2. Extremities
• Cirrhosis • Sjogren syndrome.
• Thin and Long finger (arachnodactyly)
• Endemic parotitis
• encircling test
Neck Examination : • Flat foot or pes cavus.
3.Chest
1. General ex. • Pectus excavatum or pectus carinatum
• Look for scars, lumps, rashes, hair loss, or other le- • Kyphoscoliosis.
sions. • Associated Ht. Lesions:
• Look for facial asymmetry, involuntary movements, or • Dissecting Aneurysm of aorta\ A.R. \ A coarctation
edema. • Mitral valve prolapse M.I.,
• Palpate to identify any areas of tenderness or • AV bundle conduction abnormalities.
deformity. 4. Skeletal
2 . Pul sa tion : Arterial & venous. (See latter) • Loose sublaxated Joints.
3. Thyroid enlargement : (see latter) • High stature.
4. L.N.: (see latter)
5. Torticolli s: Hysterical, myositis of stemomastoid
6. Rigidity : Meningeal irritation & cervical spondylosis i•ti,t441
7. Trache a: See the chest. • Here ditary telang iect as ia:
8 . Supra sternal pulsation s: (see latter) with pulmonary A-V. fistula
9. Neuromu scular examination of head and neck: see • Neurofibromatosis: with pheochromocytoma
neurology • Polyd actyl : with ASD
10. Special Test s: • Low set ear & depressed no se: in cong. A.S.
• Facial Tenderness • So me Gen etic defect s:
• Sinus Transillumination • Down's syndrome: (A.S.D.).
• Temporomandibular Joint. • Turner's syndrome: (coarctation of aorta).
► N.B.
Causes of 1' carotid pulsation(causes of suprasternal pulsations:
• A.R.
• Hyperdynamic circulation states e.g. Thyrotoxicosis
• Carotid aneurysm.
• After exercise or anxiety in thin persons .
•
Upper Limb:
1. Appearance and size of hand and fingers: e.g. spade hand (Acromegaly) (See page 31 picture HS)
2. Temperature of hands.
Warm hands: Cold hands:
• Fever • Low C.O.P state.
• Hyperdyn amic circ • Peripheral cyanosis.
• Central cyanosis.
3. Sweating:
• Thyrotoxicosis • Hyperhydrosis
• Neurosis. • Toxaemia
4. Capillary refill. (defect filling in atherosclerosis) (See page 31 picture H9)
5. Osier's nodes, Jan way's patches & Splinter Hemorrhage (Inf. End) (Seepage3I
pictureH7& 8)
6. S.C. nodules: S.C. firm non tender nodules on extensor surface of arm & along
tendons. ( Rh. Fever/ Rheuma-
toid arthritis).
7. Nails: (see above)
8. Joint abnorma lities: (as Rh . A.)
9. Edema: (as above)
10. Tremors: (See page 31 picture Hl,2,3&4)
• fine tremors: use a paper sheet ( you can not count them )
• Flapping tremors= astrexsis = coarse tremors: rapid flexion and extension
of MCP joint
examined by asking your patient to outstretc he arms and fanning of fingers and
if not appeared induce it by
sudden dorsiflexi on of pronated wrist.
11. Skin:
Dry skin in myxedema, moist in thyrotosxicosis, tight is scleroderma.
12. Lymph Nodes of the Upper Extremity:
• Epitrochlear Nodes: in the inner aspect, just above the elbow.
• Axillary Nodes:
• Ask the patient to lift both arms away from the sides of his body.
• Then extend the fingers of both your hands and gently direct them towards
the apices of the arm pits.
13. palmer erythema : PALM (See page 31 picture H6)
Polythycemia and Pregnancy
Alcohol intake, Autoimm une (RA and SLE)
LCF& Leukemia
Medicatio ns "CCP" Misellani ous "Thyrotoxicosis" .
14. Motor and sensory: see Neurology.
► N.B.
Describe the following in any nodule or swelling
• Size: Pathologic nodes are generally greater than 1 cm
• Firmness: Malignan cy makes nodes feel harder
• Quantity: The greater the number of nodes, the more likely true patholog
y exists
• Pain: Often associated with inflamma tion (e.g. infection )
• Relation to other nodes and surround ing tissue
EifflU,M,iE•
Definition : Xanthomas are smooth surfaced yellow or orange plaques or nodules
in the skin due to focal dermal
aggregations of lipid-load ed cells {foamy histocytes)
Different types of hyperlipi demia may induce varying patterns of xanthom
as :
1. Xanthelasma: 4. Tendinous xanthoma :
Subcutaneous deposits of cholesterol just medial to the Over the tendons eg. Achilles tendon , patellar tendon
eyelids (with type IIA & III or without lipid abnorma lity & finger extensor tendons (Types IIA& Ill)
2. Plane xanthoma :
5. Eruptive xanthoma: (Seepage3 lpictureX3 )
• On palmer creases (Type Ill) (See page 31 picture Xl)
• Occur on the buttocks, posterior thighs
• Also occur with primary biliary cirrhosis
(hyperlip idemia type I, 11B, Ill, IV & V)
3. Tuberous xanthoma : (See page 31 picture X2) • occur with primary biliary cirrhosis
Over the joints especially knees and elbow (type IIA, Ill)
Nail Examination :
L Coiour changes 3. Capil lary pulsc>tion in A.I.
• Pallor: see before. ~ Sp f,,,_e,- 1--lr:,es· (See page 31 picture N7)
• Cyanosis: see before. linear hges under nails.
• Leuconychia: (See page 3 1 picture N3) Hypoalbumin emia Causes:
• Yellow: (See page 31 picture N 4) Nicotine stains/Yellow nail • Trauma in manual workers (common)
syndrome [peripheral edema, bronchiectas is, pleural • Infective endocarditis .
effusion] 5 . O ,ychoivs s· Trauma/ Psoriasis/Th yrotoxicosis/
• Red Cherry red: CO poisoning fungal infection.
• Terry's nails (See p age 31 picture NS ) (distal half is brown, (See page 3 1 picture N l,2)
while proximal half is white-pink) : Cirrhosis/ Chronic 6 Bar.ds
renal failure • Beau's: multiple, unpigmented , transverse lines
• Nail bed erythema = telangiectasia: SLE (Shock/ Malnutrition / Weight loss)
2. Spooning (l<oi!onvchia): in sever chronic • Mees's: solitary, white, transverse band (Renal failure
(See page 31 picture N6) / Chemothera py)
• iron deficiency anaemia . • Muehrke's: multiple, opaque, transverse bands
(Hypoalbum inemia / Chemothera py)
Lower Limb Examination :
as upper limbs without tremors.
1. Oedema: (see above)
2. Cyanosis.
3. Clubbing of toes.
4. Pellargic rash over the greate r trochanter.
5. B.P. difference between upper and lower limbs (Hill's and reversal of Hill's)
6. Venous system for D.V.T & Varicose veins.
7. Deformity as in: Marfan's, Duchenne, myopathy, Friedriech's ataxia & other congenital diseases.
► Example for general examinatio n (for long case) :
General condition attachment& . ap pearance: • Trachea: central, normal cricosternal distance,

he looks ill with cannula in left forearm No trachea tuge
Mentality: patient is full conscious, oriented to • No thyroid swelling
time, place & persons, good mood & memory, he is • No cervical L.N.++ (if present describe it)
cooperative with an average intelligence ~, .1er ~- ':ls. both sides
Built: average body built (just look, no measure- • Hand:
ment) • Normal shape
• Decubitus: patient in semi sitting position • Clubbing
• Vital signs. • NAD:
• Pulse: Patient pulse is regular, 75 beats I min- • Skin, pigmental, scars ... etc
ute, average volume, equal in both sides, no • Muscles wasting, hypertrophy ... etc
special character, normal vascular wall & intact • Drained L.N. axillary LN
peripheral pulsations with no radiofemora l • Lower •1rr bs: both sides
delay. • Feet:
• BP: 130/80 mmHg • Shape
• Temperature: 37.1 °C • Clubbing
• R.R.: 16 cycles/min/ Abdomino thoracic • Odema
• Face: • (NAD):
• No specific feature • Skin pigmental, scars, ...... .
• No pallor, jaundice or cyanosis • Muscles wasting, hypertrophy, ......
• (NAD) no abnormalitie s detected • Drained L.N. poplilteal & inguinal LN
• Neck examination . 3 tubes + 2 glands+ skin Bar · No deformity, scar, swelling, tenderness, or
• Neck vein: non Congested neck veins with nor- pigmental
mal waves (Systolic collapse and normal inspira- S 1s:c,, e • No abnormalitie s were detected
2
tory empyting). C ✓P <' 7 C-r water. as regard CVS, chest, neurological or abdominal
• Carotid A.: palpable, equal, No thrill or burit examination
•
ALL AM'S CLINICAL EXAMIN.A.TION GENERAL:
► Importa nt Signs in General Examination :

!i_Z,:flappinG lrnmors t,4- f lapplpg Tremor.
[Dut5treached hancti' pnduced by wrist dor1Flexlon}
.,___._.
S. Osler•~ nodule ,
ALLAM'S CLINICAL EXAM INATION GENERAL:
- Red 6lazZ!!d mng~ GIOS$it;l~)
-
ALLAM S CLINICAL EXAMINATION GENERAL:
GENERALIZED LYMPHADENOPATHY
G!i1H4M
• Infective: bacterial (T.B.), viral (viral hepatitis, IMN), protozoa! (toxoplasmosis, syphilis).
• Haemotological malignancy: leukemia (CLL), lymphoma (Hodgkin's - lymphosarcoma).
• Neoplastic: secondaries.
• Infiltrative: amyloidosis.
• Miscellaneous:
• Collagen : SLE, Felty syndrome & Still's disease.
• Sarcoidosis.
• Serum sickness.
• Grave's disease.
• Drugs: phenytoin.
P=MMfi
• Onset: acute in leukemia, gradual in CLL.
• Age: middle age in T.B. - old CLL - Hodgkin age 18 - 25 years, another peak at 60 - 70 y.
• Fever: Pel Ebstein in Hodgkin.
• T.B.: toxemia, anti T.B., santorial ttt, LN biopsy (+sinus, scare).
• Leukemia: bleeding & bony pain.
► Examination of Lymph Nodes :

Using your middle 3 fingers, glands are rolled up & down, back & forward in a rotator movement.
• Cervical LN: Waldeyer ring
• Circular group: submental - submandibular - pre auricular - post auricular - occipital.
• Vertical group: upper-& lower deep cervical (under cover of sternomastoid).
\.....,
• Supra-clavicular LN: palpated in supra clavicular fossa.
• Virchow's gland: left supra clavicular LN (suggestive of abdominal carcinoma).
• Scalene LN: part of supra clavicular LN - they lie on scalenous anterior muscle.
• Axillary LN: arm is abducted & supported on examiner forearm - these consists of:
• Anterior group: behind pectoralis major.
• Posterior group: on posterior wall of axilla.
• Lateral group: along axillary vessels.
• Medial group : on chest wall.
• Apical group: in the apex of axilla.
• Supra (epi) trochlear: little above medial epicondyle of humerus.
• para aortic LN: umbilical & epigastric regions along lateral border of aorta.
• Mediastinal LN: D'espine sign in chest
Despin's sign: bronchial breathing below the level of trachea "4th thoracic vertebra" due to enlargement
of
the inter bronchial lymph node.
Causes:
• T.B.
• Carcinoma ..
• Inguinal LN:
• Superficial group (arranged transversely).
• Deep group (arranged vertically along medial side of femoral vein).
See next page
► Lymph nodes examination :
...__,,
..J
ALLAM'S CLINICAL EXAMINATION ► CARDIOLOGY:
► Surface anatomy of the heart:
• The upper limit of the heart reaches as high as the third costal cartilage on the right side
of the sternum
and the second intercostal space on the left side of the sternum .
• The right margin of the heart extends from the right third costal cartilage to near the right
sixth costal
cartilage.
• The left margin of the heart descends laterally from the second intercostal space to the apex
located
near the midclavicular line in the fifth intercostal space.
• The lower margin of the heart extends from the sternal end of the right sixth costal cartilage
to the apex
in the fifth intercostal space near the midclavicu lar line.
Surface anatomy of the cardiac valves
• P (pulmonary): deep to the left 2nd sterno-costal junction.
• A (Aortic): opposite the left 3rd intercostal space.
• M (mitral): deep to the left 4th sterno-costal junction. So the above three valves present
behind the left
border of the sternum.
• T (tricuspid): behind the center of the sternum opposite the left 5th intercostal space.
Site for Auscultation:

To listen for valve sounds, position the stethoscope downstrea m from the flow of blood through
the valves
• The tricuspid valve is heard just to the left of the lower part of the sternum near the fifth
intercostal
space.
• The mitral valve is heard over the apex of the heart in the left fifth intercostal space at the
midclavicular
line.
• The pulmonary valve is heard over the medial end of the left second intercostal space.
• The aortic valve is heard over the medial end of the right second intercostal space .
CARDIAC SHEET
1- History: ~ Personal history.

General ~ 2- Examination: Complaint.
Local 3- Investigations. History of present illness: ] Analysis of the complaint.
4 _ Diagnosis. Past history Symptoms of the related system .
Family history. Other systems.
5 - Treatmen t.
Investigations and treatment history.
OM & HTN
__,
CARDIOLOGY HISTORY
► Personal History:
1. Name: 14.!1 clip 1"""1 5. Marital state: 1a..... rl5' o=- ~_;:;...:,11 rl5' 1~Y.9I ei=- ltj>'-°
to be familiar with the patient. for possible sterility or impotence.
...__,,
2. Age: 1 a.., rl5' ei=- 6. Residence: 1~ &S'L..
As certain diseases are more common in certain 7. Special habits: '-../
ages, e.g. 10.,iiAII o.a J~ J ~ 1a..... fl5' cl!~ 1 f~I J OJ~ fl5' l.p~
• Congenital heart diseases: infants & young 14.!) opl tjl 1..:..~L:.tl ~ Y.9 ~ ~P. 1..:..lj~ .91 op YF-
children. e.g. Smoking is considerd as a risk factor for alot of
• Cronary heart disease: middle aged and old. cardiac diseases as ischemic heart diseases.
3.Sex 8. Mensterual History.
4. Occupation: 14.!1 ~ '-J
► Complaint:
On patient's own words+ duration 1 ..,.,.,..,1 4-!I ~1 4.1~ 1~11!4~ lf)I <I.!! 1 ~1, .;i1 4-!I
(take the most recent and most important complaint and it should be brief)
Examples:
the patient is complaining of shortness of breath of 2 days duration
► History of present illness (H.P.1):
2. Symptoms of the related system. • As long as possible and Contains medical terms.
3. Systemic Review. • In chronological arrangement.
1- Analysis Of The Complaint:

For analysis of any complaint in chest as usual (8) + 3 for any excreta.
8 as usual:
• Onset - course - duration. 1 ..:..wjl ~ 6 ~ .911 J~ .9i ~L..l ..,..1..o J&. Y.9 ~J..ww ..:..~ '-"'1.rt,,11 <I.!! ~i JJu Y.9 o~ ..:.,~ ..,µ1
• Association. 1 o~~,.. 0~ ~ lfJI a.,.;w1 '-"'1.rt,,1_,s:;;;3 ~~ <4~ c.;l5' J.<l>
• What increase and what decrease. 1 ~ lfJI 4-!) 3 1 o~ '-"'ji/1 ~3-►--! .;i1 <I.!!
• Effect of treatment. 1 ":!"' Lo <#j ~ y3 ~ '-"'1.rt,,1 t:,i.,,JI .i.,;.~ u, J.<l> m 4<- t:,i.,,JI ~\:;
• Date of last attack. 1 _,..o) 015' " o~ '-"'__..,.)1 l"""l J_9,0j3 " '-"'ji/1 cl/~ o->-° _,.;.1
+ 3 for any pain:
• Site -../
• Character
• Radiation
'-"
When you were a kid at primary school, Miss Hanan taught

you how blood moves inside the heart and the great
vessels; Will, we call this HAEMODYNAMICS; you better
recall this as we gonna use it next page explaining the
symptomatology of valvular heart disease ...
Wasn't she awesome?! @
•
ALLAM S CLINICAL EXAMINATI ON ► CARDIOLOGY:
► Introduction to cardiology symptoms :
Aortic Stenosis {AS): Aortic Regurge (AR):

.J,COP ➔ LVF (Pulmonary Congestion) Regular Palpitations+ LVF (Pulmonary Congestion)+
Peripheral signs
.J, COP (1 st )
1( '0 ~ '
) \' Lung Congestion
R',\
II \
Mitral Stenosis(MS): Mitral Regurge (MR):

Pulmonary Congestion ➔ PH ( .J,COP) ➔ RVF Regular Palpitations ➔ LVF (Pulmonary Congestion)
(Systemic Congestion)± AF (Irregular Palpitations)
Lung Congestion (1 st )
Systemic Venous ~ Back Pressure ➔ PH
Congestion -;, (f{ \~~

If0( /.~ ~(
/ ✓ ~~
"1!?1 t}J
Tricuspid Regurge (TR):
Regular Palpitations+ RVF (Systemi c Congestion)
Symptomatic Diagnostic Approach:

1st Presentation: Pulmonary Congestion ➔ MS Palpitations:
1st Presentation: -.1,COP ➔ AS • Irregular: AF
Rheumatic Disease with -.1,COP: • Regular:
• MS: Dyspnea (Pulmonary Congestion) fol- • AR: Peripheral Signs
lowed by -.1,COP • MR: Palpitations Only
• AS: -.1,COP as 1st presentation • TR: Systmic Venous Congestion
2- Symptoms of Cardiology:
1. Pulmonary Congestion.
2. Systemic venous Congestion.
3. Low Ca rdiac output.
4. Cyanosis.
5. Palpitation.
6. Pain.
7. Pressure manifestations.
8. Blood pressure changes.
9. Fever.
+ C
•
10. Thrombo-embo lic manifestations .
ALLAM 'SCLINICAL EXAMINAllON ► CARDIOLOGY:
1. Pulmonary Congestion :
Caused by: M.S. & LVF
Including: (dyspnea, cough, haemoptysis & recurrent chest infection)
'--../
► Dyspnea:
'-/
Is abnormally uncomfortable awareness of the act of breathing= Shortness of breath (SOB)
Types:
• Exertional
• Postural
• Orthopnea : dyspnea on lying flat relieved with erect position.
• Platypnea : dyspnea on erect position
• Trepopnea : dyspnea on lying on one side.
• Nocturnal
Pathogensis of cardiac dyspnea:

• Mechanical factors:
• Pulmonary congestion: (leading to '1, lung compliance) occurs in left sided heart failure or lesion lead- '-"
ing to:
• Decreased lung compliance due to interstitial edema (the most important factor).
• Diminished alveolar capacity with transudation in some alveoli.
• Congestion of bronchial mucosa with or without bronchospasm.
• Infra-diaphragmatic causes:
Pericardia I effusion, constrictive pericarditis and right sided failure with SVC lead to enlarged liver and
ascites which decrease diaphragmatic mobility.
• Fatigue of respiratory muscles:
Decreased respiratory muscles' perfusion due to low cardiac output.
• Pericardia! effusion and pleural effusion (with heart failure):
Leading to mechanical compression of the lungs.
• Nervous factors:
• Activation of Hering - Breuer reflex:
This is a normally present reflex in which impulses arise from stretch receptors present in the terminal
air passages at the end of inspiration, this leads to reflex inhibition of inspiratory center and passive
relaxation of the chest ➔ expiration.
In left sided failure, interstitial oedema activates this reflex, causing shallow rapid breathing.
• Churchill - cope reflex: '-,/
It occurs in pulmonary venous congestion which leads to reflex stimulation of respiratory center,
through the juxtacapillary receptors of the lung which are stimulated due to pulmonary venous
congestion (high pulmonary capillary pressure).
• Chemical factors:
Pulmonary venous congestion and diminished tissue perfusion ( '1, COP) lead to hypoxia, which '----'
stimulate respiration.
'-._/
Complaint: -
• Shortness of breath (SOB) - exertional m .,..AJ u} ,I.:,~ .:1.= JAo
• Orthopnea: - Dyspnea on lying flat & relieved on erect position. mo..1:u rlS J&, r~ ~).I .;l.J
NYHA classification of dyspnea:
I Dyspnea on more than ordinary effort

II Dyspnea on ordinary effort
Ill Dyspnea on sub ordinary effort
IV Dyspnea on Rest
'--../
ALLAM 'S CLINICAL EXAMINATION ► CARDIOLOGY:
► Paroxysmal nocturnal dyspnea (PND) :
Dyspnea, cough+ wheeze developed 1-2 hours after sleep, Spontaneously resolved called the Cardiac Asthma
~~~ ,u.! Js-3 m '-'"°! .. ~ Y3 ~~~ v=--~ \J3 ~ r~ ~ rL:.:.i u.,, J~
Mechanism of PND:
• Increased V.R . during sleep leading to aggravation of pulmonary congestion.
• Absorption of oedema fluid into the circulation causing further increase in V.R .
• Dim inished Sympathetic activity during sleep causing reduction of cardiac contractility.
• Night mares lead to tachycardia and elevation of BP.
• Slipping down from high pillows.
► N.B.
PND is highly specific for cardiac cases.
Other symptoms + cardiac symptoms chest symptoms Diagnostic for left sided HTF.
Duration short duration long But we have to exclude B.A.
Time of attack 1 - 2 hrs after sleep Early in the morni ng
Relieved S ontaneously Bronchodilators
Dyspnea lnspiratory E><piratory
Sputum Frothy (may be blood Thick.
tinged)
2. Systemic congestion :
Caused by: right ventricular failure (M .S. & T.R.)
► Q : Jaundice in cardiac patient?
Manifested by: • Associated viral infection .
• Oedema LL. usually before ascites: • Haemolytic Jaundice= pulmonary infarction or
bilateral, pitting, painless, dependent metalic valve
Ascites precox = ascites before LL oedema in • Hepatocellular Jaundice= hepatic congestion (car-
cases of pericardia I & tricuspid diseases. diac cirrhosis)
• Hepatic congestion: Pain in right • Obstructed Jaundice = hepatic congestion obstruct
hypochondri um + Jaundice . the biliary tract
• G.I.T congestion = Dyspepsia.
► Mechanism Of ascites precox: Occures in Pericardia! effusion or constrictive pericarditis

due to kinkling of
hepatic viens with sever hepatic congestion and also with tricusped diseased due to marked hepatic congestion
3. Low cardiac output:
• Syncope The key word is Syncope

• Headache . Syncope : sudden transient complete loss of consciou s-
.;~
• Blurring of vision+ Syncope . ness due to reduced cerebral blood flow. If the isch-
• Dizziness emia prolongs, convulsions may occur. It is associated
• Anginal pain with postural collapse with spontaneous recovery.
~IJ Complaint: Fainting or Black out .
• Kidney= Oliguria
C,"'3
• Muscle = easy fatigability
• Skin = pallor /cold .
Etiology of syncope:
1. Vasomotor syncope ► N.B.
2. Cardiac syncope (4A) Cardiac syncope:
3. Cerebral syncope • Usually exertional
4. Hypoxic syncope • Not accompanied by convulsions
5. Postural syncope
6. Situational syncope
•
Etiology of syncope:
1. Vasomotor syncope: 5. Postural syncope: (Orthostatic syncope)
• Vasovagl syncope (neurogenic syncope): • Normally, reflex VC of blood vessels of L.Ls
• It results from severe vagal stimulation occurs on standing to prevent pooling of blood
which leads to: severe bradycardia, in lower limbs.
hypotension , pallor & sweating. • This effect is mediated through sympathetic
• It results from: sudden severe fear, pain, stimulation .
and trauma (e.g. to testicles). • If this mechanism is defective, BP will be '-..J
• It is the most common cause of syncope & markedly lowered in the standing position
..__,
is known as simple fainting. (postural hypotension ) & syncope may occur.
• Carotid sinus syndrome: Causes include:
• It results from pressure on hypersensitiv e • Autonomic neuropathy, e.g. Diabetes.
carotid sinus baroreceptor s: e.g. during • Sympatholyt ic drugs, e.g. ganglion blockers &
shaving. vasodilators.
• Lumbar sympathoec tomy.
• Hyponatrem ia .
2. Cardiac syncope
• Prolonged recumbency.
(Any cause of -J,,ow COP) especially:
• Elderly patient.
• Aortic stenosis (only with exertion) (or any
• Huge varicose veins .
other valvular obstruction) .
• Hypovolaem ia. e.g.: Haemorrhag e or
• Acute heart failure (e.g. AMI) if damage > 40%
dehydration.
• Arrhythmias (whether tachy or brady
• Weakness of the muscles of the lower limbs
arrhythmia).
(muscle pump).
• Adams-stokes attacks.
• Lt. atrial myxoma
6.Situation alsyncope
3. Cerebral syncope
Rare syncope caused by a variety of activities in
(Reduced cerebral blood flow)
susceptible individuals:
• Vertebrobas ilar TIAs .
• Cough syncope (Tussive syncope).
• Micturition syncope (more common in old
4. Hypoxic syncope (-J,, 02 content of the men especially at night).
cerebral blood flow)
• Defecation syncope.
• Fallot's tetra logy & other cyanotic diseases or
Underlying mechanism:
severe anemia .
Straining ➔ decreased VR ➔ decreased COP ➔
syncope.
4. Cyanosis :
Age of onset:
• Since birth = Fallot's tetralogy.
• Few years after birth= Fallot's triology.
• In teenager= Eisenminger's syndrome (reversed shunt).
• Above age of 40 years= COPD with or without Corpulmona le.
Cyanotic spells and squatting: Fa Ilot's tetra logy.
Differential cyanosis: P.D.A with reversed shunt.
Exertional cyanosis: cases of cardiac shunts/ cases of a cyanotic Fallot's / interstitial pulmonary fibrosis .
ii®i,i
Don't forget 11 points: 5. What increase :
1. Onset: sudden for example; anginal pain • Exercise.
2. Course: intermittent. • Sexual intercourse.
3. Duration: 30 sec. ➔ 30 min. • 5 Hs.
4. Association: • Heavy meal.
• Angor animi. • Heavy smoking.
• Dyspnea. • Hypothermia .
• Sweating. • High attitude.
• Stress ~I
6. What decrease:
• Rest. ► N.B.
• Sublingual nitrate. Anginal pain never to be:
7. Effect of treatment: Respond • Localized.
8. Last attack: Describe it. • Infra mammary.
9. Site : Retrosternal. • Stitching.
10. Radiation : Left shoulder, Jaw, Epigastric & Back • > 30 min.
11. Character: any type except stitching.
6. Pressure manifestations :
The most posterior chamber of the heart is the Lt Atrium, which is markedly
enlarged in M.S. & M.R.
Pressure symptom on:
• trachea: brassy cough.
• Bronchus: dyspnea
• Oesophagus: dysphagia
• Left recurrent laryngeal nerve: hoarseness of voice (Ortner's).
• SVC: oedema and cyanosis of face and U.L.
7. Palpitation :
Complaint: Awareness of heart beats

Cause:
• Rapid heart rate. e.g. : Sinus or paroxysmal tachycardia.
• Forcible heart contraction (volume overload).e.g.: A.I. or M.I.
• Irregular heart, e.g. : extrasystole or A.F.
• Cardiac neurosis.
Ask about:
• Is it regular or irregular?
• Precipitating factors.
8. Manifestations of hypertension :
Hypertension symptoms:
• Asymptomatic ► N.B.
• Fatigue (Most Common presentation) No symptoms of diagnosis of hypertension, only
• Headache. history of regular use of anti hypertensive drug.
• Blurring of vision .
• Tinnitus.
• Epistaxis .
9. Embolic manifestation s :
Embolus: Insoluble material in circulation

Source:
Left atrium in M.S. and

A.F.
Effect:
Abdominal pain (intestinal

haematuria. I
obstruction)
• parasthesia or
• Paralysis .
•
10. Fever in cardiology :

Aetiology :
Cardiac Vessels Lung
• Endocardium: • Thrombophlebitis. • Pulmonary embolism.
• Infective endocarditis (serious) . • D.V.T. • Pulmonary infection.
• Rheumatic fever (commonest).
• Myocardium:
• Myocarditis.
• Myocardial infarction.
• Pericardium:
• Pericarditis.
• Effusion .
3- Other Systems :
Dont forget to ask about symptoms of other systems ........
4- Investigations & Treatment:
As X ray, ECG, Echo & Cathetrization
5- Diabetes Mellitus and Hypertension :

This is end of HPI, dont forget the rest of sheet
► Past History :
• Diseases as Rheumatic fever Pulmonary congestion
~~ ( ,.,..Ai ii.?}) i)~ \!J.i.;... ~
• Operations
• Drugs as: oJ.N ('IS ,fa ('~
!!
m~~s~r,;~
Drugs that cause Hypertension: 6 Cs
m o;.fa,A ;....,JI ,fa u41.&-J! si w ~
• Corticosteroids.
• Licorice.
m ('~ J_,a4 ~ I ~
Sy_s!e.!l'lic venous congestion
• Contraceptives.
m ..:,.,;..i) ~ si cllz;
• Amphetamine and thyroxin .
• Carbenoxolone.
m~l ~J~i~
• Anti Common Cold drugs. Cardiac ou.!fil!1.
m .;;ii.~! s1 ~ j si e1..1..o \!J.i.;... ~
• Cyclosporin .
m cl.~ J ~., ~ ~ u.
► Family History :
.Pressure manifestations
m e:-JI cl.¥ ~
m~IJ4.!_,,...,cl.i.;...
Palpitation
m (:is.,s;l ~! ~ .;;,4-""! ~
Blood pressure c a ges
Embolic man,festations
!! cllz; s1 !~ cl~! .,i m ci.iW \) J,5 J."'-"'
Fever
m 0;1_,~1 ~;~ J tui:i;! J."'-"'
.,~Y. '-""..,.1,1 Jw.,
•
ALU\f\/1'S CLtNlCAL EXAMINJ\TIOH r,. CARDIOLOGY:
GENERAL EXAM INATION
0 ~ts.JI Vital Signs:
• Pulse: • Blood Pressure:

• Irregular as in AF • Low systolic as in AS & HF
• Big pulse volume as in AR • High systole & low diastole in AR
• Special Character: • Respiratory Rate:
• Water Hummer Pulse as in AR Tachypnea in dyspnic patient
• Pulsus Deficit > 10 per minute in AF • Temperature: Fever in
Full comment on pulse is so important in cardiac sheet • Recurrent chest infection
• Infective endocarditis
0 Built: Over built, average built or under built
Over built average built under built

Gene ralized ed ema. • In congenital heart disease. Or
• Rheumatic disease since childhood.
G Complexion:
Pallor: Cyanosis:
• Associated anemia. • Central: Congenital heart disease, Hypoxia Jaundice: See before
• Edema (appears pale). & Corpulmonale.
• Shock. • Peripheral: Systemic venous congestion
• -1, C.O.P. • Differential Cyanosis
• Rheumatic fever.
• Infective endocarditis.
Decubitus or position
Orthopnea, Squatting & Praying position. See general
Pale: Infective endocarditis &Left atrial myxoma.

H & N : Con ested neck vein : See below
upper limb: - .....-
lower limb: L
F
Blue: Congenital heart disease.
Cl ubbing: _ __ __ ___.__ Others: Differetial clubbing & Unilateral clubbing
Manifestatio ns of IE
Lower limb edema: - , - Right sided heart failure.
l,_ Pericardia! disease.
► NB
Clubbing in LL is seen in big toe and detected by ruler; Not in other toes as they show physiological
clubbing
► Clinical significance of neck veins :
Normally: They are non congested, & are pulsating • Giant V:

with systolic collapse. • obliterated (systolic expansion of neck
Abnormally: veins):
• Abnormal pressure "congested neck vein" • TR.
• Pulsating: • AF.
• Right sided heart failure. • Constrictive pericarditis.
• Pericardia! effusion & constrictive pericardi - • Pericardia! effusion .
tis . • Rt. H.f.
• Hypervolemia.
• Non-pulsating:
• SVC obstruction (SVC thrombosis or Medias-
tinal syndrome) .
• Abnormal pulsations "abnormal waves "
• a-wave:
• Absent: AF.
• Giant: pulmonary hypertension, PS, TS.
• Cannon waves:
• Regular : nodal rhythm .
• Occasional : A-V dissociation.
► Examination of Other Systems in Cardiology Case:
Chest:
Cause Result Association · ·
Corpulmonale • Chest infection. Kartagner's syndrome= Bronch-
• Pleural effusion. ectasis + dextrocardia + absent
• Crepitations. fronta l air sinus
CNS:
-- --- -
Cause Result Association

• Silent Ml • AF ➔ Embloic hemiplegia • Carcidmyopathy in Duchenne
• Postural Hypotention • HTN ➔ Thrombotic hemiplegia myopathy & Friedreich's ataxia
Abdominal Examination:
► Causes of Pulsating Liver:
Spleen
• Tricusped Disease
• Palpable = cirrhosis .
• Palpable & tender= infective endocarditis. • Highly vascular hepatic tumour.
• transmitted from abdominal anyrism
Ascites
Detected by bimanual examination
• Normal sequels
• Ascites precox = pericardia I disease - T.R.
Liver
• Palpable= Liver cirrhosis (Cardiac cirrhosis - B
fibrosis)
• Palpable+ lender= congested liver= Rt HF/
Pericardia! diseases.
• Palpable +tender+ pulsating= pulsating liver=
T.R. (systolic) /T.S. (diastolic).
-
Other causes of pulsating liver: Highly vascular
hepatic tumor or from aortic aneurysm.
INTRODUCTION TO LOCAL CARDIAC EXAMINATION
Patient Positioning:
• Expose the patient's chest up to the umbilicus.
• Position the patient supine with the head of the table slightly elevated.
• Always examine from the patient's right side.
• Make sure that the patient is comfortable in this position.
► Value of Precordial examination :

1. Evidence of right ventricular enlargement: 4. Evidence of endocardial affection (valvu lar
• Precordial bulge affection):
• apex beat: (outermost lower most impulse) • Presence of specific murmurs & thrills.
• Diffuse.
• Shifted outwards. 5. Evidence of myocardial affection:
• Shows systolic retraction : accompanied by • Presence of S3 gallop over the mitral or
reciprocal left parasternal uplift (right ven- tricuspid areas in LV or RV affection respec-
tricular rocking) tively.
• Left parasternal & epigastric pulsation . 6. Evidence of pericardia I affection .
• Dullness over the lower half of the sternum.
7. Evidence of pulmonary hypertension:
2. Evidence of left ventricular enlargement: • Inspection, Palpation & Percussion:
• Apex beat: • Pulsations, diastolic shock & dullness in the
• Localized. second left space.
• Shifted outward & downward. • Auscultation:
• Shows systolic bulge: accompanied by recip- • Accentuated pulmonary component of the
rocal left parasternal retraction (left ventricu- second heart sound.
lar rocking) • Ejection systolic click.
• Apex impulse: • Ejection systolic murmur due to relative pul-
• Heaving (forcible, sustained): pressure over- monary stenosis.
load . • Early diastolic murmur due to functional pul-
• Hyperdynamic (forcible, non-sustained): vol- monary regurge (Graham Steel).
ume overload. • S4 over the tricuspid area.
• Hypodynamic (weak): myocardial disease.
8. Evidence of arrhythmias:
3. Evidence of great vessel dilatation: • Change in the rate or rhythm of the heart
• Dilated pulmonary artery: beats.
• Dullness & pulsation in the second left space.
• Dilated aorta:
• Dullness & pulsation in the second right
space .
KEEP CALM AND

START CARDIOLOGY EXAM INA
LOCAL CARDIAC EXAMINATION
► Inspection :
1. Precordial bulge:
s ecting Precordlum
Long standing right ventricular dilatation or
precardial effusion scince childhood. Examined by
looking tangentionally from below the patient.
2. Scar of previous operation
• Median sternotomy (open heart surgery) e.g.;
valve replacement or coronary bypass.
• lnframammary = lateral thoracotomy (closed
heart surgery) e.g.: mitral valvotomy.
3. Dilated Viens: in SVC obstruction
4. Pigmentation : not specific
5. Pulsations: (by inspection & palpation together)
lnframammarv scar
.......,,
► Palpation:
for: Pulsations, Thrill & Palpable sounds

Usually inspect and palpate at the same time for detection of palsations then search for thrill and palpable
sounds by Palpation.
• In thin person all Pulsations may be present
► Pulsations: • In obese persons, all Pulsations may be hardly to be detected
• In normal persons apical pulsations can be detected
• Visable epigastric Pulsations may be normal finding
Areas of pulsations:
Supra Sternal» •
by index
Aortic» .
Tips of fingers
Rt. Parasternal » '

base of hand
• « Pulmonary
Tips of finger
« Lt. Parasternal
base of hand or tips of finger
'
Epigastric »
Place your hand in subcostal
angle
•
Area Technique
. - .... Aetiology
1- Supra sternal in a semi setting patient Place your index in • thin person
supra sternal notch • Hyperdynamic state
• A.R. "Corrigan sign "
• Aortic aneurysm
• High arch of aorta
2- Epigastric:
Place your hand longitudinal in the subcostal angle.
Pulsation classified according to the direction into:
A) at tip of fingers Increased With deep inspiration RV++
B) from the right side Enlarged & Tender during bimanual ex. Hepatic P {TS & TR)
C) from behind Pulsating down to umbilicus Aorti c P (th in, Hyperdynamic & aneurysm)
3- Aortic area By tip of fingers (transverse) Hypertension & A. aneurysm
4- Pulmonary area By tip of fingers (transverse) PH++ & P. aneu rysm .
5- Rt. parasternal By tip of fingers (Vertical) or palm of hand Rt. Atrium++ & Lt. Atrium++
6- Lt. parasternal By base of hand (increased by inspiration) R.V. ++ & Lt. Atrium++
7-Api~I See below
► N.B.
Left parasternal Pulsations may be just a pulsations or heave. (Heave: pulsation which lift your hand upward)
• Lt. Parasternal pulsations means volume overload: TR or VSD
• Lt. Parasternal heave means tention overload: PS or PH
► Apex of the Heart :

Apex: Outermost and lowermost visible and Technique: (Inspection - palpation - left lateral position)
palpable part of the heart. It's produced by the • First, by inspection
anterior movement of the left ventricle during • Place your hand over the left hemi-thorax region
early systole, occurs during isometric contraction • Feel for the outer most and lower most pulsation.
of the left ventricle. The normal apex felt as a • Left lateral position (for detection of weak P)
gentle non sustained tap • Count the intercostal spaces (first identify the angle
of Louis= the rib attached alongside this is the 2nd
rib and the space below the rib is the 2nd space).
•
• Percussion or auscultation may be used for detection
of absent apex .
...,,
Comment on apex:
1. Site: 5th Lt. MCL ► N.B.
2. Area. Absent apex: (OPERA):
3. Chracter Definition: Not visible or palpable apex even on left
4. Thrill lateral position.
5. Rate " Pulsus deficit". • o besity.
6. Rhythm. • Pericardia! effusion - pleural effusion.
7. Rocking. • Emphysema.
• Rib "under rib".
• Anomalies "dextrocardia".
1. Site:
Normally in the Lt. 5th intercostal space just inside the M.C.L (3.5 inch from the midline)
Shifting of the apex from the normal sit:
.......
Upward:
• Upper lobe fibrosis. ._,
• Infra diaphragmatic
causes as ascites.
Inward: Outward:
• Lt pleural effusion • RV++
• Lt pneumothorax.
• Rt lung fibrosis.
- • • Rt Pleural effusion
• Rt Pneumothorax.
• Dextrocardia.
l • Lt Lung fibrosis or collapse .
Downward and Laterly:

• LV++
Downward:
• Viscero-ptosis
• Thin person
2. Area (Extent):
Normally it is localized (less than one inch & occupies one space) .
Diffuse apex: Right ventricular enlargement
The apex diameter is more than one inch or more than one space or the apex with ill-defined medial border
Localized apex: Left ventricular pulsation
The apex diameter is less than one inch or in one space or the apex with well defined medial border.
3. Character:
Defined as: Force and duration of the apex
• Hyperdynamic = forcible (In left lateral)
Volume overload as A.R. /MR/ VSD.
• Heaving= Sustained.
Tension overload as systemic Hypertension/ AS/ A coarctation
• Slapping = papable Sl MS.
__,
ALLAM 'S CLINICAL E X A M INATION ► CARDIOLOGY:
4. Apical Thrill & Palpale sound:

• Thrill: ► N.B.
• Diastolic thrill in M.S. Double apex:
• Systolic thrill in M.1. • Ventricular aneurysm : - systolic - diastolic
• Palpable sounds: 1st H.S. in M.S. pulsation (paradoxical).
• Hypertrophic Cardiomyopathy: - systolic -
5 & 6. Rate & Rhythm:
systolic pulsation.
Normal: Regular with HR equal to the radial pulse.
Irregular: {AF& extra systole) Apical rate for
counting of Pulsus deficit.
7. Rocking:
Left ventricle++: Apical bulge+ left parasternal retraction {anti-clockwise)
Right ventricle++: the reverse (clock-wise)
Don't get lost; We palpate for 3 things: Pulsations. Thrill & Palpable sounds
liiMOI
Better to be detected by the palm of hand
Apex Left parasternal Base

• Systolic= MR Systolic= VSD Aortic area Pulmonary area
• Diastolic = MS • Systolic = A.S. • Systolic = P.S.
• Continuous = PDA • Continuous= PDA
► Palpated sound :
Better to be detected by the tip

• Apex • Aortic area • Pulmonary area
• Palpable 51 in M .S. • Palpable A2 "syphilitic • Palpable pulmonary com-
• Palpable 53 or 54. A.R.". ponent of 52 in PH++.
• Palpable rub.
► Percussion: Of no value in the recent medicine
• Hepatic dullness:
• Start from the 2nd space downward on the Rt ► N.B.
MCL by heavy percussion • Heart percussion is heavy except for bare area
• When you reach the hepatic dullness ask the
patient to breath in (Tidal percussion)
• Upper border of the liver normally in the 4th or may be in the 5th space.
• Right border:
• Precede one space above i.e . 3rd space or 4th
• Percuss parallel to the right border of the sternum (from out to inward)
• Normally no dullness to the right of the sternum
• Dullness denotes: RA++, A aneurysm, pericardia I effusion,dextrocardia & chest causes
•
ALLAM'S CU ~ICAL EXAMINATION CARDIOLOGY:
• Aortic area:
• Percuss the 2nd Rt space from lateral to medial
(from MCL to the sternum).
• Normally it is resonant up to the sternum
• Dullness means:- A aneurysm (pulsating) Post
stenotic dilatation (No pulsation)
• Pulmonary area:
• Percuss the 2nd Lt Space from lateral to medial
(from MCL to the sternum).
• Normally 1.5 cm of dullness may be detected
• Increased dullness means: PH++ (pulsating) P.
dilatation (No pulsation) or Pericardia! effusion
► N.B. Dullness over Pulmonary area could be

pericarlal effusion or PH++ use shifting dullness to
diffirentiate between them
• Waist (on request) :

• Percuss the 3rd left space
• Normally there is al finger of dullness.
• Increased dullness (obliterated waist):- LA++.
• Outside the apex:
• Percuss the apex from outer to inner at the
same space
• Normal:- No dullness outside apex
• Dullness outside the apex: Pericardia I effusion
& chest causes
• Retrosternal:
• Percuss the lower 1/3 of the sternum directly by
light percussion
• Normally impaired note
• Dullness: RV++ & pericardia! effusion
• Bare area of the heart:
• Def.: Area of heart not covered by lung
• "Normally dull" (see the chest)
• hitting dullness:
• In pericardia! effusion: Over the pulmonary
area = Dullness at flat position disappear with
sitting.
► Basics Of Auscultation :
Cardiac Cycle:
ALLAM 'S CLINICA EXAMI IN ATION ► CARDIOLOGY:
-
Systole (0.3 sec) Diastole (0.5 sec)
1. first heart sound: 4. Second heart sound:
The cardiac cycle start by contraction of ventricles After evacuation of blood, the ventricles relax, so
resulting in closure or mitral & tricuspid valves the pressure in the aorta and pulmonary artery will
producing the first heart sound (S1) exceed the pressure in the ventricles resulting in
closure of aortic & pulmonary valves producing the
second heart sound (S2)
2. Isometric contraction phase: 5. Isometric relaxation phase:
The ventricles continue to contract while the 4 valves The ventricles continue to relax while 4
valves of the
of the heart are closed, so the pressure inside the heart are closed, so pressure inside the ventricles fall
ventricles rises rapidly without change in the volume rapidly without change in the volume
3. Ejection phase: 6. Ventricular filling phase:
When the pressure in the ventricles exceeds the When the pressure in the ventricles becomes lower
pressure in the aorta & pulmonary artery, the aortic than the pressure in the atria, blood flows to the
& pulmonary valves will open (normally with no ventricles passively,
sound) • First rapidly: maximum filling phase
Then the blood is pushed from the ventricles to the • Then slowly: reduced filling phase
aorta and pulmonary artery
7. Atrial systole:
First rapidly: maximum ejection phase
Then slowly: reduced ejection phase
• The last amount of blood in the atria is pushed
actively by atrial contraction in the late diastole
8. Ventricular contraction: occurs agaih & the cycle is repeated
Any change in the heart rate, is a change in diastole, systole is constant:
Tachycardia shortness diastole while Bradycardia lengthens diastole
► Auscultation:
• Stethoscope.
• Site of auscultatio n.
• The maneuver of auscultatio n.
Ideal stethosco pe:
• Optimal stethoscope tubing length is twelve inches (30 cm)
• Make sure that the earpieces are fit in the external ear.
• Make sure no air leaks occur between the chest wall and the stethoscope earpiece.
is best listened to low pitched sounds e.g.: S3 / S4 / Identifies high pitched sounds e.g.: normal heart
rumbling murmur of MS. sounds and the murmur of aortic incompetence.
The anatomic al sites of valves:
• P = 2nd left sternal border.
• A= 3rd left sternal border.
• M = 4th left sternal border.
• T = 5th left sternal border.
Site of auscultat ion: 0
• Mitral: - apex (It 5th space at the MCL)
• Tricuspid: - at lower end of the sternum
• Pulmonary: - left 2nd space
• Aortic
• Al= right 2nd space.
• A2 = left 3rd space. (Erb's area)
► N.B.
Other rare areas
Pulmonary & tricuspid valves are anterior
• Lt Parasternal spaces:- VSD
So, heard at their anatomical sites
• Left infra clavicular:- PDA.
But the aortic & mitral valves are posterior
• Posterior thorax, T2-T6: coarctation of aorta.
So, heard at the direction of blood flow•
•
The maneuver of auscultation:

• Cone
• Start with the cone of the stethoscope listens to the:
• Mitral area
• Tricuspid area
• You may need special maneuver as:
Roll the patient on to their left lateral position and listen for the murmur
of mitral stenosis. ..._,
• Diaphragm
• Start with mitral area then in a Z shape direction listen to
• Tricuspid
• Pulmonary
• Then aortic areas.
• You may need special maneuver as:
• Listen into the axilla area for the murmur of mitral incompetence.
• Over T area ask the patient to breath in (murmur of right side increased
with inspiration)
• Over P area compare between A2 and P2 (52 of P accentuated in PH++)
• Over A area, listen on the carotid a. (propagation of AS murmur) & ask
the patient to set and holding breath in expiration (or hearing of AR)
► Auscultatory findings:
Comment on: In each sound comment on
1. Heard sounds (51&52) • Def. & mechanism
2. Additional sounds(S3 54, EC & OS) • Causes __.
3. Murmurs • Site
4. Pericardia! rub • Timing
5. Crepitation (Chest) • Character
1. Heart Sounds :
Ml1ral & Tricuspid Closure Aortic & Pulmonary

• M uscle Con traction »Sl Closure »S2
• ._,
First heart sound Second heart sound

Formed • Valvular: closure of the mitral and • Closure of the semi lunar valves (P & A)
tricuspid valve. • Vibration of the great vessels
• Muscular: contraction of the ventricle .
Site Over M & T areas Over the base (A & p)
Time At the start of systole (carotid ascend) At the end of systole (carotid descend).
Accentuated Thin person, Tachycardia & Children.
• M.S. = decreased filling of left ventricle • Pulmonary hypertensi on .
= closure of the valve from a lower • Systemic hypertensi on .
position. • Aneurysm of ascending aorta
• Hyperdynamic states. (magnifica tion) .
• Short P.R. interval= decreased filling of • Hyperdyna mic circulation .
the heart.
• S. hypertension= left ventricula r+++
(muscular componen t).
Weak Mechanical factor e.g. thick chest wall, obesity emphysema, pericardia! effusion.
(Muffled) (Distant heart sound).
Shock - hypotensio n
• M.I. - T.I. (Improper closure). • A.I. (Improper closure) .
• Severe myocardial diseases or heart • A.S. - Severe pulmonary stenosis (Low
failure. pressure gradient of closure).
• Calcific M.S .
Variable atrial fibrillation
► Tic Tac Rhythm:

Abscence of muscular componen t of Sl in cases of myocarditis so become only valvular as S2
51 : The mitral precedes and louder than Tricuspid

52: • Aortic componen t louder & heard all over the precordium .
• Pulmonary componen t heard on pulmonary area only.
So the pulmonary componen t and aortic componen t heard over the pulmonary area and this
is called
physiological splitting which increase during inspiration and decrease during expiration.
Splitting of the second H.S.:

• Physiologically the 2nd HS is formed by aortic and pulmonary componen ts
• The aortic valve is closed by pressure greater than that of pulmonary valve . So the aortic
valve is closed
before the pulmonary valve
• The two componen t are so closed so heard as a single HS
Normal (&:~h~siological} splitting:
During inspiration the pulmonary flow is increased
Expiration Inspiratio n
so the closure of P valve physiologically delayed &
lungs expand ➔ retain some blood from Lt. side
➔ -..1, L.V. load and It ventricle is strong so early
closure of aortic valve occure I I I II
Sl S2 Sl A2 P2
Wide splitting:
From the start the P valve is delayed so accepted Expirati on Inspiration
I II I II
as two sounds
By inspiration the pulmonary flow is increased so
the splitting will be increases
Causes: PS/ RBBB / ASD
S1 A2 P2 S1 A2 P2
•
ALLAM 1S CLINICAL EXAMINAT ION ► CARDIOLOGY:
Paradoxical splitting:
From the start the A valve is delayed so accepted Expiration Inspiration
I II I I
as two sounds
By inspiration the pulmonary flow is increased so
the splitting will disappear
Causes: AS/ LBBB Sl P2 A 2 Sl S2
Fixed splitting:
Expiration Inspiration
The second HS formed by two component not
I II I II
changed by inspiration
Causes: A.S.D.:
During Expiration, blood passes from L.A. to R.A.
➔ 1' Load on Rt & -.1, Load on Lt ➔ Aorta closes S1 A2 P2 Sl A2 P2
before Pulmonary;
During inspiration ➔ 1' Venous return to R.A.
which equalize pressure of L.A ➔ Stoppage of
shunt, so return to normal physiology (Aorta
before Pulmonary)
Single S2: Sever P.S. /Sever A.S./ Single ventricle.
Closed splitting: PH++
2. Additional Sounds: S3, 54, EC, & OS
Third heart sound Fourth heart sound
Def Low pitched sound heard due to gush of Low pitched sound heard due to forced atrial
blood from atrium to ventricle or flabby contraction against resistance which gush
ventricular wall blood to ventricles
(70 % Passive fill ing phase) (30 % atrial contraction phase)
Physiological:
• in children and young adults.
V. overload:
T. overload :
• S. hypertension/ IHD / A.S.
• P.S., P. embolism & PH++
!
-
• MR/ AR/ TR/ VSD / ASD / Hyperdy-
namic
Diminished V distinsability:
• LVF \ RVF
• Constrictive pericarditis (Pericardia!
knock)
Site Mitra I (left sided causes) or Tricuspid (right sided causes)
Timing Early diastolic (protodiastolic) Late diastolic (presystolic)
I 11 I
S1 S2 S1
I I 11
S1 S2 S1
Gallop: additional HS (3rd or 4th) plus tachycardia. It is so called because it .._,,

is a triple rhythm resembles the sound of a galloping horse.
Causes
• S3 gallop= protodiastolic gallop= LVF (M) / RVF (T)
• S4 gallop= presystolic gallop = S hypertension & tachycardia
• Summation Gallop: Third & fourth sounds plus tachycardia in
Hypertensive heart failure/ IHD
•
ALLAM 'S CLI NICAL EXAMIN ATION ► CARDIOLOGY:
Ejectio n Click Opening Snap

Def Openin g of the normal aortic (or pulmon ary) Snappy sound in M.S due to rigid periphe ry &
valve is soundless while openin g of the ste- pliable centre of the mitral valve in M.S.
nosed aortic (or Pulmon ary) valve produc es
ejection click (a clicky sound) due to doming
of this stenose d valve.
• No ejection systolic click with subvalv ular
or Calcific A.S.
Site Aortic area (A.I.) Pulmon ary area Betwee n M & T areas.
• A.S. (valvula r) • P.S. (valvula r) .
• S. hyperte nsion. • PH++
Timing Systolic Ejection Phase Early diastol ic/ separa ted from S2 by the iso-
metric relaxat ion phase / heard by cone
Significance:
• Diagno stic for M.S.
• Non calcified.
• Detect severit y of M.S.
(Dimini shed distanc e betwee n O.S. & S2 =
sever lesion).
I. I I
S1 S2 S1
I I. I
Sl S2 S1
3. Murm urs:
Mechanism of Turbulence (murm ur):
1. Timing:
• Passage of blood through
• A.S / M.R / T.R. / VSD = systolic.
• Stenosis (A.S. / M.S / P.S)
• A.R./ M.S. = Diastolic.
• Irregula rity (conge nital bicuspi d aortic valve)
2. Chraracter:
• Shunt (VSD / P.D.A.)
• A.S. = Harsh.
• Abnorm al directio n of Blood (M.R. and A.R.)
• A.R. = Soft blowing .
• Over blood flow (relativ e stenosis)
• M.S. = Rumbli ng.
• Passage of blood into a relative ly dilated
• M.R. = Soft (80%), harsh = (20%)
structu re (ejectio n systolic murmu r in PH ++ or S
3. Site:
hyperte nsion)
Accord ing to the diseased valve, A.R. murmu r at
Comm ent on:
A2 (Left 3rd I.C. space)
1. Timing 4. Propagation
4. Propagation :
2. Character 5. What increase
• M.R.: Axilla / Sternu m & base.
3. Site 6. Grading • A.S.: Carotid & Apex.
5. Increased by :
► Other method : SCRIPT • Mitral murmur: by
• Site. • Left lateral position .
• Character. • Exercise.
• Relatio n to respira tion & positio n • Aortic murmur: by
• Left sided heart murmu rs are louder on • Leaning forward .
expirat ion. • Expirat ion.
• Right sided heart murmu rs are louder on • Right. Sided murmurs: by Inspira tion "
inspira tion. Carvallo's sign"
• Intensit y.
• Propag ation.
• Timing .
•
ALLAM 'S CLINICAL EXA MINATION ► CARDIOLOGY:
6. Grades (Intensity):
Intensity of a murmur is described in grades as follows:
Grade I Just audible in a quiet room . (Heard by an expert)
No Thrill Grade II Quiet- (Heard by a non expert)
Grade Ill Loud without thrill. (Easily heard)
Grade IV Loud with thrill.
Thrill Grade V Very loud with the thrill. (Heard over wide area)
Grade VI Audible without a stethoscope. (Extremely loud)
► N.B. ► N.B.
Severity of the lesion detected by duration Functional murmur: Murmur without stractural
of the murmur not by grad. As duration of lesion as overflow or hyperdynamic circulation
murmur depends on the pressure gradient & usually has no cardiac clinical picture &
across the valve murmur is faint, soft, localized without thrill
4. Pericardia! Rub :
Superficial, gritty, high pitched sound caused by friction of parietal & visceral layer of pericardium.
It is best heard at the left of the lower sternum with the patient breathing out using the diaphragm of the
stethoscope.
Timing: To & Fro = Systolic & Diastolic.
D.D.:
• Pleural rub:- disappeared by withholding breath
• Friction of stethoscope: disappeared by firm pressure
S. Crepitations :
Summary of Local examination of valvular diseases
A.S
..
~
• Apex: sustained ..
~
ID
• Apex: Hyperdynamic
.
ID
n
0
CL
•
•
Chamber++: LV++
Thrill: systolic (Al)
.
n
0
CL
iii'
• Chamber++: LV++
~
ID ID
?< ?C
)>
C • H.S.: 52-.!, )>
C • H.S.: 52-.!,
n
CII
C
• Murmur: "'
n
C
• Murmur:
~ • Ejection systolic ;;-
II.I
• Early diastolic
c:r. !l'.
0 • Harsh 0 • Soft blowing
:I
:I
• Over Al • Over A2
• Propagated: apex and carotid Jju ~u. • Increase by expiration
• increase by leaning forward & expi- • S3 + peripheral signs
,~
rat&ion
• EC & 54 S1 S2 S1
51 S2 S1
I I
I. 1
-.!,S2
I -.!,S2
•
M.R.
~
l'I)
8
• Apex: Slaping
• Chamber ++: L.A.
...
"tll
l'I)
• Apex: hyperdynamic
n • Chambe r++: LV++
a. • Thrill: Diastorlic & palpable 51 ...CL •
0
Thrill: Systolic (Over Mitra I)
iii'
l'I)
~
l'I)
?< ?<
~ • H.S.: 511'
Ill
)>
C • H.S.: 51 -.1,
n • Murmur : Ill
C
;:;'
n
C
• Murmur :
• mid-diastolic with presystolic accentua- ;:;' • pansystolic
~-
Ill
0
::,
tion which lost in AF ~-
Ill
0 • Soft (80%) / Harsh (20%)

• Rumbling ::,
• Over M (apex)
• At or inside the apex
• Propagated: Axilla (ant. Leaflet) and Ster-
• localized num (post. Leaflet)
• Increased by Left lateral or exercise
• Increase d by Left lat/ exercise
• OS
• S3
51 52 51 51 S2 S1
LJ.....11
1'51 o.s.
-.. .L _J
-.1,S1 S3
► Diagnosis :
T.R.
The diagnosis should include the followin g four
"tll
-,
l'I)
• Apex: hyperdynamic
categories:
n • Chambe r++: RV++
0
-, Aetiolog ical:
0.. • Thrill: Systolic (Over Tri cuspid)
• Rheumatic: multival vular - history of rheuma tic
~
l'I) fever.
?<
• Congenital: since birth + anomalies .
)>
C • H.S.: 51 -.L, • lschemic.
Ill
n
C
• Murmur : • Hypertensive.
i;" • pansystolic • Surgical.
~-
0
::,
• Soft Anatom ical:
• Over T (apex) • Valve lesion.
• Increased by inspiration ( sign) • Pericardium: constrictive pericarditis.
• S3 • Myocard ium : cardiom yopathy.
Pathological:
S1 S2 51 • Stenosis. Or
-.. .L _J • Regurge. Or
• Double.
Functional:
-.l,Sl 53 • Compensated: no manifestations of LVF or RVF.
• Non-compensated: manifestations of LVF or
RVF.
• Or complicated by:
• A.F. or any arrhythm ia.
• Embolic manifestations e.g. hemiplegia .
• Infective endocarditis.
• Chest infection.
Example s of diagnosis:
• Rheumatic heart disease (M.S. - M.1.) compensated, non-complicated
.
• Rh. Heart disease (M.I. - A.I,) left sided heart failure complicated with
infective endocarditis.
• Congenital Heart disea se (V.S.D.) compensated
ALl_AfV1 'S CLINICAL EXAMINATION ► CARDIOLOGY:
INVESTIGATIONS IN CARDIOLOGY
Scheme for investigations

1. Laboratory: Urine/ stool/ blood/ others. 3. ECG
2. Images: 4. Nuclear medicine as isotopic scan (for IHD)
• X ray :- Plain or with Contrast 5. Endoscopy
• Echocardiography & Doppler. 6. Catheterization
• C.T. I MRI. (limited for pericardia! diseases or tumours) 7. Biopsy
Laboratory: ECG:
-- .
Indication Values
-
lndic~ti_o ~:f Value$· _
Arthralgia For diagnosis of Rheumatic fever. All Cardiac • Chamber enlargement

- cases (hypertrophy ).
Fever For diagnosis of infective endocarditis .
• Arrhythmia as A.F.
Pallor For diagnosis of anemia.
• lschemia (angina & M.I.).
Image s:
A. X ray:
- I - - - - ----~- -- ~·
Plain -With contrast (Br;·Swallow )

-
Indication Values Indications Values
All Cardiac cases • Chamber enlargement . Mitra! valve disease LA++

• Pulmonary vasculature .
• Calcific valve .
8. Echocardiography & Doppler

Investigation of choice: - simple, cheep, available, non invasive & highly diagnostic.
-- -- - ----
Echocardio graphy I
Doppler
Indication Values Values
All Cardiac cases 1. Aetiology: Rh( excessive fibrosis) congenital (ASD - VSD) For blood flow :
2. Lesions: which valve. • Direction:
3. Severity: see later. • Regurge .
4. Effect: chamber++. • Pressure: PH++ .
5. Complications: • Velocity.
• PH+++ .
• Calcification .
• Thrombosis .
6. Function:
Ejection fraction= Stroke volume/ end diastolic volume
..J'
Valve area (normal = 4-6 cm2) ► N.B.

MS
Tight MS=< 1 cm2 Trans-esophageal echo (TEE):
Pressure gradient (normal = 0 mmHg) • Heart thrombus.
AS Sever AS=> 50 mm Hg • Vegetation.
Any regurge Degree of dilatation & EF
Catheteriz ation
It is a long, elastic, radio-opaque , thin cord like with a central lumen .
Pathway:
Right sided catheter le~ sic;!ed c_aJheter ~- - - - -
Any vein ➔ I.V.C. ➔ R.A. ➔ tricuspid valve ➔ Rt. Vent. Any artery ➔ aorta ➔ aortic valve ➔ left ventricle.
➔ Pulmonary artery. Mitral valve:
As right sided ➔ RA ➔ artificia l ASD ➔ LA ➔ M valve
•
Values: As Echo & Doppler but superior in IHD
ALLAM'S CLINICAL EXAMINATIO N ► CARDIOLOGY:
Treatment of the cause of possible. Recent less invasive by catheteriza-

Prophylaxis: tion. • Failure of medical treatment.
• For rheumatic fever ➔ to • Severe cases.
prevent recurrence of activity • In cases of stenosis ➔ • Complicated cases.
which is usually fatal (causes ballooning dilatation. (Balloon
myocarditis, develops new valvoplast) Includes:
lesion or increases severity of • In cases of IHD ➔ coronary 1. Mitral valvotomy of MS
present lesions). angioplasty Isolated MS - non calcific valves.
• For infective endocarditis . May be complicated by :
Symptomatic: •• Restenosis
iatrogenic MR.
• Treatment of AF.
• Treatment of HF.
• Treatment of thrombosis.
I
2. Valve repair in regurge: usually
failed.
3. Valve replacement:
• Tissue valve:
Curative • Short life span.
• Only in cases of AR by: • No anticoagulant.
Vasodilators to reduce the Used for:
peripheral resistance and • Old age.
prevent blood regurge though • Female in child bearing
the aorta. period.
• Prosthetic valve:
• Long life span.
• Anticoagulant needed .
May be complicated by:
• Dysfunction.
• Hemolytic anemia.
• Endocarditis.
Heart lung machine ➔ used

Needs high experience.
Mortality High_ _ __
---- -
_ _ __ _ _ _ 1 Low
Scar - - -- -----,- Median sternotomy Lateral inframammary s~
The other cases. Mitra! valvotomy in cases of M.S.
• Isolated.
• Not calcified.
► Valve replaceme nt. Complications of the replaced valve:

Which valve is replaced? • Dysfunction
• From History. • Haemolytic anemia .
• Metallic H.S • Haemolytic jaundice.
• S1 = Mitral. • Prosthetic valve endocarditis
• S2 = Aortic. • anticoagulant use
Function of the replaced valve:
• No symptoms or signs of the disease.
• Local examination i.e. no murmur.
. VALVULAR HEART DISEASES
Mitra! stenosis (MS)
Etiology: Clinical picture:

• Rheumatic fever: (the most common cause). Symptoms:
• Congenital: rare • Stage one: No symptoms.
• Relative stenosis (not an organic stenosis) • Stage two:
• Increased blood flow through the mitral valve. • Symptoms of pulmonary congestion (but
• Carey-coombs murmur in acute rheumatic pulmonary oedema is not common).
valvulitis. • Symptoms of low CO. .,,
• Austin flint murmur in severe aortic regurage. • Stage three:
Pathophysiology: • Symptoms of pulmonary congestions: improve.
• In mild cases: No symptoms occur. • Symptoms of Low CO: increase.
• In severe cases: (valve area less than 2 cm2): • Stage four:
Blood stagnate in pulmonary veins (pulmonary • Symptoms of systemic congestion.
venous congestion). • Dyspnea is the most common symptom
• Later on: Vasoconstriction of pulmonary arterioles Signs:
occurs to ~ pulmonary congestion, but this will lead General:
to: pulmonary hypertension. • Stage one: No signs.
• Finally: RV enlargement & then RVF will occur • Stage two: signs of pulmonary congestion (BBC).
secondary to pulmonary HTN. • Stage three: signs of low cardiac output.
Therefore four stages will occur in patient with MS : • Stage four: signs of systemic congestion.
• Stage one: "Mild or asymptomatic mitral stenosis" Precordial examination:
The only abnormality is anatomical narrowing of the • Stage one & stage two:
mitral valve, but the patient is fully compensated (no • Apex: normal site & slapping character.
symptoms). • Diastolic thrill: ending in a palpable 51.
• Stage two: "mitral stenosis with pulmonary • Stage three & stage four:
congestion" • The previous findings.
The pulmonary venous pressure is elevated. • Signs of: pulmonary hypertension.
• Stage three: "mitral stenosis with pulmonary • Signs of: right ventricular enlargement.
hypertension" Auscultation:
......
The pulmonary arterial pressure is elevated. • Stage one & stage two (over the mitral area):
• Stage four: "mitral stenosis with right ventricular Accentuated first heart sound: due to:
failure" • Fibrosis of the mitral cusps.
• Forcible closure of the mitral cusps: because:
• They are displaced downwards due to high LA
pressure.
• The mitral valve is opened as wide as possible
. Lung Congestion (l5') during the diastole.
Systemic Venous
Congestion ~ .
t
rn ,
ro
Back Pressure ➔ PH
► N.B.
Diminished Sl in mitral stenosis denotes:
Jo\\
RA '
I
• Double mitral lesion (with predominant
regurge) or
,0~ RV
• Calcified mitral valve.
Mitra! opening snap: It is sharp & snapping due to

opening of the rigid cusps of mitral valve. It heard
__,
in the early diastole. Just after S2 (separated from it
by the isometric relaxation phase). Just before the
murmur of mitral stenosis. Its presence diagnostic
for mitral stenosis and can detect Severity & denotes
noncalcification of the mitral valve .
•
Murmur of mitral stenosis:

• Timing: Mid-diastolic pre-systolic with pre-systolic ► Complications:
accentuation. • In the mitral valve:
In AF, there is loss of pre-systolic accentuation (due • Rheumatic activity.
to loss of atrial contraction) & Sl became variabe. • Calcification.
• Character: rumbling . • Infective endocarditis.
• Site: at or slightly inside the apex. • In the left atrium:
• Propagation : not propagated . • LA enlargement , causing symptoms (Pressure
• Position: Best heard with the cone of the symptoms)
stethoscope . in the left lateral position. • Arrhythmias, especially AF.
Silent mitral stenosis: (MS with no murmur) due to: • Thrombo-em bolic complications
• High LV pressure: LVF. • In the right ventricle:
• Low LA pressure: • RVF.
• Severe pulmonary hypertension. • In the lung:
• RVF. • Hemoptysis.
• In association with ASD. • Pulmonary infection.
• Stage three: • Pulmonary embolism (secondary to DVT).
The previous findings. • Pulmonary oedema is not common in mitral
Auscultatory findings of pulmonary hypertension: stenosis.
Over the pulmonary area: • Complications of Treatment. Traumatic MR,
• P2 is accentuated . Complications of general anasthesia, Complications
• Systolic ejection click. of anticoagulants)
• Systolic ejection murmur (Functional PS)
• Soft early diastolic murmur: (Graham Steel
murmur= Functional Pl) Investigations
Over the tricuspid area: • Chest X-ray:
• S4 gallop • ECG
• Stage four: • Echocardiography:
The previous findings. The most sensitive & specific non-invasive method
Auscultation over tricuspid area: diagnosing MS.
• Pan systolic murmur of functional tricuspid Detects the severity of stenos is.
regurge. Detects chamber enlargement.
• Prtodiastolic gallop (S3) due to RVF. • Cardiac catheterizati on & angiocardiography:
Tight MS is diagnosed:
Summary of Local Examination:
• According to the stage: Stage two with dyspnea
more than grade two, or Stage three, or Stage
four.
;.,, • Apex: Slapping
• According to the echocardiography: Valve area
8 • Chamber ++: L.A.
a. • Thrill: Diastolic & palpable 51 less than 1 cm2.
~ Treatment
~ Medical:
r • H.S.: 511'
Ill
• Prophylaxis against: rheumatic activity, infective
endocarditis (uncommon) .
• Murmur:
2 • Symptomatic for: complications e.g. HF, AF,
• mid-diastolic with presystolic accentua -
~
0 tion which lost in AF
infection, embolization .
Surgical:
:I
• Rumbling
Indications:
• At or inside the apex
• Tight mitral stenosis (valve area is< 1 cm2) .
• localized
• Marked symptoms not responding to adequate
• Increased by Left lateral or exercise
medical treatment .
• Embolization with no serious deterioration of the
S1 S2 51 condition of the patient.
~
1'51 0.5.
Types of operations:
• Mitra I commissuro tomy: closed or open:
• Valve replacement
Mitral Regurge (MR)
Etiology: • Murmur of mitral regurge:

Organic: • Timing: pansystolic starting with Sl.
• Rheumatic fever: the most common cause. • Character: soft or harsh .
• Congenital. • Site: over the apex.
• Prolapse of the mitral valve (MVP) • Propagation:
• Papillary mu scle dysfunction e.g. CAD. • To the axilla.
• Infective endocarditis. • To the base of the heart & medially in posterior
• Iatrogenic: following mitral valvatomy. leaflet disease.
Relative: • Position: heard best in the left lateral position. ....,/
• Dilatation of the mitral ring secondary to LV dilatation .

pathophysiology:
During systole: M.R .
A part of blood regurgitates from LV to LA leading to : ,, • Apex: hyperdynamic
;
Low CO. 8 • Chamber++: LV++
LA dilatation: due to increased blood volume in LA. a. • Thrill: Systolic (Over Mitral)
During diastole: ~
A large volume of blood ➔ LV ➔ LV enlargement ~
which may end in LVF.
~ • H.S. : Sl -1,
II)
n • Murmur:
C
~ • pansystolic
:::r. • Soft (80%) / Harsh (20%)
0
:::s
Lung Congestion • Over M (apex)
• Propagated : Axilla (ant. Leaflet) and Ster-
num (post. Leaflet)
• Increased by Left lat/ exercise
• S3
Sl S2 S1
Clinical picture:
Symptoms:
• No symptoms: in early cases . -.1,Sl S3
• Symptoms of low cardiac output: in late cases .
• Symptoms of pulmonary congestion: in late cases. complications:
• PALPITATION (Most Common) • Same complications of MS, but:
• Infective endocarditis : is common.
Signs: • Left ventricular failure : occurs.
General:
Investigations:
• No signs : in early cases .
• Chest X-ray:
• Signs of low cardiac output: in late cases.
• ECG:
• Signs of pulmonary congestion: in late cases.
• Echocardiogrpahy:
Precordial examination:
• Detects the severity of mitral regurgitation.
• Signs of LV enlargement: with hyperdynamic apex.
• Detects chamber enlargement.
• Systolic thrill: over the apex.
• Detects the cause: e.g. MVP.
Auscultation:
• First heart sound: weak (muffled) due to failure of
proper mitral closure .
• Cardiac catheterization & angiocardiography:
Treatment:
• Medical : Same as that of mitral stenos is.
--
• Third heart sound: present due to excessive flow of
• Surgical: Valve replacement.
blood from LA to LV.
► N.B. Causes of acute Mitral Regurge:

• Post valvotomy (Traumatic)
• Infective endocarditis affecting valve leaflets
• lschemia affecting chorda tendineae (Ml)
•
..._,..
-
ALLAM 'S CLINIC AL EXAM INATIO N ► CARDIOLOG
Y:
,
Aorti c Stenosis (AS)
Etiology: Precordial exam inatio n:

• Rheumatic fever. • Signs of LVH: with a heaving apex.
• Calcific. • Systolic thrill: over second right space propagated
• Congenital: to
apex & carotid arteries.
it may be: valvular, subvalvular or supravalvular .
..._ Auscultation:
Hyper trophi c cardio myop athy (Idiop athic
Over the aortic area:
Hyper trophi c Subaortic Stenosis; IHSS):
• Second heart sound : weak.
It produces a subvalvular obstru ction in the
• Systolic ejection click: due to openi ng of the rigid
systole due to: contra ction of the hyper trophi ed
cusps.
interv entric ular septu m.
• Systolic ejection murm ur:
• Relative stenosis (not an organic stenosis):
Midsystolic, harsh.
• Dilata tion of the aorta:
Maxim um over second right space propagated to
• Hypertension, atherosclerosis, aortic aneurysm.
apex & carotid arteries.
• Increased blood flow across the aortic valve:
Over the pulmo nary area:
Hyper dynam ic circulation, AR.
Reversed splittin g of the second heart sound.
Pathophysiology: Over the mitral area:
During systole, there is obstru ction of blood flow from • S4.
LV to aorta leading to: • Propagated murm ur of AS.
• Low cardiac outpu t.
• Pressure overload on LV leading to LVH & LVF.
Normally, the aortic valve area is 3 - 4 cm2. In severe A.S
AS, it is less than 0.8 cm2. ... •
"0
II)
Apex: sustained
n • Cham ber++ : LV++
..J,, COP (1" ) ... •
0
Q. Thrill: systolic (Al)
~
II)
?C
__:J ✓ Lung Congestion
) I.Ao
l>
C
CII
• H.S.: S2 ..1,-
2 •
;;;
Murm ur:
1 • Ejection systolic
0
LV
~-
GI
0
:s
• Harsh
~ RV • Over Al
\ I 0 • Propagated : apex and carotid Jjll E1U.
..____
• increase by leaning forword & expiration
Clinical picture:
Symptoms: 51 52 Sl
• No symptoms: in mild cases.
• Symptoms of low CO : in severe cases.
• Symptoms of pulmo nary congestion: due to LVF.
I. 1 I
• SYNCOPE: especially exerti onal due to low fixed - ~S2
CO.
• ANGINA: due to
• Reduced coron ary blood flow: due to low CO & complications:
shorte ned diastole. • LVF.
• Left ventri cular hyper trophy : increases the myoca • Infective endocarditis.
r-
dial 02 demands. • Sudden death : usually due to VF.
....., • Associated coron ary atherosclerosis: especially • Heart block: in calcific AS due to extension of calcifi
-
in
calcific AS . cation to AV bundl e .
Signs: General: • Rh. Activi ty with Rh. A.S.
• Pulse: Investigations:
Pulsus parvus et tardus (plateau pulse): rises • Chest X-ray, ECG. Echocardiopraphy, Cardiac cathe
ter-
slowly, of small volum e , return s slowly. ization & angiocardiography :
Pulsus bisferiens: bifid pulse occuring in doubl e Treat ment :
aortic lesion. • Medical: Same as that of mitral stenosis.
• BP: low SBP in severe cases. • Anginal attacks: may be relieved by SL nitrate
s.
• Systolic thrill: over the carotid arteries.
e• • Surgical: (Aortic valve replacement)
Balloon dilatation: Children & Elderly
Aortic Regurge (AR)
Etiology: • Corrigan's sign: promin ent carotid pulsations.

• Rheumatic fever: the most commo n cause. • Systolic thrill: over the carotid arteries.
• Infective endoca rditis. • Arterio lar pulsatio n: seen by fund us examin ation
• Congenital. • muller' s sign: pulsating uvula + capillary pulsations
• Dilatation of the ascending aorta as in : by fund us exam
• Syphilic aortitis : syphilis produces dilatati on of the 3 upper limb
aortic ring. • Water hamme r pulse: Raises rapidly, of big volume ,
• Severe hypertension. collapses rapidly.
...,,
• Ankylosing spondylitis. • Blood pressure: Wide pulse pressure: exaggerated
• Aortic aneurysm: with dissection . differences betwee n systolic and diastoli c blood
• Marfan 's syndro me. pressure.
Pathophysiology: • Capillary pulsations: detecte d in nail bed, lips or
Regurgitation of blood from the aorta to the LV in diasto- ear lobule.
le leads to: 3 lower limb
• Increased LV stroke volume , this results in: • Pistol shots: loud boomin g sounds heard with each
• Increased SBP. pulse beat over the arteries (especially femora l) ..,
• Peripheral VD which (togeth er with regurig itation) due to sudden distension of collapsed arteries.
will decrease the DBP. • Duroziez's sign: It consists of systolic & diastoli c
• 1' SBP & '1, DBP ➔ wide pulse pressure causing murmu rs over the femora l artery if it is slightly
periphe ral signs of AR . compressed with the stethoscope bell.
• Volume overloa d on the LV leading to LV dilatati on & The systolic murmu r is due to the rapid flow of
later on LVF. blood to periphery, while the diastolic murmu r is
due to rapid regurge of blood to the heart.
• Hill's sign: Exaggerated differen ce betwee n SBP in
LLs & ULs: more than 50 mm Hg.
j Lung Congestion Normally, SBP in LLs is higher than in ULs: by about
I 10-20 mmHg.
I
• Signs of LV enlargement: with hyperd ynamic apex.
• No thrill over the aortic area: in isolated AR .
Auscultation:
Over the arotic area:
Clinical picture: • Normal second heart sound.
Symptoms: • Murmu r of AR:
• Generalized body throbbi ng: due to increased arterial • Timing: early diastolic.
pulsation. • Character: soft blowing , decrescendo.
• Palpitation : due to forcible LV contrac tion. • Site: maximu m over the third space.
• Symptoms of pulmon ary congestion: when LVF oc- • Propagation: to the apex.
curs . • Position: best heard with the diaphra gm of the
• Angina pectori s: "two types of angina occur in aortic stethoscope, the patient is :
regurge " • Sitting up.
• Classic angina of effort : Decreased DBP: reduces • Leaning forward .
corona ry filling . • Holding his breath in forced expiration.
• Angina of Lewis: Noctur nal & associated with au- • Soft ejection systolic murmu r:
tonomi c disturb ance e.g. sweating & tachycardia. • Due to 1' blood flow across the aortic valve (rela-
Signs: tive AS) .
General: "Peripheral signs of aortic regurge" Over the mitral area:
• S3.
Peripheral signs of aortic regurge: • Propagated murmu r: of AR .
4 head and neck, 3 upper limb and 3 lower limb • Pan systolic murmu r: of functio nal MR.
4 head and neck • Austin Flint murmu r: (mid-diastolic) due to :
• De-Musset sign: nodding of the head. • Elevation of anterio r leaflet of the mitral valve by the
regurgi tant blood from the aorta cau ses relative MS.
CD
ALLAM'S CLINICA L EXAMINATION ► CARDIOLOGY:
Summa ry of Local Examin ation:

Complications:
• Rheumatic activity.
,:, • Apex: Hyperdynarnic • Infective endocarditis.
~ • Chamber++: LV++ • LVF.
a. Investigations:
e1: • Chest X-ray : "Aortic configur ation (Boot-shaped
~ heart)"
• ECG:
~ • H.S.:S2 -1, • Echocardiography:
2 • Murmur: • Cardiac catheter ization & angiocardiography:
iff'
d'.
• Early diastolic
Treatm ent:
0 • Soft blowing
::, • Medical:
• Over A2
• Same as that of mitral stenosis .
• Increase by expiration
• Syphilis: anti-syp hilitic treatme nt.
• Surgical : (aortic valve replacement)
S1 S2 S1
I I~
-1,S2
I
Marfan 's syndrome
Definition: humb Sign & wrist sign
Multisys tem connective tissue disorde r autosomal domi-
._ nant trait characterized by systemic affection.
Features:
1. Positive family history
2. Skeletal manifestations:
• Long bone disprop ortionat e tall stature
• Short bone: arachno dactyly (long slender finger)
proved by:
• Thumb test & Wrist test
• High arched palate
• Flat foot & pes plan us
• Pectus excavatum or carinatu m
• Kyphoscoliosis
3. Eye: subluxation of lens, ectopic lentis
4. Chest: cystic diseases
5. Cardiovascular:
• Aortic aneurysm
• Dilated ascending aorta > AR
• Mitra! valve prolapse > MR
DD:
• Marfano id feature: skeletal manifes tation only
• Homocystinuria
• Patient have many symptom s and signs as tall
stature & ectopic lens
• Aortic aneurysm is not a feature
• Inherita nce is recessive
• Familial thoracic aortic aneurysm syndrome:
Has many feature of Marfan syndrom e+
autosom al domina nt trait
• MASS phenoty pe:
•
• Has many feature of Marfan syndrome
• But follow a more benign course
Tricuspid Regurgitation (TR)
Etiology: Summary of Local Examination:

• Functional: the most common cause due to dilatation
T. ;
of the tricuspid ring secondary to RV dilatation.
• Organic: rare: ~ • Apex: hyperdynamic
• Rheumatic fever. 8 • Chamber++: RV++
• Infective endocarditis. a. • Thrill: Systolic (Over Tricuspid)
iu
• Congenital.
• Carcinoid syndrome. ~
Pathophysiology: ~ • H.S. : 51 ~
• During systole, blood regurgitates from RV to RA "'nC • Murmur:
causing : iir" • pansystolic
• Low CO. !:t. • Soft
0
:,
• RA enlargement. • Over T (apex)
• RV enlargement.66 • Increased by inspiration (Carvallo's sign)
• RVF (systemic congestion) . • S3
Clinical picture:
_,,
Symptoms: S1 S2 51
• Systemic congestion.
• Low CO.
Signs:
-...L__J
~51 S3
General:
• Systemic congestion including:
• Congested pulsating neck veins: with systolic ex- Investigations:
pansion . • Chest X-ray
• Enlarged tender pulsating liver. • ECG
• Ascites before oedema of Lls (Ascites precox). • Echocardiography
• Mild jaundice & peripheral cyanosis (cyano-icteric • Cardiac catherization & angiocardiography
face).
Treatment:
• LowCO.
• Medical : Treatment of right sided heart failure.
• Surgical : Valve replacement.
• RA & RV enlargement.
• Rarely: systolic thrill over tricuspid area.
Auscultation: "over tricuspid area"
• Weak muffled 51.
• 53 .
• Pan systolic murmur.
• Timing: pan systolic.
• Character: soft or harsh.
• Site: tricuspid area . As a medical
• Propagation: to the apex, but not to the axilla . doctor, it is my duty to
• Caravallo's sign: murmur increases with inspiration evaluate the situation with as
being of right side origin. much data as I can gather and as
much expertise as I have and as much
experience as I have to determine
whether or not the wish of the
patient is medically justified.
Jack Kevorkian
•
....... - -· - - - -
_ ' ·CO~GENITAL 'H~ART DISEASE:
Classifications
Cyanotic Acyanotic
• Fallot's tetralogy
• Right Ventricle: • Left Ventricle: • Biventricular: VSD
• Fallot's triology
• A: ASD • A: AS • No ventricl: Dextrocardia
• TGA
• P: PS • P: PDA
• Eisnmeger's Syndrome
• C: Coarctation
lncidance:
Generally CHO characterized by:
0.5 - 0.8 % of childern
• Murmur since birth
Risk factors:
• Cyanosis since birth
• Maternal:
• No history of Rheumatic Fever
• Drugs: Alcohol
• Infant with recurrent chest infection
• Diseases:
• HTN in child:
• Rubella
• GN
• Coarctation of aorta
• DM
• Chromosomal:
• +ve Family history ±
• Down's Syndrome: VSD
• Growth failure & poor feeding
• Turner's : Coarctation of A
F~_l_lot's Tetra logy
Components: 4. Paroxysmal hypercvanotic spells:

1. Pulmonary Stenosis • lnfundibular spasm due to:
• 50% infundibular • Crying
• 10% valve • Feeding
• 30% both • defecation
2. RVH (mild) Presented by:
3. VSD (large & nonfunctioning) • 1' cyanosis
4. Overriding of aorta • Convulsion
Haemodynamics: • Cardiac arrest
degree of PS detect degree of Rt. to Lt . shunt • Hyperapnea (rapid, deep breathing) ➔ respiratory
• Sever PS ➔ Rt. to Lt. ➔ 1st week cyanosis acidosis
• Moderate ➔ balanced shunt ➔ delayed cyanosis 5. Growth Retardation
(within months) 6. Neck vein: despite PS there's no gaint A wave 0
• Mild ➔ Lt. to Rt. ➔ 1' Pul. BL. Flow ➔ 1' liability to 7. Cardiac examination: ~
HF ➔ within time ➔ PS 1'1' ➔ Lt.to Rt. shunt-!, ➔
• Normal Ht. size or mild Rt.V++
cyanosis & spells • Systolic thrill & murmur over pulmonary Area
• Single S2 (A2 only)
► N.B. Complications:
Pulmonary Blood Flow is maintained in by PDA in • Brain abscess
neonates • Pulmonary T.B.
• Infective Endocarditis
• Thrombosis
Clinical Picture:
• HF ➔ rare ➔ may be with pink fallot's
1. Central cyanosis
2. Blue Clubbing
3. Squatting position
Investigations: Treatment:
• X-ray: Medical:
• Oligemic lung • Cyanotic spells:
• Coeur en sabot (boat shaped Ht.) : • Squating position
• Narrow base, exaggerated waist & outward • Na HC03
shifted apex • Propranolol 0.1 mg/kg IV.
• ECG: Rt.V++ • Morphin 0.1 mg/kgsc. To suppress R.C.
• Echo: Diagnostic • Thrombosis: exchange transfusion
• Catheter: Pre-operatively • Prophylaxis against IE
• ABG: hypoxia Surgical:
• CBC: polycysthemia • Blalock - Taussing operation
Anastmosis between Aorta & Pulmonary
(subclavian & lpsilateral pulmoary artery) as PDA
• Total correction
Fallot's trilogy (F3}

• PS (valvular)
• Rtv ++ (marked)
• ASD
..,
Ventricular Septa! Defect (VSD)
Definition: Defect in interventricular septum • Heart:

Types: • Size: • Biventricular ++
• < 0.5 cm ➔ small • Thrill (Systolic in It parasternal area)
• 0.5 -1 cm ➔ medium • Murmur :
• > 1 cm ➔ large • Pan systolic harsh on Lt 3rd & 4th spaced
• Site: propagated to all over the precordium .
• Membranous 70% • Intensity of murmur is indirectly
• Ventricular 30% proportionated with the size of VSD
Haemodynamics: • 53
• Pulmonary Hypertention
Blood from Lt. to Rt . ➔ 1' pulmonary Blood Flow
• Relative Ms
➔ "!'input to Lt. At. ➔ Lt.V.F.
Long standing 1' Pulmonary blood flow ➔ VC ➔ Complications:
PH++ ➔ Reversal of shunt Eisenmenger's Syndrome • HF & Pulmonary infection
& Rt.V.F. • IE & Eisenmenger's
Clinical Picture: Investigations:
• Small: asymptomatic • Chest X-ray
• Large: • ECG
• Pulmonary Congestion • Echocardiography
• Heart failure (Lt. then Rt. side HF) Treamtment:
• Medical: Prophylactic & Symptomatic
• surgical
.....,
•
ALLAM S CLI NICAL EXAMIN ATIO N CARDIOLOGY:
LO NG CARDIOLOGY CASE
► 1-listory : • Upper limbs:

Personal history: • Pulse: 85 beats/ min., irregular, variable volume,
Mr. xxxx 41 years old, from Giza, driver, married 21 equal in both sides, pulse deficit> 10 / min.,
years ago and has 3 daughters, the youngest is 2 condition of blood vessels are normal with
years old, he is moderate smoker. palpable doraslis pedis.
He is complaining of: shortening of breathing of 1 • Blood pressure= 110 / 70.
week duration. • No hand clubbing.
• Lower limbs:
• No lower limb edema.
patient was quiet well until he suffered from an
• Intact peripheral pulsations.
exersional dyspnea of gradual onset and progressive
course with 10 years duration. Local Examination:
This dyspnea increased by exercise and decreased by
rest, treated by digoxin but recurrent, By Inspection:
No orthopnea or P.N.D. • No precordial bulge.
No cough, haemoptysis or recurrent chest infection. • No scars.
3 years later he developed regular palpitation of • No dilated vein or pigmentations.
gradual onset and progressive course, increased by • Visible apical pulsation.
exercise & decreased by rest. By Palpation:
2 months ago palpitation became irregular without • Apex:
precipitating or relieving factors. • Site: left 5th I.C. / M.C.L.
No symptoms of systemic venous congestion. • Area: localized.
No cyanosis, no symptoms of low cardiac output or • Character: hyper dynamic.
syncope. • Thrill: systolic thrill.
No chest pain, pressure manifestations, B.P. changes, By Percussion:
fever or embolic manifestations. • Hepatic dullness in 5th I.C. space.
No symptoms of other systems affection. • No dullness outside right border of the heart.
Patient investigated by E.C.G., chest X-ray, Echo • No dullness on base of the heart.
cardiography and Doppler and treated by digoxin, • No dullness outside the apex.
marivan and lasilacton. • No sternal dullness.
Past history of rheumatic fever at age of 7, manifested By Auscultation:
by fever, polyarthritis and skin rash, investigated by • Of Apex:
blood analysis and treated by aspirin long acting • Variable Sl.
penicillin every month without compliance. • Murmur:
Past History: • Pansystolic.
No history of surgical operation, allergy, or drugs • Soft.
intake. • On apex.
Family History: • Propagated to axilla.
Irrelevant family history. • Ill Ill by exercise.
• Of Tricuspid area:
► General Examination : • Variable Sl.
• Patient with an average general condition. patient is • No murmur.
fully conscious, oriented by time, place and persons, • Of Base:
with good mood and memory; he is co-operative with • Normal S2.
an average inelegancy. • No murmur.
• Average built, Patient lies comfortable in bed. • No additional sounds or crepitation.
• Body temperature: 37.1 °C.
Proper Diagnosis :
• No pallor, jaundice or cyanosis.
• Neck: A case of rheumatic valvular heart disease, most
• Not congested neck veins. probably M.S. & M.R. Patient is compensated but
• Normal carotid pulsation. complicated by A.F.
• Central trachea.
• No thyroid or lymph node enlargement .
•
ALLAM 'S CLINICAL EXAMINATION ► CHEST:
INTRODUCTION
► Surface anatom y of the chest:
liFii,t¥1
From 6th cervical vertebra to 4th thoracic vertebra (angle of Lewis) .
10 cm length (upper½ in the neck and lower½ in the chest). Ended by 2 bronchi
(Carina Angle)
Normal Trachea is slightly shifted to the right due to presence of the arch of aorta.
■i!i,t&
1. Apex:
Represented by curved line, a point 3 cm above
the medial ½ of the clavicle.
2. Anterio r border:
Represented by a line drawn downwar ds and
medially from the sterno-clavicular joint to the
sternal angle near the midline, then:
In the right lung: it extends vertically downwar ds
to the 6th sternocostal junction.
In the left lung: it extends vertically downwar ds
to the level of the 4th costal cartilage, where it
curves laterally for 3.5 cm and then downwar ds
and medially to reach the 6th costal cartilage 4 cm
from the midline.
3. Inferior border:
Represented by a line drawn laterally and
backwards cutting the following ribs:
6th rib, at the midclavicular line.
8th rib, at the midaxillary line.
10th rib, at the scapular line.
4. Posterior border: ► N.B.
Represented by a vertical line drawn from the Surface anatomy of the pleura: the same as lung by
posterior end of the inferior border up to the apex add 2 ribs over the inferior border of the lung.
of the lung.
Lung fissures:
Oblique fissure: (both lungs): Transverse fissure (Rt lung only):
starts at T3 posterior ly and extends obliquely down- starts at Rt 4th costocho ndral junction runs lateraly and
ward and forward along the course of 6th rib till MAL ends at 6th rib at MAL
and it ends at 6th costocon dral junction .
Lung Segments: (Broncho pulmona ry Segments)

Each lung is divided into a functiona lly independ ant
segment, each is suplied by a tertiary bronchus called
bronchopulmonary segment, Each one has its own
pulmona ry artery and vein.
See the picture here and the tables next page ... Upper
lobe
Bronchi Btonchl
(anterior (ante rior
view) view)
Lower
IObe
ALLAM'S CLI NICAL EXAM INATI ON ► CHEST:
Right lung (3 lobes) Left lung {2 lobes)

Upper (3) M iddle (2) Lower 5) Upper (4) Lower (4)
• Apical. • Medial. • Superior. Proper (2 segments) • Superior.
• Anterior. • Lateral. • Anterior. • Apico-posterior. • Antero basal.
• Posterior. • Posterior. • Aplco-anterior. • Lateral basal.
• Medial. Lingula (2 segments) • Post. Basal.
• Lateral. • Superior.
• Inferior.
► Chest Cases:
1. Suppurative Lung Syndrome {SLS):
Group of diseases characterized by cough & expectoration of
• Big amount (profuse). The diseases are
• Purulent. • Lung abscess.
• Postural. • Bronchiectasis.
• Paroxysmal. • Infected lung cyst.
• ± Foetid (bad odor). • Empyaema with bronchopleural fistula.
2. Chronic Obstructive Pulmonary Disease (COPD):
Cough, Expectoration, Dyspnea ± Wheezes.
Obstructive airway diseases
lrreversable
-
Reversible (attacks)
Progressive: gradually
Patient in between is free, e.g.
top of wheezy chest. increased.
Bronchial Asthma.
May be complicated by: Corpulmonale, complication of
chronic cough or respiratory failure.
Chronic Bronchitis: Productive cough everyday or most of days for 3 successive months in 2 successive years.
Asthmatic bronchitis: chronic bronchitis with evidance of BA as seasonal variation or increased eosinophil or
some response'to bronchodilators.
....,
3. fibrosis:
Dyspnea ( the main symptom) ± cough
if fibrosis is 2ry to TB, toxic manifestations, chest troubles and history of multiple drugs for prolonged duration
can diagnose TB.
4. Pleural Effusion:
• Pleuritic Pain (stitching then dullaching).
• Dry cough and Dyspnea
• History of aspiration ( Amount, color, aspect, complications)
► ~..!.Q_u lmonale:
Right ventricular hypertrophy and/ or failure due to chest disease, on top of healthy left side.
Causes of Acute Corpulmonale: 3. Causes of Chronic Corpulmonale:

• Massive P.E. Hypoxic: occurs in almost cases of chronic lung disease :
• Tension Pneumothorax. COPD &IPF. \...__,/
• Massive Lung Collapse. Vascular:

1ry Hypertension & pulmonary Bilharziasis.
Causes of Sub acute Corpulmonale:
• Lymphangitis Carcinomatosis.
• Recurrent showers of P.Emboli.
-........
ALLAM'S CLINICAL EXAMINATION ► CHEST:
CHEST SHEET
1- History: ~ Personal history.

General 2- Examination: Complaint.
Local :=]""" 3- Investigations. History of present illness: ] Analysis of the complain t.
. . Past history
4 - D1agnos1s. . . Symptoms of the related system .
5- Treatme nt.
Investigations and treatmen t history.
OM & Hypertension
CHEST HISTORY
1. Name: ~"-!, l!!Jp I"-""' 5. Marital state: ~a... eis o~ l°"°'fa"' ~ eis ~~':.1,1 I!!~ ~[,_;.:o
to be familiar with the patient. for possible sterility or impotenc e.
......., 2. Age: ~ a... eis I!!~ Infertility in lmmotile cilia Syndrome or cyctic
As certain diseases are more common in certain fibrosis (absent vas deferenc e)
ages, e.g. 6. Residence: ~~ ~L...
• T.B. more common in children and young adults. may reflect socioecnomic condition and may
• Corpulm onale and bronchogenic carcinoma occasionally point to certain disease e.g.
more common in old age. Helwan: interstitia l pulmona ry fibrosis.
3. Sex: 7. Special habits:
Bronchogenic carcinoma more common in male. ~ofaill o.l..a. J~ .fe. ~ ~a,... elS cl.I~~ f~I .fe. o;~ elS ~~~
Adenocarcinoma in female. ~"-!! opl t~ ~c,~1...1,1 J ':.19 ~ a.a;,P. ~ul;~ ,i OJ-OP" y ~
4. Occupation: ~"-!1 ~ e.g. chronic bronchitis, emphysema (COPD) -
persons in certain occupations are more bronchial asthma - cancer lip and tongue - post
susceptible to certain diseases e.g. operative pneumon ia.
• Asbestosis: IPF - bronchogenic carcinoma or
mesothe lioma.
• Farmers: bilharziasis - farmer's lung.
► Compla int:
On patient's own words+ duration~ ..,....:JI "-!I ~1 ,.,~ ~~11!.L ~ lfl' "-!! ~ ~u \f/1 "-!'
(take the most recent and most importan t complain t and it should be brief)
Example: the patient is complain ing of shortenin g of breathing of 1 week duration.
► History of present illness (H .P.I):

1. Analysis of complain t.
HPI should be:
2. Symptoms of the related system.
• As long as possible and Contains medical terms.
3. Systemic Review:.
• In chronological arrangem ent.
4. Investigation & treatmen t (related diseases).
• In the form of a story.
5. OM & Hyperten tion
For analysis of any complain t in chest as usual (8) + 3 variants+ 3 for any excreta.
8 as usual:
• Onset - course - duration.~ c.4~ J ..:.~ ,1 ~ ;~ ,i ~L...i ,s..1..o Js. ':J.9 ~;.i.:.14 uA,li, J:,l_,•.l,11 ~ 4-!!
~i ~ ':.l.9 o~ c.A,li, ,.sµ1
• Association.~ o~~,.. w~ ~ \f/1 ~w, J:>lyYI _iS:i:; 9 ~~ ~~ c..;is J.o,
• What increase and what decreas e.~~ \fl' 4-!!s ~ o~ J:,.,ill ~,~ lfl' 4-!!
• Effect of treatmen t. ~ <-:I" Lo '?.j ~ ':.l.9 ~ J:>lyYI ['>WI J.>-~ u. J.o, m 4:,1.. ['>WI ~b
• Date of last attack. ~ ...,...1 ;_;IS" o~ J:>_,,.JI I"-""! J,_a:;9 " J:>p/1 cl.I~.;_,.. _,.;,.1
+ 3 variants + 3 for any excreta:

• Postura l.~~ E-"'' J ~~ F- I!!~ • Amount.
• Diurnal.~ J:.l.! ':.Is ;l&-11 J ~~ o~ J:>p/1 • Content - Color - Consistency.
• Seasonal.~ ~_,.;,. ':.19 ~J ~ .1:;..;; ':.t.9 ~ ~ ,1 ~~
•
• Odour.
2- Symptoms of the chest: (chest+ 3 Cs+ 2 Ps)

~
+'
Haemoptysis.
VI
<lJ Expectoration .
..c commonest causes of chronic cough:
u Shortness of breathing {S.O.B.) {dyspnea) .
T .~ ti (Wheeze). 1. Chronic bronchitis.
2. S.L.S.
nstitutional manifestations. 3. Bronchial carcinoma.
3C
E Cyanosis.
Systemic venous Congestion.{Cor-pulmonale) .
4. Pulmonary T.B. - Pneumoconiosis & sarcoidosis.
5. Post-nasal discharge as chronic sinusitis.
r-- Pain.
2P L__ ~ ure manifestations.
•E·i1i4M
Defintion: explosive expiration for clearing oftracheo- C r . f h
bronchial tree. "Mainly in COPD & SLS" omp ,cations O coug :
Analysis: As before but never forget:
• Association: • Muscle (chest) pain. • Eye puffiness.
• Wheeze: B.A. • Fracture rib (stress • Sub-conjunctiva! haem-
• Hoarseness: laryngitis. fracture). orrhage.
• Vomiting: pharyngitis. • Pneumothorax. • Hernia.
• Diurnal Variation: • Emphysema. • Prolapse.
• Nocturnal: cardiac. • Haemoptysis .
• Early morning: bronchiectasis & B.A. .:.....-------'------------'
• All over the day: chest infection.
• Seasonal variation: allergy.
+ character of cough:
• Brassy: tracheal causes (metallic sound form mediastinal syndrome).
• Bovine: left recurrent laryngeal nerve paralysis (hollow) .
• Barking: hysterical.
• Paroxysmal: whooping cough - cavity syndrome - B.A. + pharyngeal, laryngeal and auditory irritation.
Aetiology: ( Reflex - Central - hysterical )

I- Reflex cough: Due to irritation of vagal receptors)
A- Respiratory causes
1. Pharyngeal diseases: Painful, non-productive ± nausea

. ___&
___P_haryngitis, tonsillitis~ cers, Tumors, post-nasal discharge__ g_ __
_ v_o_m_i_ti_n.:::.
2. Laryngeal diseases: Paroxysmal, painful, barking ±
Foreign body, laryngitis, ulcers, tumors hoarseness of voice or strid_o_r._ _____
3. Trachea- bronchial diseases: Accordingtothecause+expectoration
Bronchiectasis, Bronchial asthma, Bronchial tumours,
Pressure as mediaslinal syndrome
- - -- - -
4. Parenchymatous lung diseases:
• Pneumonias, abscess, T.B.
• Collapse, fibrosis, interstitial lung dis
• Pulmonary infarction
5. Pleural diseases: Usually dry cough due to irritation
Pleurisy, effusion, pneumothorax, hydropneumothorax & pleural exaggerated by activity and body
fibrosis. movement
Some types of expectoration (See later)
•
B- Extra-respiratory causes:
Cardiovascular diseases:
• Pulmonary congestion e.g. left ventricular failure & MS
• Pulmonary embolism
• Pressure: aortic aneurysm, massive pericardia! effusion or huge left atrium.
Mediastinal diseases: Aortic aneurysm, tumour, L.N. retrosternal goiter
• Brassy:- tracheal causes (metallic form= mediastinal synd .)
• Bovine:- Lt. RLN paralysis (hollow).
Other causes:
...,, • Abdominal causes: e.g. subphrenic abscess
• Meningeal causes: e.g. meningitis & subarachnoid haemorrhage .
• Aural causes: e.g. otitis medial or extema.
II- Central cough: Due to irritation of cough center.
Causes: Brain tumours, cerebrovascular strokes, encephalitis.
Features: Dry cough and neurological manifestations.
Ill- Hysterical {Psychogenic} cough:
Usually in young females.Dry & barking cough occurring in front of audience
2. H~_ery1optysis:
Definetion : coughing of blood. "Mainly in S.L.S. (50% of bronchiectasis)."
Classification: Differentiate d by investigations (laryngoscopy).
• True: below the vocal cord. see next table
• False: above the vocal cord.
True haemoptys is
Frothy blood tinged A.P.O. "Acute pulmonary edema"

Blood stained
- -- -
_ _ _ __ _____ _____A_cute infection - bronchogenic carcino_m _a
_._ __
Blood streaked Chronic bronchitis - bronchogenic carcionoma - T.B.
Red current jelly {blood + sputum + hg. debris). Bronchogenic carcinoma .
Klebsilla Pneumonia
Rusty (golden brown) Lobar pneumon_ia_. ______ _
Frank T.B. - pulmonary embolism - M.S. - B - bronchectasis
sicca haemorrhagica.
DD:
'-'
Preceded by ICough -Nausea & vomiting
During
• Contents Froth Food
• Color Bright red Dark
• PH Alkaline. Acidic
Followed by Blood tinged sputum Melena.
'-'
Analysis: Cause of Death in haemoptysis is asphyxia, so
As before but never forget: endotracheal tube is mandatory.
• Effect of treatment: History of blood transfusion,
Causes of Haematemesis with Fresh Blood :
indicates severe haemoptysis
• Achlorohydria.
• Massive Bleeding.
T.B is the most serious cause of haemoptysis as it
may be followed by fatal haemoptysis.
ALLAM 'S CLI NICAL EXAMINATION ► CHEST:
Causes of haemoptysis
1. larynx: e.g. laryngitis, foreign body, tumors, ulcers.
2. Tracheobronchial:
• Bronchogenic carcinoma
• Bronchiectasis
• Acute & chronic bronchitis.
• Inhaled foreign body.
3. Pulmonary: ,._,
• Infections :- Pulmonary tuberculosis. • Trauma
• Laung abscess • Vasculitis e.g. Wegener's granulomatosis.
• Pneumonia • Goodpasture's syndrome
• Aspergilloma • Pulmonary haemosiderosis
• Massive pulmonary embolism • Pulmonary A-V malformation
4. Cardiovascular causes: '-.../
• Pulmonary congestion: due to left-sided heart failure.

\,__./
• Pulmonary oedema
• Severe hypertension.
\,__./
5. Systemic causes:
• Haemorrhagic blood diseases as purpura & haemophilia
► N.B.
Bronchiectosis Sicca Haemorrhagica:
Special type of brenchictasis c;aused by TB charachterized by frank haemoptysis.
Explained as; TB usually affects the apical part of the lung, with good drainage so, presented with Dry
cough and Frank haemoptysis.
\,__./
3. Expectoration:
Definition: excessive spitting. " Mainly in COPD - SLS"
Analysis: As before but never forget:
• Postura Variation!: e.g. Postural variation can diagnose hardly the anatomical site of the lesion.
• Postural variation: with S.l.S.
• Unilateral: increased on healthy side in lung abscess.
• Bilateral: increased with leaning forward in bronchiectasis.
+ 3 for any excreta:
• Amount, > 250 cc= 1 cup
• Content - Color - Consistency.
• Odour; very bad odour in anaerobic or fungal infection
Expectoration in COPD and S.L.S.:
- - COPD
S.L.S.
Type Purulent. Mucoid or muco-purulent
Postural Positive. No
Association Toxemia. Dyspnea - wheeze
► N.B. ► N.B .
Excessive eosinophils can cause sputum to appear Anti biotic is indicated in COPD only if sputum
purulent like (yellow) , become yellowish in color.
\___.,I
• \_,,
Different types of expector ation:

1. Frothy (serous) • Pulmonary oedema (pink frothy sputum) . Red Curr~bt Jell S utum
• Pulmonary venous congestion .

• Broncho alveolar carcinoma .
2. Mucoid • Chronic bronchitis.
• Bronchial asthma .
3. Purulent Mucopuru lent • abscess and bronchiectasis .
• any form of broncho pulmonary infection .
~
4. Rusty Golden brown • Pneumonia . (altered blood pigment)

~
5. Chocolate • Amebic lung abscess (Anchovy Sauce).

6. Red-current jelly • Klebsilla Pneumonia
• Bronchogenic carcinoma .
7. Caseous • TB; nummular sputum (coin like).
8. Black • Inhalation of carbon .
4. Dyspnea: C/0 = SOB

May be Obstructive (COPD) or Restrictive (fibrosis).
Analysis: 8 as usual+ 3 variants + in C.V.S.
► N.B. ► N.B.
Causes of paroxysmal dyspnea: Causes of Exertiona l Dyspnea :
8 = Asthma (bronchia l/ cardiac/ uraemic) 1. Hypoventilation:
.!:! = Hysterical. obstructio n (COPD) or restriction (fibrosis) .
.!,, = Laryngismus stridulus. 2. Hypodiffusion:
8. = Allergic alveolitis. fibrosis or congestion (left sided failure).
M = Myesthenia gravis / mediastinal syndrome.
Causes of acute dyspnea:
cardiac dyspnea usually exertional associated with
1.Hypoven tilation:
cardiac symptoms (PND or orthopnea).
obstruction (foreign body or 1st attack of br. asthma)
or restriction (pneumothorax).
2. Hypodiffusion: cardiac asthma (APO).
3.Hypoperfusion: pulmonary embolism.
5. Wheeze: Analysis : 8 as usual+ 3 variants
Wheeze
Continuous Paroxysmal
Asthmatic Bronchitis Bronchial Asthma
(lrreversable) (Reversable)
6. Constitut ional manifest ations (toxic) :
• Anorexia. ~
• Loss of weight. in S.L.S. & T.B.
• Fever.
• Sweating.
7. Cyanosis: Ask about cyanosi s in patient own words
•
8. Systemic venous congestion:

Stress on jaundice and lower limb edema.
► Jaundice in chest case: ► LL oedema in chest case:

• Hepatocelleular: • R.V.F.: corpulmonale.
in cor-pulmonale (liver congestion) . • Hypo-albuminemia: Excessive expectoration for
• Haemolytic: in pulmonary infarction. a long time, or Frequent aspiration of empyema.
• Obstructive: • Nephrotic syndrome: due to renal amyloidosis in
in bronchial carcinoma (liver metastasis). chronic S.L.S.
• Acid-base disturbance in COPD
increased CO2 » Resp. Acidosis »
Compansatory Met. Alkalosis (1' Hco3 retention)
• Hypoxia and Toxins» increase capillary
Permeablity
9. Chest Pain:
Analysis: 8 as usual + 3 variants

Chest pain of pulmonary origin:
. Non central Ce_nt.ral (Retro sternal)
• Skin: H.Z. • Acute mediastinitis.
• Muscle: Ms Strain & Myositis • Mediastinal tumors.
• Ribs: Fracture or Osteomylitis • Tracheitis.
• Pleura: • Mediastinal emphysema.
• Plurisy (Stitching)
• Plural Effusion (Dull Aching)
• Embyema (Throbbing)
• Pneumothorax (Tearing)
► Specific for pleural diseases: ► N.B.

• Characterized by: Stitching. • Lung Diseases as Pneumonia, Pulmonary infarc-
• Increased with breathing, cough and straining. tion, lung abscess or bronchogenic carcenoma
• Relived by lying on the diseased side. may cause pain due to pleurisy
• Localized except diaphragmatic pleurisy
10. Pressure manifestations:

Mass in the chest (mediastinal syndrome}. See CVS
3. Other Systems:
CVS: Systemic congesion, pulmonary congesion & low cardiac outpot manifestation as syncope
Neurology: motor and sensory affection
if nothing involved write
eg. no symptoms suggest other systems affection
4. Investigation & treatment (related diseases):

eg. patient investigated by ECG, chest X-ray, ECHO cardiography and treated by Beta blocker
5- DM and Hypertension:
DM and HTN are usually considerd as past history, but they better be considerd as present history as they are
highly important and never cured (controled not cured) .
• Diabetes Mellitus: 1 -:,~w,., \?i J..=- 1 rlS .:,IS~~ ?i 1 "-!! ~i =.p 1 "-!! ~~ -:i.i.:;.i 1 ..,.-..10,o 1 ~ l!I.=
• Hypertension: J..=- 1 rlS .:,IS ~ 1 ~ o.,-o ?i 1 "-!! ~i =.p 1 "-!.! ~~ -:i~i 1 ..,.-..J 0,o 1 ..biw l!i.=
_,,
ALL.AM'S CLINICAL EXAMINATION CHEST:
v ► Past History: ► Family History:

• T.B. • History of chest infection e.g. T.B.
• D.M. (T.B. follows D.M. as its shadow). • Similar conditions.
• Similar attack. • History of allergy (asthma).
• Asthma. • History of D.M. (T.B. follows D.M. as its shadow).
V • Bilharziasis.
• Chest trauma.
V • History of anasthesia or coma (aspiration).
v Diagnostic Algorithm for chest symptoms and diseases:
Cough, Dyspnea or Wheeze
Continuous Paroxysmal
Bronchia l Asthma
No Expectoration Expectoration
Fibrosis Analyse:
Causes: Radiation, IPF, Amount, Odour, Color,
TB ... etc Positional variation
Big, Foetid Purelent Small, no odour

with positional variation and white
SLS COPD
Increases with Increases with laying

leaning forward on the healthy side
Bronchiectas is Lung Abscess
Summary of History:
V
Constitutional symptoms
m l§ljJ ~., !! !i~ .::..,.i; mW~
,m ~""-! 4-!~ .;:.;IS
V m ~ .;,1 "tl.9 m la.),~ .;,1 4!I
m ~~ ~., ~ ' ~.,~~.Rm IJ!"" ..:.i3 ~ ~~ Systemic Congestion m~~.,l~J
Haemoptysis m~i~.;~14.e i
ml'~~ Cyanosis
V m ~J.l.:.!¼ ~, o~ ..:...,.i;., 11 _,l.ol .,..
m ~~ 4!~ .:.;IS' Chest pain
m a,.,J1_,J1 m ~I ,ujl !i ~! .)I~,
Expectoration Pressure manifestations
m~11!.U,_..,JA
mo.)l,J~l!li= m ~1 ,>. 4!,a.o <!!.i..a. JA
V
m ~ .far~ u. ~.i:!! ~, m )I!. r1.)'II ~ u. ~ E:"'-' ~ ....,..r.! Other Systems
v m !...!JI~ ~ I I.\~ 111:,iWI.:,... _;;Si~ I"-"',-. J ..uj:,!
!! ,i:,,,l!,Jl.9 !! ~ I ~! .u,I m ~! ,)1 ~ I m ~ . ; ljl:i ._,. 1§1.; JS~ <!J.,.;s JA
Dyspnea (Shortening of breathmg) !i ~! .::.Lo,..s ..:.Lu:
_
m.,.._a;~l!.l.i..a. m ~I t~ .:,J.;.i9
Wheeze ( .~ i,'.i }
\....,;
•
_,,.
GENERAL EXAMINATION
e ~19) Vitals: Blood pressure. pulse, Respiratory rate, Temperature.

Fever:-.- Low grade: TB & Carcinoma
L_ High grade: Pneumonia & Abscess
BP: Hyper tension: Vasculitis, BA treated with steroids

L Hypotension: CorPulmonale ( '1,COP) & Addison's Disease caused by TB.
Pulse : Big volume: due to Hypoxia.
1
Small volume: Car Pulmonale
Pulsus Paradoxus: See General.
Unequal Pulse Volume: Pancost Tumor
AF: My occure in COPD
0 ~ uilt: Over built, average built or under built
Over Built: L Pichwichian syndrome. (restrictive hypoventilation by obes ity)

Car Pulmonale (edema)
Under Built: ~ Underbu ilt in TB. ,,
Cachexi a in Bronchgenic Carcinoma.
Short status in chest disease since birth (Cystic Fibrosis).
G Complexion:
Pallor: TB, Pneumonia, Carcinoma.
Cyanosis: --.-- Central: CO PS, Fibrosis, Repiratory Failure
L- Peripheral: Rt Heart failure
Jaundice: see above
.._.,,
G Decubitus or position
• Lateral Decubitus: in unilateral chest disease.
• Orthopnea in Emphysema
£ .•
• Platypnea in apical lung lesion or tumor
• leaning forward or praying Cor-pulmonale.
position
- in Pleural effusion, Massive pleural effusion or pneumothorax.
Mediastinal syndrome. • Chronic obstructive pulmonary disease.
0
E
H & N : Con ested neck vein
upper limb
lower limb: Lower limb edema
L • Mediastinal syndrome.
T,emors ---,- • Flapp;ng, ;n respkatory fa;lure (CO, retention)
~=~ L- • Fine: Beta stimulation as in bronchodilators
....,,
Clubb; ng L• •
Blue ----C : ~~-, D (m;ld & osoally ;r assodated w;t'
Pale ---C • SLS Br.carcinoma or Bronchiactesis)
A L • Bronchogenic Carcinoma
w, fa Mentality: Disturbed mentality (CO, narcosis). • MPc;nthPlinmr1
...__,/
Face+ general lock. ► Enlarged lymph nodes due to:
Puffiness (chronic cough). • Bronchogenic carcinoma (Scalene lymph nodes).
• Tuberculosis
• Sarcoidosis.
_,,
•
.....,
Value of Other System examination
► CVS examination
Cause Result ·- J -. Association
• Pulmonary congestion. • Cor-pulmonale. • K-artagner 's syndrome.
• Pleural effusion.
'-
• Left sided failure (BBC) .
► Abdominal examination
Liver (hepatomegaly) Spleen (splenomegaly) Ascites
• Cor-pulmonale. • Cor-pulmonale. • Cor-pulmonale.
• Ptosed liver (emphysema). • Miliary T.B. • T.B. 1:>eritonitis
• Amoebic liver abscess. • Sc1rcoidosis.
• 2ry from Br. Carcinoma. • Amyloldosis.
• Fatty changes (toxemia). • Associated .
• Association.
► N.B.
• Ascites + Rt pleural effusion = suggestive to liver
cirrhosis.
• Ascites + left pleural effusion = suggestive to lung
disease e.g. T.B.
INTRODUCTION TO LOCAL CHEST EXAMINATION

- - --
Lines of the chest:
Parasternal: midway between MCL MAL: apex of axilla. Paravertebral: midway between
and lateral border of the sternum . mid line and medial aspect of the .......
, sca pula.
MCL: midway between the acromion PAL: posterior fold of axilla. Scapular line: from the angle of the
process and sternoclavicular joint scapula.
(as Mid way of inguinal line).
..._,,
Areas of the chest:
• Supra-mammary. • Upper lateral. • Supra scapular.

• Mammary. • Lower lateral. • Inter scapular.
• Infra mammary. • Infra scapular.
Supramammary
Lower Lat.
Upper Lat.
..,,
LOCAL CHEST EXAMINATION ......._
J1nspectiori·{6) (s°Ms~fpI,+;f~P.iipati·on ts) (T) · 1Per_cu~sion (4) ·Aus~tdtation (3)

1. Shape of the chest.
- I~
1. i rachea . 1. Lung proper. 1. Breath sound .
--
2. Respiratory M ovement.
3. )kin lesion.
-
2. Tendern ess.
3. T.V. F.
- - T3.2. Traub's
Bare area .
area.
2. Adventitious sounds.
3. Voca l Resonance.
-
4. · rachea (Trill's sign) 4. Palpable wheeze . ~ _;:; 4. Kronig's isthmus.
5. : ·ulsations. 5. Expansion ~...
6. Litten's sign .
► Inspection:
-
1. Shape of Chest:
Normal Chest Shape:
• Elliptical in shape
• Diameters: Transverse : Antropost. = 7:5
• Symmetrical
• Subcostal angle: ~ 90
• Ribs : Oblique
• Spaces: Narrow
► Abnormal Shapes:
1. Barrel shaped chest: "Emphysematous"
as in COPD
• Antero posterior ~ t ran sverse.
• J-3-9 Th ick shoulder.
• ..:.,._:,.j Sub-costal angle : wide.
• r~I Protrusion of the sternum.

• uJ;;. Kyphosis.
• Ribs : tran sverse with wide I.C. spaces.
► N.B.
Short cricosternal distance <5cm (3 fingers) is the
surest sign for barrel shapped chest
2. Funnel chest: "Pectus excavatum"

Congenital or occupational.
3. Pigeon chest: "Pectus carniatum"

Congenital or Rickets .
4. Unilateral retraction:
Fibrosi s & collapse.
5. Unilateral bulge:
• Pleura : effusion, pneumo-thorax.
• Chest wall: emphysema, tumors.
► N.B.
To differentiate between retraction and bulging look
at the moving side which is the healthy one.
e
2. Respiratory Movement:
Rate: (12 - 20 cycles per min.) ( pulse/ Res. = 4 / 1).
Abnormal rate: -r-- Tachyp nea as in Acute Dyspnea or Fever.
L (1'20) - E 1'1CT
Bradypnea due to suppresion of RC by Morphine
(-J.. 12) Alcohol
Rhythm: Regular (Normal Rhythm) or irregular
I _ _ _ Irregular Respiratory rhythms:

• Chyene Stokes Breathing: • Biot's (Ataxic} Rhythm:
"-'
Gradual decrease in the depth of respiration till Irregular breathing in rate and depth with periods
apnea for a period then gradual increase in the of apnea
depth of respiration till a peak and so on Occurs in:
Occurs in: • Meningeal lrretation
• Elderly (During sleep) • Subarchenoid Hge
• increased ICT
• Depressed RC
Depth: average, deep or shallow.
~
Normally inspiration is produced by contraction of diaphragm & intercostal muscles, while expiration is an passive
process produced by the recoiling action of the elastic lung tissue .
• In male: Respiration is mainly abdomino-thoracic.
• In female it's mainly thoraco-abdominal.
Abdonrmal respiration:
• Abdominal: • Thoracic:
• lntercostal muscle paralysis • Diaphragmatic paralysis
• Limitation of chest expantion (Ankylosing) • Abdominal destention
Degree of chest expansion :
Normally: Chest moves freely w ith respiration. chest expansion is detected accuratlly by a tape meter.
Limitation in chest movement:
• Unilateral: Fibrosis, collapse on the affected side
• Bilateral: Emphysema, Bronchiectasis (Bilateral diseases)
3. Skin Lesion:
Scars, dilated veins & pigmentations .. etc.
4. Trachea (Trill's Sign):

Trill's sign
Prominent sternomastoid tendon on the shifted side
......
S. Pulsations:
Apex: absent in emphysema.
Epigastric & left parasternal pulsations (RV++).
6. Litten's Sign:
Shadow (effect) of diaphragmatic descent which normally appear on chest wall during inspiration.
Its presence exclude: Its absence may be : Exaggerated:
• Paralysis of diaphragm . • Diaphragmatic paralysis. with Resp. Distress
• Pleural effusion . • Pleural effusion .
• Normal but in Obese.
► N.B.
Hoover's sign:
It refers to inward movement of the lower rib cage during inspiration in Respiratory Distress.
► N.B. ► N.B.
Signs of Respiratory Distress: (On Request). Respiratory Faliure is a Lab
1. Exaggerated litten's sign Diagnosis depends on ABG.
2. Hoover's sign
3. Tracheal tug with inspiration
4. Working Ala Nasi
5. Abdominal movement of accessory muscles
6. Tripod position:
one sits or stands leaning forward and supporting the upper body with hands on the knees or on another
surface, so he can use latismus dorsi in approximating ribs .
7. Pursing lips : To 1' intrabronchial pressure and prevent collapse of alveoli
8. tachpynea
9. Tachcardia
10. Cyanosis
► Palpation:
1. Trachea:
Trachea is clinically central. but radiologically shifted
to the right because of aortic arch .
Technique of palpation:
• Put the patient in the sitting position .
• Fix his head by your left hand .
• Insert your index in the pouch between the two
sternal ends of sternomastoid.
Cricosternal Distance = 3 finger breadth from the

patient ' s fingers ( roughly ;:: 5 Cm ).
• if shorter than that means Barrel shaped Chest .
.......
Causes of tracheal shift:
• Fibrosis • Pleural effusion

• collapse • pneumothorax
• pneumonectomy. • hydro-pneumothorax
• unilateral emphysema.
► Tracheal tug:
1. Campbell's sign = tracheal tug with inspiration: Trachea descent with inspiration in severe COPD (It is not
specific).
...._,,,
Explained by pulling on the trachea during inspiration due to strong diaphragmatic contraction in COPD.
2. Oliver's sign = tracheal tug with pulsation: descent of cricoid cartilage with ventricular contraction in cases of
aortic aneurysm.
according the site '--"

2. Tenderness:
..__,,
1101
Definition: vibration of the vocal cords transmitted
through airway & chest wall to be palpated on the ► N.B.
chest wall.
Causes of increased T.V.S.: 3 Cs
Technique:
• ~ onsolidation.
• Ask the patient to say 99 (44 in Arabic)
• ~ ollapse Or fibrosis with a patent bronchus.
• Palpate the chest area by area
• ~ avity if superficial & surrounded by
4. Palpable Wheeze: consolidation.
Technique: T.V.F. is reduced in any other chest diseases.
• With deep respiration. Physiologically higher in the 2nd right space, As the
• Palpate the chest area by area right bronchus is more superficial.
Causes in COPD. TVF can't be done with:
5. Expansion: • Hoarsness of voice.
Technique: • Vocal Cord Paralysis.
Front:
Supramammary: Put your hand on both sides close to ► N.B.
each others and ask your patient for deep respiration Pah;;able Rub Detected in: Pleurisy
Pa pable Crepitations Detected in:
& observe movement. .._,,
Mammary and lnframammary: take a skin pinch by Coarse cerpitations
your hand and ask the patient to inhale.
Back: supra-scapular (Put you hands and observe ► N.B.
elevation of them with respiration Examine Mediastinum: means
& infra scapular areas (pinching). • Trachea
Normaly Chest expands about 5 - 7 cm • Inspection ➔ Trills
Causes of limitation of chest expansion: • Palpation
• Bilateral: COPD & bronchiectasis. • Heart ➔ Apex.
• Unilateral: fibrosis & collapse.
► N.B.
Start by palpable wheeze and tenderness at the same time by asking the patient to take a breath while papat-
ing chest areas area by area with comparision (rt and It) also look at the patient face to observe tenderness.
Then TVF by asking the patient to say 44 in arabic or 99 in english while palpating chest areas area by area with
comparison (rt and It)
Then Chest expansion
► Chest Palpation area by area with Rt and Lt comparison

( searching for tenderness, palpable wheezes and TVF):
► Palpating chest expansion:

Mam. and Infra Mam Ch!!St fx ansio11
'---·
► Percussion:
Principle and technique: fair is resonant. everything else is dull)
We use the middle finger of the right hand, it struck sharply and quickly with the tip over the shaft of the middle
phalanx of the left middle finger.
Place the left hand on the chest wall with the fingers parallel to the ribs, the middle finger is placed firmly in the
inter-costal space chosen.
Light percussion gives palpable rather than audible vibration .
Heavy percussion gives palpable and audible vibration.
Types of percussion notes:
1. Tympanic: hollow e.g. normal traub's area .
2. Hyper-resonance: emphysema and pneumothorax.
3. Resonance: normal lung.
4. Impaired note: pulmonary consolidation or fibrosis .
5. Dullness: pulmonary consolidation , pulmonary collapse & fibro sis.
6. Stony: pleural effusion.
Methods:
• Hepatic Dullness {Tidal Percussion)
• Heart Percussion
• Chest Percussion:
• Lung Proper
• Special Areas
1. Lung Proper:
Started by Kronig's isthmus.

2. Infra clavicular. I Then,
3. Space with space at MCL except • Supra scapu lar.
left 4th & 5th spaces at AAL. • Inter scapular.
4. Ends at the Rt. Side by hepatic • Infra scapular.
dullness (tidal P.) ends at the Lt.
side by tympanitic resonance of Alternative, Space by space
traub's area.
-2
-3
-4
- 5
-6
-7
-8
-9
Tidal percussion
of liver Rt lobe
• Percussion of chest from front by light percussion

• Percussion of chest from back by Heavy percussion
..__,,
....,
2. Bare Area:
Definition: area of the heart not covered by the lung.
Anatomy: left 4th & 5th inter-costal spaces, from the left
border of the sternum to the left parasternal line.
Normally: dullness (blood) .
Abnormalities:
• Resonant of the bare area in:
• Emphysema (the surest sign) .
• Pneumothorax.
• dullness of the bare area in:
• Collapse.
• Rt. V ++.
• Pericardia! effusion.
3. Traub's Area:
Definition: area of the chest overlying the air bubbles at
the fund us of the stomach.
Anatomy:
• 5th rib at MCL.
• 9th rib at MAL.
• Costal margin at MAL.
• 8th costochondral junction.
Normally: tympanitic resonant. (air bubbles).
Abnormalities:
• Dullness:
• Above: pleural effusion & pericardia! effusion .
• Down: ascites, pregnancy and tumors.
• Right: hepatomegaly.
• Left: splenomegaly. l=hflikffi,.1§.i,i-ttifl'htiS
• Full stomach or gastric tumor.
• Wide area:
• Lobectomy, splenoectomy.
• Shrunken liver or dilated stomach.
4. Kronig's Isthmus:
Definition: a band of resonance overlying lung apex.
Anatomy:
• Anterior: clavicle (medial 2/3).
• Posterior: trapezius muscle (medial½) .
• Medial: root of the neck.
Bony border:
• Anterior: medial 2/3 of the clavicle.
• Posterior: medial ½ of the spine of the scapula .
• Lateral: a line connects 2 points:
• Junction between med 2/3 & lat½ of the clavicle.
• Junction between med ½ & lat 2/3 of scapula spin
• Medial: a line connects sternocalvicular joint and
Cl
• Normally: resonant.
Abnormalities: dullness in apical lesions as:
• T.B.
• Pancost tumor.
• Friedlender's pneumonia .
• Fibrosis/ collapse.
• Pleural thickness .
•
► Tidal Percussion:
Percuss the Right Ant. chest wall at MCL from above at 2nd intercostal space downwards till the upper border of
the liver (Dullness) then ask the patient to take a breath, Percuss again ➔ the dullness converts to resonance due to
movement of the diaphragm.
Values of Tidal Percussion:
• Differentiate supra from infra diaphragmatic dullness (se e the lower table)
• Diaphragmatic movement : measuring the distance between the lower border of pulmonary resonance in full
inspiration and forced expiration at the back of the chest .
Normal: dullness at TlO changed to resonance by inspiration
Abnormalities
Resonant becomes dull on inspira- Dullness above TlO (didn't

nance by inspiration. tion (diaphragmatic paralysis). change).
► Shifting dullness:
Used to differentiate pleural effusion, from hydro pneumothorax by percussing in 3 planes.
In pleural effusion no change while in hydro pneumothorax it is changed.
• 1st plane: Percuss the M.C.L from above downward till the dullness, proceeds one space above (resonant),
ask the patient to sit, the resonance will be dull in hydro pneumothorax).
• 2nd plane: Percuss from the sternum to the axillary line till the dullness, ask the patient to lie on the
opposite side. The dullness will be resonance in hydro pneumothorax.
• 3rd plane: Percuss the back (scapular line) from above downward till the dullness, ask the patient to lean
forward. The dullness will be resonant.
_,
► N.B.
Classical Percussion is in all spaces & in all lines by
comparison.
► Muscles of Respiration
• Diaphragm.
• lnter-costal muscles. • Sternomastoid . • Abdominal muscle.
"only for inspiration as expiration is a ! • Trapezius. • Latissimus doraslis.
passive process". 1 Scalenii.
•
• Lips.
Components & Types of Respiratory Failure.

► N.B.
Type 1 : Hypoxia with normo/hypo-capnea. Usage of accessory muscle means difficult breathing
Type 2 : Hypoxia & Hypercapnea . in cases of airway obstruction as COPD.
Normal Respiratory Failure

P02 80 - 100 mmHg < 60 rnmHg
- ·
35-45 mmHg > 50 mrnHg
--PC01.
.
PH 7.35 - 7.45 '1, in type 2
e
► Auscultation:
• We can use either diaphragm or bell (cone) .
• Most of the sounds reaching the chest wall from the bronchi and lungs are of low
frequency so, the bell is preferred.
• Stretching of the skin and hairs under the diaphragm during deep breathing
produce sounds like pleural rub or crepitations so the bell is preferred.
• The patient is relaxed and breathing deeply and fairly rapidly through the mouth .
• Avoid prolonged deep breathing to avoid giddiness or tetany.
• In each area we comment on and compare the following:
1. Air entry.
2. Breath sounds.
3. Additional sounds.
4. ± vocal resonance.
1. Air Entry:
Reduced air entry
2. Breath Sounds:
Vesicular breathing (V.B.) Bronchial breathing (B.B.)
(alveolar breathing) The alveoli are out of function
The alveoli are functioning.
Charachter Soft. Hollow.
No gap. Gap.
Inspiration > Exp (3:1) lnsp. s Exp.
Causes A. In normal persons. A. Normally on trachea.
B. Vesicular breathing with prolonged expiration B. Abnormally in (3 Cs):
(harsh vesicular): • Consolidations .
Obstructive airway as; COPD. but may be • Collapse with patent bronchus .
diminished breath sound in severe COPD. • Cavity if superficial & surrounded by
consolidations.
Subtypes of B.B. are:
tubular, cavernous & amphorous.
-
~ ~ Normal prolonged expiration (Har. hl
/~ Bronchial
to confirm bronchial breathing:
• compare with trachea.
• whispering pectrology
Bronchial Breathing
Tubular Cavernous Amphoric

High pitched sound Low pitched sound Low pitched sound
• Consolidations. Cavity: Cavity with tense wall
• Collapse with patent bronchus . • T.B. • Tension pneumothorax.
• Cavity if superficial & surrounded • Abscess. • Large superficial cavity.
by consolidation. • Bronchopleural fistula.
I
Despin's sign: bronchial breathing below the
► N.B. level of trachea "4th thoracic vertebra" due to
Broncho Vesicular Breathing: Vesicular enlargement of the inter bronchial lymph node.
Inspiration & bronchial expiration occures in patchy Causes:
consolidation • T.B. • Carcinoma .
3. Additional Sounds:
Additional Sounds are t hree:
1. Rhonchi.
2. Crepitations.
3. Rub.
In any additional sounds: ......
• Distribution .
• Timing.
• Type.
• Effect of cough.
1. Wheezes (Rhonchi)
► N.B.
Definition: it is continuou s musical sound . Character of rhonchi in COPD:
Causes: bronchiolar or bronchial obstruction by: • Generalized (bilateral).
• Spasm of the wall. • lnspiratory & expiratory but mainly expiratory.
• Mucous in the lumen. • Changed with cough .
• Pressure from outside by L.N . enlargement. • Polyphonic.
so the air passes in a narrowed bronchus.
• it occurs in B.A. & C.O.P.D. due to spasm & mucous secretion .
Types of Wheezes
Siblent Sonorous ► N.B.

high pitched low pitched • Wheezes may be heard in fibrosis.
distal small bronchioles central big bronchioles or • Localized, monophonic, fixed wheeze is specific
bronchi for tumor.
best heard over sides best heard over midline
e.g: bronchial asthma. e.g: chronic bronchitis.
it can be:
• Generalized: bronchitis.
• Localized: Foreign body, any secretions.
Effect of Cough :
• inspiratory rhonchi changes with cough due to the secretions which present in bronchi.
• Expiratory rhonchi not changed with cough as it is due to spasm or edema of bronchial wall.
2. Crepitations (Rales, crackles)
► N.B.
Definition: it is an interrupted moist non musical sound . Early inspiratory crepitations may occur in COPD,
Mechanism of crepitations: called opening snap of the chest, but late inspiratory
• Air passage "Bubbles through fluid ". crepitations indicate infection.
• Reduction of the lung elasticity with ._!, alveolar
compliance (crackles).
• Fluid in the interstitium.
Types and Causes:
Fine (~ 6 cycles/ min) Med ium (3 - 6 cycles/ min) Coarse {1 - 2 cycles/ min)
• Early pneumonia. • Pneumonia. • Late pneumonia.
• Early T.B. • T.B. • Late T.B.
• Early interstitial lung disease. • Lung abscess. • Lung abscess.
• BBC • Bronchiectasis. • Bronchiectasis.
• APO
it can be:
"-- ► N.B.
• Generalized: Pulmonary edema.
Consonating or non consonating.
• Localized: bil ateral basal Crepitations.
Effect of Cough : Consonating = metalic tone (in medium sized
• Air passage "Bubbles through fluid" :change by cough . crepitations = surrounded by consolidations).
• Reduction of the lung elasticity as in fibrosis : not
changed with cough.
3. Rub (pleural rub)

Definition: it is a stitching friction gritty sound, disappears
by holding of breath.
Causes: Pleaural Diseases Pleurisy (dry or with effusion) .
D.D:
• Pericardia! rub (with heart beats).
• Friction of the stethoscope : disappears by firm pressure
effect of cough: Unchanged.
Timing with Resp Cycle: lnspiratory & expiratory.
e
ALLAM 'S CLINICAL EXA MINATION ► CHEST:
4. Vocal Resonance:
Definition: it is vibrations of the vocal cord transmitted through airway and chest wall to be auscultated.
Called: voice sound
Diminished in all chest lesions except: 3 Cs
• Consolidations.
• Collapse or fibrosis with patent bronchus.
► N.B.
• Cavity if superficial & surrounded by consolidations.
• Aegophony is heard in upper border of pleural
Method: patient say 99 "44 in Arabic"
effusion with nasal tone.
Bronchophony: in a loud voice.
• E to A changes: is a variant of aegophony.
Whispering pectrology: by whispering "diagnostic".
INVESTIGATIONS IN CHEST
Scheme for investigations 2. Radiological:

1. Aetiological Diagnosis. • X ray:
2. Anatomical Diagnosis. for detection of many diseases as Pleural effusion,
3. Functional Diagnosis. Pneumothorax, SLS, COPD ... etc.
details in Paraclinical book.
4. Pathological Diagnosis.
• CT scan:
1. Aetiological Diagnosis
is investigation of choice for many Diseases as : SLS
• Patch test in allergic Bronchial Asthma.
& Lung Fibrosis.
• investigations for T.B ➔ See Theoritical Book.
3. Pulmonary Function Tests.
2. Anatomical Diagnosis
1.for accurate Diagnosis by Spirometry that detect
• by Plain X ray as a simple rapid investigation.
several vital volumes and capacities.
3. Functional Diagnosis • Forced Vital Capacity (FVC)= Max. volume of air ex-
a- Compensation : pired by deep expiration after deep inspiration.
by ABG for detection of Resp. Failure. • Forced Exp. Volume in the 1st seconed (FEV 1) = Max.
b- Complications : volume of air expired by deep expiration after deep
as Corpulmonale : ECG and Echo. inspiration in the 1st seconed.
• Timed Vital Capacity (TVC) or Forced Exp. Ratio (FER)
4. Pathological Diagnosis
= FEV 1/ FVC = (70 % : 80% ) .
Scheme for investigations
• if more than 80% means restriction airway disease
1. Laboratory. as fibrosis.
2. Radilogical. • if less than 70% means obstruction.
3. Pulmonary Function Tests. then repeat Test again after adminstration of
4. Broncoscopy. Bronchodilators:
1. Laboratory: • if improved more than 15% means BA.
1. CBC. • if improved less than 15% means COPD.
► N.B.
Indication Values Residual Volume (RV): volume of air present in lung
polycythemia in chronic hypoxia as COPD & IPF. after deep expiration 1' in COPD & -.!, in fibrosis, but
eosinophilia in Allergic BA. can not detected by Spirometry :)
Anemia in chronic toxic Diseases. 2. For Follow up (Flowmeter)
Leucocytosis with infection . that means Peaked Exp. Flow Rate. (PEFR)
(Max. amount of air expired by deep expiration in a minute.)
2. Sputum Analysis. For Example:
• eosinophils in BA. BA with PEFR > 80 % = mild
• For Culture & Sensitivity for Detection of Caus- 60 : 80 % = moderate
ative organism & Suitable Antibiotic. < 60% = severe.
3. Serous Fluid Analysis (Pleural Aspiration):
4. Broncoscopy.
for detection of nature of effusion.
4. Sweet Test: for Cystic Fibrosis. Diagostic Therapeutic
5. Serum a 1 antitrypsin level:
• Good Visualization. • remove FB or mucous blug.
in primary Emphysema. • injection of AB in Abscess
• take a biopsy.
or Cytotoxic in Malignancy.
0
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

.......,
Definition Clinical Picture
1. Chronic obstructive bronchitis & emphysema commonly LfLJ,h,iulj
coexist and the condition is known, chronic obstructive Patient: Male, chronic heavy smoker & above 50 years
pulmonary disease (COPD). Bronchitis: Long history of chronic cough with mucoid or
2.Persistent 1' in airway resistance. mucopurulent expectoration.
3. Persistent~ in FEVl. Emphysema: Dyspnea is gradual progressive occurring ini-
Aetiology tially on exertion but later on at rest± wheeze.
1. Chronic obstructive bronchitis: Complications: Chest pain (Chronic cough, pneumothorax)
-
• Irritation: smoking & pollution. Respiratory failure Oedema of lower limbs (RVF
• Allergy.
• Infection. 1- General examination (A, B, C, E & F)
2. Emphysema A• Pulse:
False True W' • Tachycardia & big pulse volume hyperdynamic
• Senile • Primary: a 1 antitrypsin Circulation. (hypercapnia & hypoxia)
• Compensatory deficiency. • Small pulse volume severe pulmonary
• Congenital • Secondary:lnfections- hypertension± heart failure
obstruction • Pulsus paradoxus may be present in severe
cases.
Pathological stages of Chronic obstructive bronchitis:
• Respiratory rate:
1. Simple chronic bronchitis: reversible chronic irritation
Tachypnea with working accessory respiratory
of bronchi with excessive mucus secretion (e.g. muscles.
smoking cough)
2. Muco-purulent chronic bronchitis: recurrent infection
G Cyanosis (in severe hypoxia)
of the bronchi G May be Orthopnic.

3. Obstructive chronic bronchitis: irreversible narrowing
caused by (sub-mucosal thickening - sub-mucosal (H & N):
inflammatory cell infiltration - muscular hypertrophy) • Central cyanosis may be present.
- usually complicated with emphysema. • Puffiness of eyelids due to chronic cough
• Congested neck veins (increased
Pathophysiology intrathoracic pressure, Cor-pulmonale,RVF)
1. Chronic obstructive bronchitis. upper limb:
Respiratory dysfunction: Clubbing: if associated bronchiectasis
• Obstructive hypoventilation lower limb: Oedema of the lower limbs may
• Hypoxaemia & hypercapnia occur due to cor-pulmonale
Later on pulmonary hypertension & corpulmonale (RVF)
Hypercapnia decreases the sensitivity of respiratory cen-
0 Drowsiness: Sign of respiratory failure.
tre. So no dyspnea. 2- Abdominal examination:

Type B - bronchitic Type or "Blue Bloater". • Palpable liver due to :
2. Emphysema • Depression of the liver by flat diaphragm (not
Respiratory dysfunction: tender)
• Diffusion defect (decreasing surface area). • Congested liver due to cor pulmonale (tender)
• Hypoxia + normo- or hypocapnia. • Ascites may be present: due to right-sided heart failure
Sensitivity of respiratory centre is normal 3- Local Chest examination:
(no hypercapnia) severe dyspnea.
Type A, emphysematous Type "Pink puffer"
3. Cor pulmonale:
► Inspection
• Barrel chest.
• Bilateral limitation of expansion.
7<
:::c
• Hypoxia: resulting in vasoconstriction of pulmonary • Weak or absent cardiac pulsations "C
Q:.ffi Mfi, [I) II

(I)
arterioles. :::!.
::::s
• Reduction of the pulmonary vascular bed. • Trachea is central. ~
Q,)
► Chronic obstructive bronchitis: Disease charachterized • TVF is decreased bilaterally !:t.

0
by cough daily or most of days for about 3 months/ ► Percussion ::::s
►
year for 2 successive years
Emphysema: Disease of respiratory unit dilatation,
with or without damage of alveolar wall.
• Hyperresonance.
• Encroachment on cardiac & hepatic dullness. J
e
► Auscultation 7 ► Respiratory function tests

0
C"' • Ventilation tests:
• Vesicular breath sounds with prolonged
expiration (harsh). ...~
C:
• Residual volume (RV) is increased ..
• Generalized wheezes (rhonchi). n • Forced vital capacity (FVC) usually decrease.
!:t.
• Minimal crepitations may occur 0 • FEVl, timed vital capacity & PEFR are decreased
:::I
_J • Diffusion tests: CO transfer factor is decreased.
Complications.
• Arterial blood gases: Decreased P02, increased PC02
Di-1¥ii Treatment
Respiratory:
• Respiratory failure.
• Infections.
•
•
Bronchial obstruction.
Pneumothorax
Wi4,t4h•
• Avoidance of the cause (bronchial irritation or infection).
► Extra-thoracic • Cigarette smoking should be stopped.
CVS: Renal: • Changing residence.
• Cor pulmonale • Salt & fluid retention • Proper treatment of upper respiratory infections.
• Right-sided heart failure • Proteinuria • Pneumococcal vaccination
• Left-sided heart failure ► Symptomatic treatment
GIT:
• Thrombembolism. • Mucolytics e.g. bromhexine hydrochloride (bisolvon).
• Peptic ulcer
• Erythrocytosis • Expectorants e.g. potassium iodide.
• Bronchodilators e.g.
Causes of Lt. V. F in COPD:
• Associated Disease of the left side of the heart • lpratropium bromide by inhalation.
especially Coronary artery disease. • Aminophylline IV or orally.
• Reversed Bernhiem effect. • Steroids (in resistant cases)
• Acidosis leading to myocardial depression. • Thiophylline.
• Hypoxia leading to myocardia; ischemia. • Corticosteroids. ( in acute exacerbation or in patients
• volume overload due to hyperdynamic circulation (VD) with overlap asthma).
• 1' blood viscosity due to polycythemia. • Antibiotics.
• a 1 antitrypsin replacement (congenital emphysema).
1#i•i11j.jit¥i,t•i,p-id,
see symptomalo ogy
1Mehii•hi4J
► Treatment of complications
Investigations • Heart failure.
► Chest X-ray • Erythrocytosis : venesection may be needed
• Hyperinflation: ► Oxygen therapy (long term)
• Hypertranslucency of the lungs. It is indicated in:
• Transverse & wide intercostals spaces. • Severe hypoxia.
• Low flat diaphragm. • PO2 <40 mmHg with exertion or <55 mm Hg at
• Ribbon-shaped heart. rest.
• Exaggerated broncho-vascular markings Values:
(chronic obstructive bronchitis) • Decrease complications.
• Improve symptoms, exercise tolerance, quality of
life & survival
► Lung transplantation is the only radical treatment.
► Sputum culture & sensitivity

• may detect organisms (pneumococci & H. influenza)
► Blood Picture
• may show erythrocytosis
e
LUNG ABSCESS
Definition
Localized suppuration of the lung associated with cavity 2. Red hepatization: alveoli are filled with RBCs and few WBCs.
formation often with a fluid level on the chest X-ray. 3. Gray hepatization: the release of proteolysis enzymes From
' WBCs ➔ lysis of RBCs and bacteria
Aetiology 4. Resolution: liquefaction of exudate to be excreted and absorbed
1. Primary (Aspiration lung abscess) common : by blood and lymphatics. In all stages the overlying pleura may show
evidence of pleurisy.
This involves introduction of infected material down the
• Stage of acute abscess:
respiratory passages, to the lungs.
• Tissue necrosis and suppuration occur in the
Accordingly there should be:
consolidated area.
• Absent cough reflex:
• Rupture into the draining bronchus leaving a
• Coma.
cavity.
• Convulsions.
• characterized by irregular necrotic wall and
• Anesthesia.
surrounded by consolidated area.
• Old age. • Stage of chronic abscess:
• Bui bar paralysis
• The abscess wall becomes thickened by fibrous
• Source of infected material: tissue.
• FB aspiration in children. • The covering pleura may show thickening and
• Vomiting. fibrous adhesions.
• Zencker's diverticulum. B- Pathology of pyaemic abscesses:
• Esophageal tumors. They are usually bilateral, multiple, small and of
• Reflex oesophagitis. equal size.
• Blood (in upper air way surgery or with C- Pathology of secondary abscesses:
hematemesis). Related to the site of primary lesion: e.g. abscess on
• Alcohol abuse top of cancer
• The causative organisms include: Clinical Picture
anerobes , staphylococcus, streptococcus, H. influenza. There are three stages :
2. Secondary lung abscess: • Pneumonic = pneumonia.
from the 4 surrounding structures+ 1 • Acute abscess.
1. Lung: spread from the lung diseases as • Chronic abscess = chronic empyema.
pneumonia(especially staphylococcal and Friedlander's Pneumonic stage Symptoms and signs : as
pneumonia), TB, Lung abscess, infarction and • Fever:
malignancy . • Starts acutely.
2. Mediastinal: spread from the mediastinal diseases as • May reach 39 - 400 C.
pericarditis, mediastinitis or malignancies. • Ends by crisis (drop to normal within 12 hours in
3. Chest wall: spread from the chest wall as fracture ribs or patients not receiving antibiotics or antipyretics).
osteomyelitis. • Tinge of jaundice because of RBCs lysis. Working ala
4. Subdiaphragmatic: spread from behind the diaphragm nasi and cyanosis in severe cases.
as amaebic or pyogenic liver abscess, subphrenic • Herpes simplex eruption around lips.
abscess or pancreatitis. • Convulsions in children with neck rigidity (meningism
5. Pyaemia: ( pyaemic abscesses): may occur due to Local:
e.g. infective endocarditis, septic thrombophlebitis, • Inspection:
osteomyelitis (septic focus). Caused by Staph. Aureus. • Normal shape of chest.
• Restricted movement on affected side.
■trumt-t¥J • Mediastinum central.
A- Pathology of inhalation abscess: • Palpation:
• Site: it is usually solitary, occurring more commonly in • Tenderness on affected side.
the right lower lobe (the right bronchus is wider and • 1' TVF over the affected lobe.
more in direct continuity with the trachea). • Trachea central.
• Passes through 3 stages: • Palpable rub may be present.
• Pneumonic stage: • Respiratory movement restricted on affected side.
Consolidation involves an entire single lung lobe and • Percussion: Dullness taking shape of affected lobe +
passes in the following stages. tenderness due to pleurisy.
1. Congestion: Inflammatory reaction due to the presence of • Auscultation: On the affected side there may be:
organism ➔ BVs show VD ➔ exudates collects in alveoli.
• Bronchial breathing.
• Consonating rales (Fine in early stages, then becomes

Consonating in hepatization stage and coarse non
► Inspection
Consonating in resolution stage).
• Shape: Normal or retracting.
• Aegophony and whispering pectriliquy.
• Movement: Restricted on affected side.
• Pleural rub
• Mediastinum: Shifted to same side of lesion.
Acute abscess stage (after 9-12 days)
ijfilUUntj Qtiffitt,M,i
• Trachea: May be shifted to same side ofthe lesion.
• Productive cough with:
• Tenderness on affected side.
• Excessive purulent sputum.
• Fetid (anaerobic bacteria).
• 1' TVF on affected side.
• Palpable rub on affected side.
• 1' With lying on healthy side.
• Apical pulsations may be shifted to the same side
• Dyspnea: 2ry to pleurisy and consolidation.
of lesion.
• Pleuritic chest pain.
• Respiratory movements are restricted on the
• Constitutional manifestations (FAHM ) which
-
affected side
improve with clearing of pus by cough.
► Percussion • Dullness over the abscess.
• General: Fever and tachycardia.
► Auscultation • As acute abscess.
• Local:
► Inspection Complications
• Shape: Normal. 1. Chest complications
• Movement restricted on affected side. • Severe haemoptysis.
• Mediastinum: Central. • Spread of infection to other parts of the lung leading
QWi¥i,M,i to recurrent pneumonia & abscesses.
• Tenderness on affected side. • Fibrosis & bronchiectasis around the abscess cavity.
• 1' TVF on affected side . • Pleurisy, effusion, empyema, pyopneumothorax &
• Trachea: Central. pleural fibrosis.
• Palpable movement restricted on affected side. 2. General complications
• Palpable rub . • Metastatic abscesses especially in the brain.
• Apical pulsations are not displaced. • Anaemia & amyloidosis in chronic cases.
Signs o~ a cavity are variable depending on :
► Percussion • Dullness on affected site.
• Site: superficial or deep.
► Auscultation • Size: small or large.
• Surroundings: consolidation or fibrosis.
• Bronchial breathing of caverenous type.
• Draining bronchus: patent or occluded.
• Consonating crepitations.
• Contents: full or empty.
• Pleural rub.
• Aegophony and whispering pectrology on the affected Investigations
side.
► laboratory
• Post tussive suction may be heard after prolonged
cough in collapsible cavity. • Sputum culture & sensitivity.
Chronic abscess stage • Blood: Leucocytosis and blood culture may be +ve in
pyaemic abscesses.
ijh5.(Uulj as acute absce ss +
• Tuberculin test: For suspected T.B.
• Retention syndrome: attacks of bronchial
► Radiological
obstruction by thick mucus pellets ➔ fever+
cessation of purulent sputum ➔ this is followed by • Chest X-ray:
violent cough with expectoration of thick, blood • Cavity with fluid level.
tinged mucus pellet and return of suppurative • The cavity is thin walled and irregular in acute
syndrome features and drop of fever. abscess, while it's thick and regular with possible
- • Deterioration of general health. mediastinal shift to the same side in chronic

abscess.
• CT chest:
• General:
• Localizes abscess site.
• Bad general condition with loss of body weight and
• May help to define the underlying cause.
recurrent fever.
• Buffy eye lids from chronic cough. ► Bronchoscopy
• Clubbing and possibly pulmonary osteodystrophy. • Diagnostic and Therapeutic.
e
~ ,CLAM'S CLINICAL EXAMINATION CHEST:
Treatment B. Drainage of pus:

(4 as in any infectious disease) + Pus drainage+ Surgical) • Postural change:
1. General: - Bed rest - plenty of fluid - nutrient diet. Patient should lie on the healthy side 2-3 times/day for
2. Symptomatic: few minutes with percussion of affected side.
• Antipyertics for fever e.g. paracetamol. • Bronchoscopic aspiration:
• Analgesics for pain. • Allows removal of thick pus and any bronchial
• Mucolytic and expectorant ( bromhexine } and obstruction.
steam inhalation to liquefy thick sputum. • With injection of antibiotics ( is rarely used}.
• oxygen therapy in severe cases. • Percutaneous drainage:
...___, 3. Specific ( Antibiotics+ pus drainage } : By CT guided Percutaneous catheter insertion
A. Antibiotics: • Treatment of complications
• Should cover both aerobes and anaerobes. Surgical lobectomy or segmentectomy if:
• Initial treatment should include IV: • Failed medical treatment.
• Metronidazole 500 mg/8 hrs or clindamycin 600 • Huge abscess(> 4 cm).
mg/8 hrs (for anaerobes}. • Surrounding bronchiectasis or suspected
• Amoxycillin - clavulinic acid lgm IV/ 8 hrs. malignancy.
• Treatment should be continued then according to • Complicating empyema or pyopneumothor ax
culture and sensitivity.
BRONCHIECTASIS
Definition Clinical Picture
Abnormal and permanent dilatation of the central ijllit.11,1, ,tj
and medium-sized airways (bronchi and bronchioles ) • Dyspnea: secondary to:
with suppuration. • Bronchitis and emphysema
Aetiology • Fibrosis
• Pneumonia
1. Congenital bronchiectasis (2)
• Cough: productive cough with purulent, fetid sputum
1. Primary : Isolated bronchiectasis that increases by leaning forward or lying down and
2. Secondary: with winter exacerbation.
1. lmmotile cilia syndrome • Haemoptysis: either blood tinged sputum or frank
• Bronchiectasis. blood. In cases secondary to TB the patient may
• Sinusitis & otitis media. present only by hemoptysis (Brochiectasis sicca
• Male sterility. hemrrhagica)
• May be associated with dextrocardia & situs inver- • Wheezy chest due to associated bronchitis .
sus totalis (Kartagener's syndrome). • Chest pain secondary to:
2. Cystic fibrosis. • Repeated coughing
3. Immunodeficien cy syndromes • Associated pleurisy or complicating
2. Acquired bronchiectasis (2) pneumothorax.
1. Infection and Fibrosis : • Constitutional manifestations: FAHM.
•Destruction of the bronchial muscles & elastic fibers • Symptoms of the cause: e.g. sinusitis ( commonly
resulting in bronchial dilatation . associated ).
• Peribronchial fibrosis causes traction over the
bronchi leading to further dilatation.
• (As, broncnopneumon ia, whooping cough, measles,
TB & lung abscess especially during childhood).
2. Bronchial obstruction:
• Partial obstruction: valve-like mechanism
• Complete obstruction.
-
•
• Symptoms of complications: e.g. empyema
General:
Puffy eye lids: due to:
• Repeated coughing with increased intrathoracic
pressure interfering with venous return.
• As a part of the generalized edema from cor-
f@Uflbilateral pulmonale or amylodosis.
• Site: & basal, But may be apical in TB or localized
in foreign body or tumor. • Right ventricular enlargement secondary to
• Shape: bronchi may be cylindrical, tubular, fusiform or pulmonary hypertension.
serpentine. • Clubbing and pulmonary osteodystrophy.
• Changes: bronchi are dilated with desquamation & • Lower limb edema: secondary to:
ulceration of the mucous membrane. • Cor pulmonale
• Others: The surrounding lung tissue may show • Amylodosis
consolidation, Emphysema of the upper parts of the lungs. • Loss of body weight and pallor
Local: ► Instrumental
(Basal fibrosis and consolidation+ apical emphysema) .
• Bronchography (obsolete):
► Inspection • It was the investigation of choice to confirm the diag-
• Shape: basal part may show retraction (Fibrosis) and the nosis and to localize the site, extent of bronchiectasis
up per part may be bulging( emphyse ma) before surgery.
• Movement: restricted bilaterally mainly on the basal part. • Bronchiectasis appears as cylindrical, saccular, fusiform
• Apex: not shifted unless bronchiectasis is unilateral. or varicose dilatation of the bronchi.
Q:ffiitM,/.t,1 • Using Lipidol was used to diagnose the condition by
demonstrating the dilated bronchi before surgery
• Trachea is central unless th e bronchiectasis is unilateral
• Tenderness: may be present on the affected side • Bronchoscopy:
• TVF: 1' on the basal part but decreased on the upper • Diagnostic:
part of the chest. • Show the cause of bronchial obstruction
• Movement restricted on the basal part mainly • Sample the sputum for culture and sensitivity.
• Rub or rhonchi may be felt on the affected side. • Therapeutic:
• Apical pulsations are not shifted unless bronchiectasis • To remove obstructing foreign body.
is unilateral. • To suction pus and inject antibiotics .
► Percussion
► investigations fot the etiology
Bilateral basal dullness, with hyper-resonance on the
as Sweat test for Cystic Fibrosis .
apical part of the chest .
► Auscultation Treatment
• Bilateral basal bronchial breathing, crepitations,
whispering pectrilequy, aegophony and possibly rub (4 as in any infectious disease) + Pus drainage+ Surgical)
1. General:
• In the apical part there may be vesicular breathing
• Bed rest.
with rolon ed ex iration, and wheezes
• plenty of fluid
As L. Abscess • nutrient diet.
Investigations 2. Symptomatic:
• Antipyertics for fever e.g. paracetamol.
► laboratory • Analgesics for pain.
• Blood: Leucocytosis due to infection and Estimation • Muco lytic and expectorant ( bromhexine) and steam
of serum immunoglobulin level. inhalation to liquefy thick sputum .
• Sputum culture & sensitivity. microscopic • oxygen therapy in severe cases.
examination, culture and sensitivity (the most 3. Specifi c ( Antibiotics+ pus drainage ) :
common organisms are H. Influenza, and Strept. A. Antibiotics:
Pneumoniea). • According to culture and sensitivity
• Tuberculin test. • Sta rt with:
► Radiological • Ampicillin 500 mg/8 hrs
• Ciprofloxacin: 250 mg/8hrs
• Chest X-ray:
• Sutrim : 2 tab/12 hrs
• Basal part may show cystic changes (Honey comb
• If the sputum is fetid : add an antibiotic that covers
appearance) or thickened bronchial walls (Tram
anaerobic organisms e.g. metronidazole (Flagyl) or
line appearance) surrounded by fluffy cotton areas
clindamycin (Dalacin) .
of pneumonia and fibro sis.
B. Drainage of pus:
• Apical part may show hypertranslucency due to
• Postural change:
emphysema.
• May show the cause (bronchial tumor) or
Patient should lie prone 2-3 times/day and it may be
complications e.g. cor-pulmonale. helped by percussion .
• Bronchoscopic aspiration:
• CT chest:
• Allows removal of thick pus and any bronchial
obstruction.
• With injection of antibiotics ( is rarely used).
• Treatment of complications
Surgical lobectomy treatment if:
• Persistent or recurrent infection not responding to
medical treatment.
• Severe haemoptysis.
• Surrounding abscesses or suspected malignancy.
• Complicating empyema or pyopneumothorax.
•
ALLAM'SCLI NICAL EXAMINATION CHEST:
FIBROSIS
[...- -- - - Pulmonary .- -- -- - Pleura-Pulmonary
Parenchymateous I.P.F l
1 Empyema,Hemothorax
T.8 ► N.B .
Syndrome of Multiple Negative: Syndrome of Multiple -ve Includes:
• Inspection: No movement Pleural Effusion, Fibrosis, Collapse.
• Palpation: NO TVF. • in Pleural Effusion ➔ Bulge.
• Percussion: NO note. • Fibrosis ➔ Retrclction & heterogenous Dullness.
• Auscaltation: NO Sound. • Collapse ➔ Retraction & homogeneous Dullness.
INTERSTITIAL PULMONARY DISEASE

Aetiology
• Idiopathic pulmonary fibros is IIPFI.
• Immune diseases.
• lnhalational lung diseases.
- • Extrinsic allergic alveolitis: (due to inhalation of organic

dust) e.g.
• Farmer's lung
• Bird fancier's
• Bagassosis
disease.
• Pneumoconiosis: (due to inhalation of inorganic dust)
e.g. Silicosis & Asbestosis.
• Chronic pulmonary diseases (Granulomatous) e.g. Sarcoidosis.
► Pulmonary Function Tests
• Ch ronic pulmonary venous congestion .
• Ventilation test.
• Familial:
• Histiocytosis X. • Decreased lung volumes especially forced vital capacity.
• Neurofibromatosis.
• Decreased lung compliance
• Malignancies:
• • Normal expiratory flow rates
Lymphangitis carcinomatosis.v
• • Diffusion tests: Decreased CO transfer factor.
Bronchoalveolar carcinoma.
• Lymphomas & Leukaemias. • Arterial blood gases:
• Miscellaneous • Decreased P02.
• Idiopathic haemosiderosis. • Decreased PCO .
• Alveolar proteinosis .
• Alveolar microlithiasis ► Investigations for the Cause
Pathophysiology Disease Activity
1. Impaired diffusion. 1. Open lung biopsy: (Old)
2. Restrictive hypoventilation. 2. Bronchoalveolar lavage: (Recent)
3. Hypoxia with normo or hypocapnia. For detection of type and amount of inflammatory cells.
Clinical Picture 3. Gallium 67 lung scan. (Recent)
Gradual progressive dyspnea.
Q:iugh. ~entral Cyanosis. Q ubbing.
Treatment
_yepitations: late or pan-inspiratory medium-sized, non-con- 1. Treatment of the cause.
sonating. 2. If the condition is of unknown aetiology e.g. IPF:
_Qtuse e.g. occupational exposure to dust. • Steroids: prednisone 1 mg/kg/d.
~omplications: • Cytotoxic drugs: e.g. Cyclophosphamide.
• Respiratory failure .
3. Symptomatic treatment: e.g. oxygen therapy.
• Pulmonary hypertension & Cor pulmonale
4. Treatment of complications:
• Pulmonary infections.
• Pulmonary infections.
Investigations
► Chest X ray • Heart failure.
Bilateral diffuse affection of lungs with reticulations
& micronodular infiltrations (usually basal).
CHEST (LONG CASE)

'
► 1 .History The patient with an average built for his age, he lies
comfortable in bed.
Personal history Mr. Muhammad Ahmad 74 years No pallor, jaundice or cyanosis.
old, married and has 3 children, the youngest is 26 years • Respiratory rate: Tachypnea with working accessory
old, he is a waiter, from lmbaba, he is a heavy smoker. respiratory muscles.
• Head examination: Puffiness of the eye lid due to chronic
ii•111M@ 0 atient is complaining of shortening cough.
of breathing and chest wheezes of 3 days duration. • Neck examination: Congested neck veins due to increased
Present history intrathoracic pressure, or cor-pulmonale.
The condition started 30 years ago by gradual onset and • Upper limbs examination
progressive course of cough, especially at early morning • Pulse: 80 beats/ min., regular, variable volume, equal in
and winter time, increased by exertion, decreased by rest, both sides, pulsus paradoxicus > 15 mmHg. (marked drop
associated with expectoration of sputum which was; scanty, of systolic pulse during inspiration).
whitish, thick, not foetid and had no special character. The • Blood pressure: 110 / 75 mm Hg.
expectoration used to increase in the early morning and winter • No hand clubbing.
time, but: there was no postural variations. • Lower limbs examination: Oedema of lower limbs (cor-pul-
Two years later, the patient started to suffer from exertional monale or less commonly salt and water retention).
dyspnea, with gradual onset & progressive course, increased • Abdominal examination (not in this patient)
by exertion, decreased by rest, not associated with orthopnea • Lower border of the liver may be displaced downwards
or PND, but: it was associated with persistent wheeze. due to (ptosed liver by flat diaphragm or enlarged liver
Patient sought medical advice and was admitted to Demi rd ash due to cor-pulmonale).
hospital where some investigations were done to him in the • Umbilical or inguinal hernia may be present as a
form of chest X-ray, sputum analysis which was negative, in complication of chronic cough.
addition to the usual routine laboratory work-up. • No ascites (only if RSHF occurred).
He received bronchodilators (Aminophylline) by infusion, • Cardiovascular examination
cortisone, antibiotics (Flumox), oxygen inhalation and doses of • Absent apex (emphysema).
bronchodilators by nebulizer when needed . He received this • Faint heart sounds.
medication for 2 weeks till his condition was stabilized & was
► 3. Local Examination
then discharged.
His condition partially improved, but he used to suffer from Inspection
repeated attacks of severe dyspnea and wheezes improved by Shape of the chest
received his usual regular medication. • Barrel shaped chest (emphysematous) with increased
Six years later, the patient started to suffer from gradual anteroposterior diameter.
persistent dull aching pain in his right hypochondrium • Relatively low-lying diaphragm.
increasing by meals & by exertion associated with oedema of • No scars, dilated veins or pigmentation.
his lower limbs but with no ascites. He sought medical advice • There is epigastric pulsation & left para sternal pulsation.
again where diuretics (lasix) were added to his usual medication (right ventricle enlargement).
& was advised proper bed rest. The oedema disappeared & the
Respir"ltory movement
pain partially improved & his condition is stationary as such up
• Diminished bilaterally.
till now.
• Mainly abdominal respiration.
There was ho haemoptysis, no cyanosis, no compression
• Suction of supra clavicular, supra sternal & lower intercostals
symptoms, no symptoms of T.B. toxemia & no symptoms of
spaces during inspiration and fullness during expiration
respiratory failure. There were no symptoms of other systems
affection. Palpation
Past history There is no past history of DM, HTN, • Central trachea.
. f • No tenderness.
T.B., a II ergy, Bi lh arziasis. T h ere is no past h 1story o
• T.V.F.: equal on both sides (diminished all over the chest).
previous operations, or blood transfusion.
• There is palpable wheezes with deep respiration.
Family history Family history is irrelevant. • Bilateral limitation of chest expansion
■•Jfii§•i•hil A case of bilateral lung disease most Percussion • Hyper-resonance all over the chest.
probably COPD due to chronic irritation, the patient • Encroachment on the normal hepatic & cardiac dullness
compensated and co mp licated by cor-pulmonale. Auscultation
► 2. General Examination • Diminished air entry.
• Vesicular breath sounds with prolonged expiration .
The patient with an average general condition, fully
Generalized wheezes (diffuse, mainly expiratory,
conscious, oriented by time, place and persons, with
polyphonic, changes with cough).
good mood and memory, co-operative with an average • Crepitation: early inspiratory (opening snap of the chest).
intelligency. • No vocal resonance .
•
ALLAM 'S CLINICAL EXAMINATION ► ABDOMEN:
INTRODUCTION
► Surface anatomy of the abdomen:

- ·-- .....,. __ .,-•---..~---- ---------
... /
I
L:itt
•
I
hy '
hypochpndnac I
I
I
reg!on •
Right upper Left upper
quandrant quandrant
'(RUO) (LUQ)
Left
Rlghtlo-r Left lower

quandrant quandrant
(RLQ) (LLQ)
The abdomen can be divided into quadrants by a vertical median plane and a horizontal transumbilical
plane, which passes through the umbilicus.
• The liver and gallbladder are in the right upper quadrant.
• The stomach and spleen are in the left upper quadrant.
• The cecum and appendix are in the right lower quadrant.
• The end of the descending colon and sigmoid colon are in the left lower quadrant.
The abdomen also can be divided into nine regions by a midclavicular sagittal plane on each side and by the
subcostal and intertubercular planes, which pass through the body transversely These planes separate the
abdomen into:
• three central regions (epigastric, umbilical, hypogastric)
• three regions on each side (hypochondrium, lumber, iliac)
► N.B.
The level of the diaphragm varies during the breathing cycle. The dome of the diaphragm on the right can reach
as high as the fourth costal cartilage during forced expiration.
Most of the liver is under the right dome of the diaphragm and is deep to the lower thoracic wall.
The inferior margin of the liver can be palpated descending below the right costal margin when a patient is
asked to inhale deeply.
ABDOMINAL SHEET
..__,
1- History: - - - - . - - Personal history.
General - , - 2- Examination: Complaint.
Local __J 3- Investigations. History of present illness: ] Analysis of the complaint.
Past history Symptoms of the related system .
4- Diagnosis.
5-Treatment. In females (menstrual and Investigations and treatment history.
obstetric history). DM & HTN
•
ALLAM'S (I..JNICAL EXAM INATION ► ABDOMEN:
ABDOMINAL HISTORY
1. Name: Y4.!l l!Up ~1
to be familiar with the patient.
2. Age: Ya... ~IS I!!~
As certain diseases are more common in certain ages, e.g.
• Calcular obstructive jaundice: middle aged females.
• Malignant obstructive jaundice: old males.
• Cirrhosis: usually in adults.
3. Sex:
• Gall Bladder stones: females.
• Cancer head of pancreas: male
4. Occupation: Y4.!1 ~
persons in certain occupations are more susceptible to certain diseases e.g.
• Farmers: bilharziasis
5. Marital state: ya.., ~IS o= ~~I y ~IS y~y_,1 I!)~ Y[.,.,...
for possible sterility or impotence.
6. Residence: Y~ .:,Sl..
may reflect socioecnomic condition and may occasionally point to certain disease e.g.
Countryside: Bilharziasis
7. Special habits:
Yo_,u/1 o.i..a. J)lp. J ~ Y.t... ~IS cl!~ Y ~,di J OJ~ ~IS Y.;_..;-.1..!
Y4.!/ o~I t~ Y.:.t.,...,W.1 J ~,~~Po Y.:.IJ.l.M _,j op y ~
e.g. Alcoholism in cirrhosis.
8. Mensterual History.
► Complaint:
On patient's own words+ duration Y-,..,.:.11 4-!' ~, 4J~ Y ~ I ~~ ,fi' 4-!! Y~l:i ,,JJI 4-!I
Examples:
the patient is complaining of abdominal swelling of 3 week duration.
the patient is complaining of Vomiting of blood of 2 days duration.
► History of present illness (H.P.I):

2. Symptoms of the related system. • As long as possible and Contains medical terms.
3. Systemic Review:. • In chronological arrangement.
5. DM & HTN
8 as usual:
• Onset - course - duration. Y.:.4~ J .:,~ .,i YJ ~ .,i &.l..i 1.5,1,o ,.fay_, ~ 1 .uJ4 .:.*
IJ"lyYI Y4-!! ~i ~ ~, o~ .:,* 15µ1
• Association. Yo~.P.¥ ..i~ ~ ,,JJI <½lWI '-"''yYI .,sj;;., ~~ 4!~ .;..;IS~
• What increase and what decrease. Y~ ,,JJI ~!,Yo~ '-"'.;JI~,~ ,,JJI ~!
• Effect of treatment. Y 1,11' Lo o§j ~ y_, JA..! '-"''yYI ['\WI ....,;.~ u. ~ m ~ ['\WI ~b
• Date of last attack. YIi"'! .;IS" 0~ IJ"_,,.}I ~! J~," '-"'_;JI cl)~ o.,.. ;i
+ 3 for any excreta:
• Amount.
• Content - Color - Consistency.
• Odour.
•
2- Symptoms of the related system: (3GPS)
E
• G.I.T. (upper & lower). '--./
• General (toxic).
3G
• Gynecological. '-.../
3P E •
•
•
Pain.
Biliary system (hepatobiliary).
Urinary system. J_,y JI J JS'L.t..,,
'-._./
E
• Abdominal swelling.
• Lower limb swelling.
3S
• Systemic review.
lldil '--./
It's classified according to Ligament of treitz into upper & lower GIT symptoms:
, Upper G.I.T. Lower G.I.T.

1. Appetite. Ym o~I $YI ~ ~ 1. Flatulence. ,, .:i1j~ <½-', . ~ , ~
Anorexia / polyphagia. 2. Audible borborygmi.
2. Dysphagia. m JS'iil .,1Jll,-..U n ~ 1IP~,- l!lu.o. JA 3. Bowel habit.
3 . Vomiting. m {!:::'r.iJ .:.u...:,. 4. Haematochezia. H jfa./l ~ .,-1r~ ~
4. Haematemesis. m oJS J:i ~~ ~.> 5. Melena. m ~.,...,1 Jli-! l!lu.o. JA
5. Water brush. !5 ~ w. .:J....A,3, i!W .;i.,. y\a.1.1½ ~
6. Halitosis. m •~ o!l.oi ~,.,
7. Heart burn: in GERO. m o.i.aJ.1 ~ .p,,.... l:.l,1,1$ JA
8. Eructation. m ~
9. Hiccough (idopathic / CRF). m # ~ J ~
'--./
UiJ·Mdtl "-./
Polyphagia with weight loss: Anorexia:
• Uncontrolled diabetes Mellitus. Lack or loss of appetite for food
• Thyrotoxicosis. • Psychological (Anorexia Nervosa) in depression
• Parasitic infestation. and other psychological troubles -.._/
• Malabsorption (Steatorrhea). • GIT: Gastritis

• Others: Cancers, TB, sever infection '-.../
Parorexia:
Disordered appetite, with craving for unusual foods
• Parasitic infestation with Ankylostoma
• Pregnancy
• Hypocalcemia
• Hysterical.
'-.../
Dysphagia: is difficulty in swallowing & Odvnophagia is Pain during swallowing.

Casuses:
• Mouth causes: Glossitis & Stomatitis
• Pharynx: Pharyngitis, Tonsilitis & Plummer Vinson Syndrome
• Oesophagus: Forign body, Corrosive atricture, Achalasla & Carcinoma .----._
For more causes see the theoretical book ... '-._/
Achalasia Carcinoma
Age: Middle aged Old
'-../
Sex: Female Male
Dysphagia for: Fluids rnore Solids rnore
'-.../
Odynophagia: maybe no pain
General Condition: good very bad
•
ALLAM'S CLINICAL EXAMINATION ► ABDOMEN:
h·b,IGl,i=i
For analysis of any complaint in GIT as usual (8) + 3 for any excreta (Stress on onset - timing - content)
Onset:
• Spontaneous.
• Induced» psychic
Timing:
Central causes Pyloric obstruction During » esophageal.

½ hour after>> G. ulcer.
3 hours after » D. ulcer.
Content
Chronic gastritis - cancer
Intestinal obstruction
Intestinal obstruction or fistula
l:&"IJ~iW~'III Ascaris
Fistula
See (Haematemesis)
Haematemesis;
Preceded by Vomoting and followed by Melena Dark, tarry stool
DD:
During
• Contents Froth Food
• Color Bright red Dark
• PH Alkaline . Acidic
Followed by Blood tinged sputum Melena.
D.D. of Halitosis:
1. Foetor hepaticus: liver cell failure .
2. Amoniacal: renal failure.
3. Aceton: D.K.A.
4. Foetoid: S.L.S.
5. Local: dental caries .
6. Dietery.
7. Achalasia of cardia
Definition: abnormal spasmodic contractions of the diaphragm (phrenic nerve irritation) .

Aetiology:
• CRF • Carcinoma • Rapid thyroid enlarge- I • Subphrenic abscess

• Psychic • Empyema ment • Hepatic abscess
• Pericarditis • Splenic abscess
• Acute gastric disten-
tion
• Haemo peritoneum
•
ALLAM'S CLIN ICAL EXAMINATION ► ABDOMEN:
Changes in the bowel habit:
Diarrhea: Constipation:
A condition of having at least 3 loose or liquid bowel Presence of two or more of the following:
motions per day, provided that patient on western diet ; • Infrequent stools< 3 per week
or: Passage of> 250 gm stool per day • Hard stools (> third of motions are hard)
Mechanisms of diarrhea: • Incomplete evacuation(> third of motions)
• Hyper motility: Exaggerated gastro-colic reflex e.g. • Straining(> third of motions)
D.M. - thyrotoxicosis. • Manual evacuation
• Osmotic: Related to food e.g. lactulase. For more causes see the theoretical book ... '-.__/
• Secretory: Infection - U.C.

• Spurious: after prolonged constipation due to '-.__/
fermentation - rectal masses.

• Steatorrhoea.
For more causes see the theoretical book ...
'-.__/
Tensmus: Melena: '-.__/
Desire of defecation without an actual motion Passage of soft black tarry offensive stools, due to
upper GIT bleeding (from the oropharynx to end of
Dysentery: Bloody stool (Diarrhea + tenesmus) mid gut) im .::j_})I ~j ~.,..,1 jl.J! -=11,..a, ~
(passage of mucus & blood with stool) ~ .,i J.aS ¥ ~ Site: above ilea-cecal junction. '-.__/
mjl~IE'° Amount: not less than 60 ml.

Causes Duration: > 8 hours.
• Infective: If less than 60 ml, it is called occult blood in the stool.
• Bacterial: bacillary. If the level below the ilea-cecal junction or the
• Parasitic: amoebic and B. duration less than 8 hours, it is called bleeding per
'-.__/
• Metabolic: C.R.F. rectum.
• Toxic: Mercury poisoning. D.D.:
• Local causes: diverticulosis, ulcerative colitis • Iron therapy or Bismuth:
"U.C.", cancer colon or rectum. • History of drug intake & constipation.
For more causes see the theoretical book ... • Hard stool with non offensive odour.
For more causes see the theoretical book ...
fXd4,Mil '-.J
Toxic manifestations: FAHM (fever, headache, anorexia and Malaise):
in patients with Hepatitis, L.C.F., Hepatocellular carcinoma & TB entritis ... etc
'--"
3. Gynecological symptoms in female:

Bleeding, Discharge, mass, Hirsutism & hot flushes
Glih,I '-.J
Don't forget {11 points) : 8 as usual + 3 (site, radiation and character).
Types of Abdominal Pain:
Visceral Parietal (Somatic) Refered
'-.J
• Felt at the site of primary stimuls • Irritation of the parietal • pain felt at a site other than
• vague & Diffuse peritoneum the site of the stimulus but in
• Types: • Sharp & Localized the area supplied by the same
• Colle: from hollow organs (Ob- neural segment
'-..../
struction) • e.g. cholecyctitis
• Dl.111 ache: from hollow or solid 's_./
organ (Distention)
-......;
Medical causes of Acute Abdominal Pain:

• Addisonian Crisis • Acute pleurisy & pneumonia
• Porphyria • Diabetic Ketoacidosis
• sever hyper calcemia • Systemic lupus erytheromatosis
• Hemolytic Anemia • Rheumatic fever ( non infective peritonitis)
• Sickle cell anemia • Familial mediterranean feve
• Myocardial Infarction • Food poisoning & uremia
Extra-Abdominal Causes of Abdominal Pain:

• Myocardial Infarction ► N.B.
• Herpes zoster Recurrent abdominal pain
• Acute Pleurisy & Pneumonia P.U. - Peritonitis - Pancreatitis - chronic
• Dissecting aortic aneurysm diverticulosis - cancer colon - chronic I. 0.
• Torsion of testis & ovary
• Cord compression (Thoracic segment)
Types of splenic pain:
5. Biliary (Hepatobiliary) :
Symptoms:
• Jaundice. ► N.B.
• Pruritis. Jaundice may be:
• Dyspepsia. • Viral : acute - short - regressive.
• Pain. • Calcular : acute intermittent.
• Malignancy : gradual - progressive (2 Months ).
• Chronic liver disease : gradual - intermittent (2Y).
► Jaundice:
Definition:
yellow discoloration of skin & mucous membranes 6. Anorexia. nausea, vomiting:
due to increased level of bilirubin > 2.5 mg %. Occur at the onset of viral hepatitis.
Analysis of the jaundice: 7. Fever:
1. Onset: • Hepatocellular: pre-ecteric phase of viral
• Acute: viral hepatitis, calcular obstruction . hepatitis.
• Gradual: malignant obstruction, cirrhosis . • Hemolytic: during hemolytic crisis - malaria -
2. Course: incompatible blood transfusion .
• Progressive: malignant obstruction, cirrhosis. • Obstructive: Charcoat's triad .
• Regressive : viral hepatitis. 8. Bleeding tendency: from skin, orifices in:
• Intermittent: calcular obstructive jaundice, • Liver cell failure .
periampullary carcinoma, hemolytic • Obstructive jaundice.
jaundice, chron ic active hepatitis. 9. Pain:
3. Duration: • Hepatocellular: dull-aching pain in right
• Short: viral hepatitis. hypochondrium in case of viral hepatitis.
• Long: cirrhosis. • Hemolytic: bone pain and abdominal pain in
• More than 2 years exclude malignancy. hemolytic crisis .
4 . Urine: • Obstructive:
• Dark: hepatocellular & obstructive . • Biliary colic (calcular obstruction).
• Pale: hemolytic. • Epigastric pain radiating to the back
5. Stool : (malignant obstruction).
• Pale clay: in obstructive. 10. Pruritis:
• Dark: in hemolytic. • In obstructive jaund ice .
• Slightly pale in hepatocellular. • Primary biliary colic .
6. Urogenital System
Micturation: Uraemic Manifestations: Sexual:
• Pain. • Anorexia • Desire.
• Micturation difficulties (dysuria). • Halitosis (Bad oral odor) • Erection troubles.
• Urine abnromalities: volume - colour - frothy. • Hicough
• Uraemic symptoms. • Disturbed consantration
7. Abdominal Swelling :
Localized · G_eneraliz~ct_ ___. -~ __ - "!-
• Spleen. • Ascites » History of aspiration: Amount, Aspect, Colour (red= hge.), Complications:
• Liver. fever (infection), wound sepsis, shock & hepatic encepahlopathy.
• Mass.
8. lower limb Swelling :

• L.C.F.
• Bilharziasial Corpulmonale. ► N.B.
..__,,
Causes of ascitis in LCF are:
► N.B. 1. Hypoalbumenemia
Causes of Lower limb edema in LCF are: 2. Salt and water retention
1. Hypoalbumenemia 3. portal HTN as a localizing factor
2. Salt and water retention 4. Lymphorrhea
5. Associated conditons as SBP or malignancy
9. Systemic review:
3. Other Systems:
CVS: Systemic congesion, pulmonary congesion & low cardiac output manifestation as syncope
Neurology: motor and sensory affection
if nothing involved write
eg. no symptoms suggest other systems affection
4. Investigation & treatment (related diseases}:

eg. patient investigated by LFT & US
► Past History :
Disease_s _ _ Operati'ons ' Drugs

• Bilharziasis. History of blood Hepato-toxk
• Hepatitis. transfusion. • Dose dependant
• T.B. Paracetamol 16 gm.
• D.M. • Non dose dependant
• Hypertension. • Acute necrosis : INH - PAS.
• Cholestasis : aldomet.
• Tumors : C. pills '--
../
Subclinical Clinical
·----------------------------------------~
-
History of contanct to canals. Unnoticed Fever.
Clinical picture of Bilharziasis. Jaundice.
Investigations Dark urine.
Fever hospital.
Easily excludeq Can't excluded
► N.B.
Bilhariziasis NEVER cause Liver Cell Failure
•
ALLAM'S CLINICAL .EXAM NATI ON ► ABDOMEN:
'-"
\...I
\...I G.I.T. (upper) Urinary and genital system

m ~ .,1 Jsl,-.U &:JI J 4-!,......, i:Jt.u. J.c, m u.ei<ll ~I .J&. ~ J~I ~ .,JS"i...,.
V m o<JS <ki ~,) .::.mr.l m ~_;; clJ_,.. m ~ J~I n J~I ~ ~J ~
!ft ~ a..~ l!.l...Ai.9 !! l!l.J 1)1.o ylall4 O"""'! m~uw.:r.=
L,,
ma.i.a1.1~.fa,,-.:1~J.c, m o~cl..ii,,.lf.J
ma.loi:j~mtfa2! Abdominal Swetung
G.I.T. (lower )
m uljt& ~, m ~ J ~ Flatulence Lower limb Swelling
'!! j,r.:.JI ~ .,......1 _r:. 4 llllanatochllzia
m .::,jjlJ ~ :,~) JIJ-! .:IL.a J.c, mclena
11 ~ I .:,.a ..:.i,..,1 4 !i ~ ,1 Jlt,,,J 4 Systemk review
General
'-.,..I !! f.lJ.oo '½I m OJl,:,dl a.rJ:, J e,tA'i_JI 4 n ~ ~ i.,... ,!··•: ·~ ti i=rb- 4
m~.w4J ,.,.>!~.,l,IJl...:i.9
m ~ - , .)IJ.AA.9 &.,ti 4 4.l_ti;.9 :
m ~~!JU •.P. 1§1 ~ JSL:..o .:I,= .)A
Gyneacological 114:!Ju~_,...i~
m 4!!~~ ..:. .....1,
Pa·n
Biliary system
\,_./
\_j
\.___./
v 0
GENERAL EXAMINATION
C, ~Ii) Vital Signs: Blood pressure. pulse. Respiratory rate. Temperature.

.....,,
• Tachypnea and Respiratory distll'ess: t ense ascites - pleural effusion.
• Hypotension: shocked - postural hypotension ( VDMs ). '-...,/
• Pulse:
• Tachycardia: hyperdynamic circulation ( VDMs) .
• Bradycardia: in obstructive jaundice.
• Fever: low grade.
- _,
Over built average built under built Dwarfism

ascites (oedema) or cortisone weight loss and wasting liver disease
(L.C.F. - carcinoma). since childhood .
G Complexion:
Pallor: Anemia (all types may occur).
Jaundice (types) .
Hyperpigmented: (Hemochromatosis - L.C.F.).
Cyanosis: tense ascites - porto-pulmonary - A.V. shunt.
Decubitus or position
Orthopnea: tense ascites - pleural effusion.
Platypnea: hepatopulmonary syndrome: see below
1•
{H & N): Congested neck vein: t e~se ascites - pleural or pericardia! effusion.
0
E upper limb - - - - - - - - . - - Flapping tremors in Hepatic pre-coma
lower limb: Lower limb edema L Clubbing Crohn's - Ulcerative colitis.
• Biliary cirrhosis .
• B. polyposis.
• Intestinal steatorrhea.
0 .»,s Mentality: Disturbed mentality {Hepatic encephalopathy).
•
FaceTemporalis muscle wasting+ enlarged parotid .
Al:LAM S CLINICAL EXAMINAT ION ► ABDOMEN:
► Functional evaluation of patient with liver cirrhosis :

Patient with cirrhosis may be compansated or decompansated (vascular or parenchymatous)
► Vascular decompensation (portal hypertension) :

Evidences of portal hypertension:
• Splenomegaly: the single most important diagnostic sign . And may lead to hypersplen ism .
• Ascites:
• Early ascites: acute portal or splenic vein thrombosis.
• Late: related to additional factors as hypo-albuimaemia.
• Portosystemic anastomosis:
Location Portal circulation Systemic circulation Consequences

Gastro-esophageal Coronary V. of stomach Azygos vein Gastro -esophageal varices
Anorectal Middle and superior Inferior hemorrhoidal vein May be mistaken for
hemorrhoidal V. hemorrhoids
V Anterior abdominal wall Para-umbilical V. in falciform Superior & Inferior epigastric Caput medusae
lig. (left portal vein) V.
V
Retroperitoneal • Splenic V. branch. • Left renal V. Between :
'-..I • Veins around liver and • Abdominal wall V. • Liver & diaph .
diaphragm. • Retroperitoneal V. • Spleen & diaph.
• Visceral veins. • Intestine & post abd.
Wall.
Presentation of Portosystemic anastmosis:

1. Asymptomatic (diagnosed by ultrasound or endoscopy) . 3. Internal bleeding.
2. Haematemesis. 4. Chronic encephalopathy.
► Parenchymatous decompensation (L.C.F.) :

Manifestations of liver cell failure: • Endocrinal
• Jaundice 0.0. • Gynecomastia.
• Encephalopathy. • Testicular atrophy.
• Ascites. • Feminine pubic hair.
• Fever (low grade). • Hyperaldosteronism.
• Fetor hepaticus 0.0. • Blood
• Flapping tremors. • Anaemia (pallor).
• Fatigue. • Bleeding tendency.
• Skin chagnes: • C.V.S:
Spider naevi 0.0. - palmar erythema - white nails • Hyperdynamic circulation.
( Decreased protein). • Kidney:
• Hepato-renal failure.
For more details about liver cell fa ilure see the theoritical book ...
► Spider Naevi :
Central dilated arteriole with radiating capillaries (looks like a spider).
Pressure on central arteriole leads to fading.
Releasing of pressure: the blood refill the "legs of the spider".
Distributed in the upper half of the body (course of the S.V.C,).
Confirmed by:
• Central pressure = blanching.
• Slide test= pulsation.
One or two spider naevi may occur in normal people. thyrotoxicosis or pregnancy.
More than 5 considered as significant and likely to due to L.C.F.
•
ALLAM'S CLINICAL EXAM'NAT ON ABDOMEN:
DD: _,,
-
.._,,
Raised Exposed area
Purpura Not Not LL (common)
Campbell de Morgan Raised Not Trunk
spots .._,,
Venous star variable ± Fading LL
.......,
► Pa lmar Erythema : marR the a
redness of thenar, hypothenar, distal ends of

metacarpal bone, pulp of fingers with central pallor.
Causes:
• Pregenancy.
• Thyrotoxicosis.
• L.C.F.
• Estrogen containing contraceptive pills.
• Familial
► Additional Items of General Examination in patient with liver disease :

1. Limbic examination . 3. Sexual chr. Evaluation .
2. Head and neck examination. 4. Systemic review (C.N.S. - Chest - C.V.S . - Kidney).
!. limbic examination :
• Koilonychia (Fe deficiency due to GIT

bleeding) .
• Leuconychia (hypoalbuminaemia).
• Muehrke's lines (hypoalbuminaemia).
-~---j,-- •~ lunlae (Wilso_n_'-'
s)_. _ _ _ __
• Asterixis: patient stretches out hands
in policeman's stop position and fingers
spread out ( + closed eye).
• Palmer erythema.
Hands
• Pallor of the creases.
• Dupuytren's contracture: (fibrosis of the
_.,
----
palm's fascia) (alcoholism, manual labor).
• Palmer or tendon xanthomata.
• Scratch marks.
• Spider naevi.
Arms
• Bruising.
• Xanthomata.
• Oedema.
• Bruising.
• Neurological examination.
• Xanthomata.
► B.
En ar
Supraclavicular nodes (Virchow's node): lung or
GIT malignancy.
•
2. Head and neck :

.---- ----- ----- ----- ,
• Cornea rings (Wilson's).
• Sciera: jaundice.
• lritis : inflammat ory bowel disease.
• Xanthelesma .
• Telangiectasia.
• Brown freckles (Peutz-Jaeghers).
• Breath: fetor hepaticus - Ethanol
(alcoholism).
• Ulcer: (Crohn's, coeliac) - white candida
patches - cracks at mouth edges.
• Teeth: cavities (acid effect).
• Gums: hypertroph y - bleeding - Gingivitis.
• Leucoplakia: smoke, spirits, sepsis,
syphilis, sore teeth.
• Atrophic glossitis: hypovitaminosis -
Plummer vinson.
• Macroglossia : B12 deficiency.
3. Sexual characte r evaluatio n:

e.g. gynecomastia and testicular atrophy.
4. Systemic review:
Cause Result .Associatio n
C.N.S'. Autoimmu ne PN (gastro
paresis diabeticoru m)
I
Hepatic encephalopathy Hepatolen tiuclar "Wilson's"
Chest Cor-pulmonale
tender liver.
➔ enlarged I
Amboebic liver abscess.
Hydatid .
Alpha one anti trypsin deficiency
C.V.S; Cardiac cirrhosis.

I
Sympathetic effustion (Rt. Pl).
Hepato-pulmonary Syndrmome.
asis.
S.B.E. = s lenomegal_y._ _ . Cor-pulrno_n_a_le_._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _---1
' Renal Hepato-renal.
Pre-renal (acute GIT bleeding).
Nephrotic (extra hepatic of HCV - B man-
soni).
►N.B.
Hepatop ulmonary syndrom e:
In advanced LCF ➔ Marked 1' vaso dilator materials (VDM) ➔ opening of pulmonary A-V shunt
➔ Cyanosis,
Hypoxia & Dyspnea.
On laying flat
➔ 1' venous return ➔ shunt become inactive, so dyspnea improves but appears
on standing (Platypnea)
•
LOCAL ABDOM INAL EXAMINATION
Inspect ion
General consideration:
• The patient must be exposed from the nipple to the symphsis pubis.
• The patient's hand should remain at his sides with head resting on a pillow.
• Flexion on the knees may relax the abdomen .
...._,,
• The patient should have an empty bladder.
• Warm room and adequate light must be provided.
4 quadrant s or 9 segments
• For easy localization of any abnorma lities it is useful to divide the abdomen in
• Watch the patient's face for signs of discomfo rt during the examinat ion.
Inspection and confirmed by Some Palpation

Front (15) = Contour+7+7 Back (5)
Midline (7) Sides (7)
1. Subcostal angle. 1. Respiratory moveme nt. 1. Scar.
2. Epigastric pulsation. 2. Breast . . 2. Deformity.
3. Visible peristalsis. 3. Hernial orifices. 3. Swelling of renal angle.
4. Divercation. 4. Pigmentation. 4. Cafe' au lait patches
5. Umbilicus. 5. Veins. "neurofib roma".
6. Hair distributi on. 6. Scratching marks. 5. Tuft of hair "spina bifida".
7. Genitalia. 7. Scars.
► Contour:
(must be the first step) can be best appreciated by standing at the foot of the FLAT
table and looking up towards the patient's head .
~
• Normal: slightly scaphoid with preserved waist.
• Abnorma l:
• Scaphoid: the anterior abdomin al wall is sunken and presents a concave in SCAPHOID
Cachectic patient.
• Bulging:
Symmetrical (5 Fs) Asymmetrical

~
~ -
DISTENDED
• Fat = obesity (sunken umbilicus) • Organ swelling (HSM)
• Flatus = (gases) • Ovarian or uterine tumor
• Foetus 11 (commen t on mass)
• Fluid = ascites ~
• Full urinary bladder
nspectln the ab~~omen abdomln11I contour]
•
Inspection of the front (midline) (7) :
1. Subcostal angle
• Normal: acute to right (70° - 90°).
• Obtuse: upper abdominal swelling (HSM) - ascites - barrel shaped chest.
2. Epigastric pulsation:
Place your hand longitudinal in the subcostal angle, Pulsation classified according to
the direction into :
• At the tip of fingers: RV++, increased with deep inspiration.
• From the right side: hepatic pulsation (tricuspid stenosis - TR), liver is
enlarged and tender during bi manual examination .
• From behind: aortic pulsation (thin - hyperdynamic - aneurysm), pulsating
down to umbilicus.
3. Visible peristalsis.
• Normal: in thin person or in emaciated person .
• Abnormal:
• Pyloric obstruction: slow waves from the left rib margin to the right.
Exaggerated by massage, tapping or drinking soda+ confirmed by Succussion
splash (see auscultation) .
• Intestinal obstruction: called step ladder.
4 . Divercation of recti :
• Sepration of rectus abdominis muscles
• Ask the patient to raise his head up without support (lift head) .
• Usually confirmed by palpating the defect between both recti.
• Causes:
• chronic increase of the intra abdominal pressure (HSM - ascites) + hypopro-
teinemia .
s. Umbilicus (4 Ss + CD)
• Normal : midway between symphysis pubis and xiph isternu m.
Site • Upper abdominal swelling and ascites slightly sh ift it downward,
vise versa.
• Normal: Inverted.
Shape • Everted umbilicus means chronic increase of the intra-abdom i-
nal pressure (HSM - ascities).
• Hernia: expansile impu lses with cough.
Swelling
• Nodules: GIT of breast cancers (Sister Mary Joseph's nodule).
• Scar.
Skin lesions
• Wound.
• Cullen's sign: intra-periton eal bleed ing - acute pancreatitis "
Colours
• Causes of generalized pigmentation (see gen eral ex VI).
• Urine: patent urachus.
• Faeces: colonic fistula.
Discharge • Pus: Suppurative inflammation .
• Bile: biliary fistula.
• Fluid: ascities (bursting abdomen).
6. Supra pubic hair distributio n: Die h;ilr normal d,1tribution
• Normal: triangular in male with apex directed {

upward (umbilicus) & horizontal in females.
• Abnormal: as in
'
• L.C.F.: feminine distribution.
• Hypogonadism: loss of hair.
/ l
7. External genitalia
If the patient is circumcised - phemosis - para
•
phemosis etc
► Inspection of the front (sides) (7) : -

1. Respiratory movement (see lung disease)
• Patient of tense ascites usually orthopnic and breath thoraco-abdom inal.
• Patient of peritonitis usually has rigid dorsal decubitus and has absolutely
thoracic breathing.
2. Breast: (one of the general examination items and must be examined in local
abdominal examination).
• Gynaecomastia: hyperplasia of the glandular component of male breast.
Confirmed by pinching test as a disc {button like).
Usually presented as a one sign of L.C.F. or caused by spironolactone.
Comment on: laterality- tender or not.
• Breast atrophy in females noticed in L.C.F.
3. Hernial orifices:
• Expansile impulses with cough.
• Preferred in standing patient.
• Palpate the orifices defect:
1. Epigastric: small, mid line through linea alba defect located between the
xiphoid process and umbilicus.
2. Umbilical: bulging defect at umbilicus.
3. lncisional: defect in abdomen muscles after surgical incision.Must palpate the
size of the defect. Sites of hernia
4. Abdominal: hernia through the abdominal wall. mmmml-

5. Inguinal: Direct or Indirect.
l!lmnh:
4. Veins
Visible or dilated:
• Visible: straight, narrow and not raised.
• Dilated: Tortuous, wide and raised above the level of the skin.
If dilated:
Prominent, dilated veins may represent collateral circulation through the abdominal
wall that has developed to compensate for obstruction of either the inferior vena
cava or or portal vein.
Portal (caput medusa) Systemic (IVC obstruc-

tion)
Central Peripheral -1
- - - - --
By Milking test: Filling By Milking test: from
away from umbilicus down to up
5. Pigmentations:
• Bluish at umbilicus: Cullen's sign (bleeding in
peritoneum).
• Bruises on flanks: Grey Turner's sign
(retroperitonea l bleeding as pancreatitis).
• Jaundice: yellow skin - usually due to liver disease
or biliary obstruction.
..._,
.......
•
6. Scratch marking:
Denotes pruritus usually with obstructive jaundice ► N.B.
• Multiple, parallel and superficial. Add for inspection in all views
• In accessible area . • Scar:
7. Scars: • Surgical (name - healing).
• Surgical (name - healing). • Traumatic.
• Traumatic. • Cautary.
• Cautery. • Striae.
• Scratch marking.
• S.C. bleeding.
• Pigmentation .
• Elasticity (dehydration ).
• Oedema.
rain (In olnal Hernia
inspection of the bacl< (5) : menlngocele
1. Scar.
2. Deformity. ~1!,
3. Swelling of renal angle. (see later)
.
. . . . .,.1 \"'·~~· .. .,·
~
4. Cafe' au lait patches (neurofibrom a).

5. Tuft of hair"spina bifida".
Palpation
General rules: Types of Palpation:

• Let you patient lay on bed comfortably. • Superficial palpation
• Ask him or her to expose from above nipple • Deep Palpation which have many methods:
to mid thigh (it's accepted to cover genitalia • Ordinary method
and breasts (in females) until it's needed to be • Enforced
examined). • Bimanual
• Ask the patient to bend his knee. • Ballotment
• Warm your hands. • Dipping
• Ask patient if any part is tender: examine that • Rolling
last. • Per Rectal (PR)
• Abdominal muscles must be relaxed by patient • Per Vaginal (PV)
knee flexion .
• Superficial palpation then deep palpation .
Normal palpable structures: Lesscommonly palpable, but normal:

• Sigmoid colon: left lower quadrant - firm, narrow • Liver: just below right costal margin (soft) .
tube. • Transverse and descending colon.
• Cecum and ascending colon : right lower quadrant - • Lower pole of the right kidney : (very deep, mostly in
a softer, wider tube . thin women).
• Pulsation's of ascending aorta : midline in upper • Iliac artery: pulsation's - left lower quadrant and right
abdomen . lower quadrant.
► Superficial palaption :
'-'
Aim:
• Gain patient's confidence
• Dectect tenderness, hyperesthesia, temperature, guarding& rigidity.
• Detect superficial swellings e.g lipoma, varicosities & hernia:
Ask the patient to contract the abdominal wall museles by raising the head
(differentiate between intra & extra-abdomina l swelling and notice the
swelling mobility with respiration.
• To prepare the patient for deep palpation
Method:
• Place your extending hand lat on the patient's abdomern
• Gently press (lCM depth) the patient's abdomen by flexion & extension of
....._,,,
the metacarpal joints of fingers (light dipping method)
• slowly progress around the 9 regions either in Sor G shaped palpation & if
the patient complains of abdominal pain let the affected region to the end
Finding:
Assessment of muscle tone:
There are 3 reactions that indicate pathology:
• Guarding: muscles contract as pressure is applied.
• Rigidity: rigid abdominal wall indicates peritoneal inflammation.
• Rebound tenderness: release of pressure causes pain.
Guarding Rigidity
Mechanism Voluntary contraction of involuntary contraction of
anterior abdominal waal anterior abdominal wall
Respiration Disappears on inspiration present with inspiration
Movement with respira- Freely mobile Limited
tion
e.g. During painful! palpation Peritonitis
Examination of patient with guarding

(Nickson's technique):
► N.B.
If the patient is frightened, initially use the patients ...._
Make a fist by your It. hand and press by it on the
hand under yours as you palpate. When patient
sternum, while examining abdomen by rt. hand;
calms then use your hands to palpate.
this will limit the chest muscles of respiration
The most sensitive indicator of tenderness is the
allowing the abdominal muscles to move which
patient's facial expression.
will release the guarding.
► Deep palaption :
Aim:
• Localize abdominal organs
• localize abdominal masses
Method:
• Each organ has a special method for palpation, see below ...
Finding:
• Describing the mass as the following: • edge
• Intra I or extra abdmonial • consistancy
• site • moves with respiration or not
• size • tenderness _,,,
• shape • pulsations
e
Palpation of Liver
Surface anatomy of the Liver: surf.lee anatomy of thu liver
The liver can essentially be visualised as a triangle,

with its upper margin below the nipples on either side
of the chest, and the lower margin making a line from
just above the tenth rib on the right side to below the
nipple on the left side.
The superior surface of the liver lies just below the
diaphragm; this means that the lower margin of the
liver will move downwards on inspiration, and this can
be palpated. As the liver is also a very dense organ, it
is very dull to percussion and you can easily percuss Borders:
out the borders of the liver if palpation is unsuccessful.
Upper border Lower border
The gallbladder area can be palpated around the
tip of the right ninth rib. The normal gallbladder is • Lt - MCL 5th intercostal • Lt - MCL 5th iritercostal
impalpable; it only becomes palpable when distended space. space.
with stones or bile, and the area will become very • Rt - MCI 5th rib. • Lt 8th costal cartilage.
tender if there is inflammation present. • Rt - MAL 7th rib. • Midway between the
Liver Span • Rt - scapular 9th rib. x!phisternurn & umbi-
• liver span of Rt lobe around 8: 12 cm in adult. licus.
• Rh 9th costal cartilage.
• Lt lobe span 4: 8 cm in adult but its ultrasonographic
finding • Rt - MCL 1 inch below
the costal margin.
► Liver Palpation : • Rt - MAL 11th rib.
• Mark the upper border 1st by tidal percussion .
• The lower border by:
1. Ordinary technique.
2. Bimanual.
3. Hooking.
4. Dipping.
5. Tip of hands (Hutchinson's method).
6. Ausultatory method (Macleod).
1. Ordinary technique:
• Right lobe at MCL begining from right iliac region.
• Left lobe at midline from umbilical region.
Ask the patient to take a deep breath. By radial
aspect of the index or tip of fingers, Feel the edge
of the liver press against your fingers.Or, it may
slide under your hand as the patient exhales.
2. Bimanual:
As ordianry with the left hand placed just below
the right costal margin.
3. Hooking method:
• Stand by the patient's chest.
• (Hock) your fingers just below the costal margin
and press firmly.
• Ask the patient to take a deep breath.
• You may feel the edge of the liver press against
your fingers.
4. Dipping: (for palpation of organs in tense ascites)
Flex MCP joint fast to displace fluid and palpate a
mass or enforced by both hands.
Disadavantage: The organ descriptive details are
impossible
._,
Comment on following items:
1. Site: in right hypochondrium 5. Consistency: normally soft
2. Size: normally not felt below costal margin • Soft & enl arged : congenital, inflammation &
• Enlarged : measure it using patient fingers below infiltration
costal margin in MCL for Rt. lobe and in midline • Firm : Bilharziasis
for Lt. lobe • Hard: malignancy
• Shrunken : liver cirrhosis & Bilharzia! fibrosis • Cystic : amebic abscess & hydatid cyst
3. Border Edge: normally felt as resistance 6. Tenderness: Test to examine tenderness: fist test ......,,,
• Sharp : liver cirrhosis & Bilharzia I fibrosis in non palpable live Congestion, inflammation &
• Rounded : congenital, inflammatory, infiltration malignancy
4. Surface: normally smooth 7. Pulsation: TR, TS, hemangioma
• Smooth : congestion, inflammation, infiltration, • Examination for pulsation by bi manual examina-
cirrhosis tion: put on hand on the liver anteriorly and the
• Irregular: liver cirrhosis if macro-nodular other hand at the back, ask the patient to hold
• Nodular: malignancy his breath and feel for pulsation.
► Example:
lntraabdominal swelling, moves up & down with respiration, in Rt. hypochondriam, 3 fingers below costal
margin, not tender, not pulsating, sharp edge, firm in consistancy, smooth surface, mostly it's Rt lobe of liver
► Causes of hepatomegaly:
Infectious: Metabolic: Circulatory: Tumors:

• Leptospirosis • Wilson's disease • Chronic venous conges- • CMV
• Pyogenic cholangitis • Hemochromatosis tion • Metastasis
• Pyelophlebitis • Fatty liver e.g. Reye's, OM • Congestive heart failure • Hepatoma
• Portal pyemia • Lipid storage disease • Pericardia! effusion • Cholangioma
• Amebic hepatitis • Glycogen storage disease • Constrictive pericarditis '--
• Toxoplasmosis • (Von Geirkes) Conginital:

• Viral hepatitis Blood: • Riedel's lobe
• Herpes simplex • Megaloblastic anemia • Polycystic _disease
Palpation of Spleen
Surface anatomy of the spleen:

Site: left hypochondrium
Under 9th, 10th & 11th ribs (long axis on 10th rib).
Medially: scapular line.
Laterally: MAL.
► Spleen Palpation :
1. Ordinary technique . 4. Dipping.
2. Bimanual. 5. Tip of hands (Hutchinson's method).
3. Hooking.
1. Ordinary technique:
Place your right hand flat on the right iliac fossa and direct your hand towards
the left costal margin & feel the edge of enlarged spleen during the peak of
inspiration (or ask the patient to take deep breath in) in one ofthe following
position:
• Radial side of index finger: parallel to the left costal margin
• Tips of fingers (middle three fingertips): perpendicular to the left costal
margin
•
2. Bimanual:
As ordianry with the left hand placed just below the
Left costal margin. If not felt do the same method in
Rt. lateral position
3. Hooking method:
• Stand by the patient's chest on the Lt. side.
• (Hock) your fingers just below the costal margin
and press firmly.
• Ask the patient to take a deep breath.
• You may feel the edge of the spleen press against
your fingers.
4. Dipping: (for palpation of organs in tense ascites)
Flex MCP joint fast to displace fluid and palpate a
mass or enforced by both hands.
Disadavantage: The organ descriptive details are
impossible
Comment on the following items:

1. Site: in left hypochondrium 6. Tenderness:
2. Size: normally Not felt below costal margin : In inflammation : typhoid & Brucellosis, TB
normally or impalpable spleen (milliary), SBE, infarction
• Palpated : enlarged at least 3 times if enlarged & 7. Pulsation: splenic arterio-venous fistula
doesn't cross the midline (or umbilicus): count 8. Pitting sign = Mofti's sign:
by patient's finger breadth • in chronic myeloid leukemia
• crossed midline : huge spleen • Press on the surface of spleen by your thumb
3. Border Edge: for a while then release the pressure, if you
• in bilharziasis has a rounded anterior edge with found an indentation, so it's positive
one ormultiple notch 9. Notch in the antro-medial border
4. Surface: in bilharziasis smooth • Embryologically, the spleen is formed by fusion
5. Consistency: of spenules. The notch is formed at the site of
• Soft & enlarged : in endocarditis, Malaria & sep- their fusion
ticemia
► Example:
Intra-abdominal swelling moves up & down with respiration, oblong in shape in left hypochondrium
extending to: Felt cm ( or finger breadth) below left costal margin in left mid clavicular line or Huge i.e.
crossing midline, Not warm, not tender, not pulsatile, Firm in consistency, sharp anterior border with smooth
surface. Hand can't reach the upper pole as you can't insinuate fingers between costal margin
► Causes of Splenomegal y :
Infectious: Blood: Conginital: Tumors:

• Paratyphoid • Thrombocytopenia • Cysts of spleen • Lymphangioma
• Typhus • Thalassemia major Metabolic: • Fibrosarcoma
• TB Circulatory: • Gaucher's disease • Waldenstrom
• Anthrax • Portal vein occlusion: • Porphyria • macroglobulinemia
• Chronic malaria • Tumour • Rickets
• Psittacosis • Thrombophlebitis
► Causes of HepatoSplenome galy :
Infectious: Blood: Circulatory: Tumors:

• Typhoid • Chronic myeloid leuke- • Portal hypertension • Hemangioma
• Brucellosis mia Colagen disease: • Malignant lymphoma
• Syphilis • Hemolytic anemias • Felty's syndrome •
• abscess • Polycythemia rubra vera • Still's disease •
• Bilharziasis (PRV) • Sarcoidosis
• Hydatid cyst • Myelofibrosis Metabolic:
• Kala azar • Amyloidosis
• Infectious mononucleosis
► lmpotant notes on liver & spleen:
Causes of tender splenomegaly: TIBS What are the causes of palpable liver without hep-
• Typhoid, typhus, TB (military) atomegaly?
• Infective endocarditis, Infectious Emphysema, subphrenic abscess
mononucleosis, Infarction Causes of enlarged tender liver:
• Brucellosis • Malignancy
• Septicemia • Infection: amebic hepatitis & abscess, viral hepa-
Causes of huge splenomegaly: spleen which crosses titis, pyogenic abscess
the midline: • Congestion: heart failure, constrictive pericardi-
•Portal hypertension (bilharziasis) tis
•Thalassemia major Causes of nodular liver:
•Chronic myeloid leukemia • Bilharzia! with coarse nodularity
•Chronic malaria • Post necrotic cirrhosis (post hepatitis)
•Myeloproliferative disorders (Polycythaemia • Malignancy
rubra • Syphilis Gumma (heparlobatum)
• vera & Myelofibrosis) • Hydatid disease
• Kala azar Causes of absent splenic notch:
• Gaucher's diseae Congenital, infarction, adhesions, tumors.
• Splenic sarcoma Causes of multiple splenic notch:
Why does enlarged spleen descend obliquely Congenital, multiple infarction of the spleen
towards
the umbilicus? Stages of Bilhariziasis:
Towards right iliac fossa : due to presence of Stage 1: Hepatomegaly
phrenicocolic ligament & it's axis. Stage 2: Hepatosplenomegly
Stage 3: shrunken liver & splenomegaly
Spleen may be found enlarged in Lt. iliac fassa In the Stage 4: Shrunken liver, splenomegaly & ascites
following cases:
• Absent phrenicocolic ligament (embryological)
• Resection: hemicolectomy
• Infiltration of phrenicocolic ligament by malig-
nancy
• Weak ligament: visceroptosis
• Huge spleen
My name is Spleen, and I enlarges that way

(towards Rt. iliac) , because that guy named
Phrinicocolic ligment prevents me from
desending to the Lt. iliac fossa. You know what,
If some one killed that bad boy, I would enlarges
in the Lt. iliac fossa ...
•
Palpation of Kidney
Surface anatomy of the kidney:

posteriorly the upper edge of Rt. kidney opposite the 11th dorsal spine and the
lower edge of the 11th rib. Its lower edge is opposite the upper edges of L3 spine
and vertebral body and about 4 cm.The left kidney is usually 1.25 cm higher, but
being a little longer than the right, its lower limit may not be quite that much
higher. The kidney is slightly lower in women and children than in men. The inner
border reaches 10 cm. and the hilum 4 to 5 cm .
Renal Angle: Angle between last rib and lateral border of sacrospinalis muscle
Loin: lies between last rib and iliac crest and from vertebral column to flank
Flank: lateral aspect of loin
► Renal angle examination :
Normally Abnormally
Skin: Normal Skin: Ulcers, scars
Shape :concave (Empty) Shape:
Inspection Fullness: swelling within renal
capsule
Bulge: swelling outside renal
capsule
No swelling Swelling
No tenderness Tenderness:
Palpation Thumb pressure test
Casto-vertebral percussion
Murphy's kidney punch
Percussion Resonant Dullness
----
Nothing
-----
Bruit maybe heard ih case of
--- -
renal artery stenosis
Ausultation (Can be heard commonly
anteriorly at transpylorlc plane)
► l(idney Palpation :
Bimanual method:
Rt. Kidney:
The Right hand is placed anteriorly in the Right lumbar region while the Left
hand is placed posteriorly in the right loin
Lt. Kidney:
The Left hand is placed anteriorly in the left lumbar region while the Right
hand is placed posteriorly in the left loin.
Ballotement for examination of renal mass:
at the same previous position, push by the anterior hand and feel by the
posterior hand (posterior ballotement) or push by the posterior and feel by
the anterior (anterior ballotement)
Addational methods:
Thumb pressure test: apply pressure with the thumb to Costovertebral angle
Costovertebral percussion: using ulnar aspect of the hand strike the patient
flank.
Murphy's kidney punch:
While the patient is sitting, examine for tenderness in the renal angle by using
the ulnar border of the right hand (making a fist) percuss over the dorsum of
the left hand placed on the renal angle; with comparing both sides.
It may help destinction between renal tenderness or tender abdominal wall
or muscles of the back
Comment on following items:

• Site: In lumbar region N.B.:
• Size: Causes of kidney swellings : hypernephroma,
Normal kidney may be palpable in: very thin
polycystic kidney, perinephric abscess & persons
hydronephrosis
• Border, edge: Rounded
• Surface: bossy, irregular in malignancy
• Consistency: Cystic in polycystic kidney
• Tenderness: Causes of tender renal swell ins :
Pyelonephritis, renal infarction , perinephric
abscess & hydronephrosis
- -
- - -
.. -
- -
" ~ - ~
- ---- --
' i<id~ey .•"L...."'rll 'SJ:!l~en·
Notch No Yes
- - (anterior & posterion) Non ballotable Anterior only
Anterior & Posterior Ballotable
Ballottement
- It is difficult to insinuate my hand between
Anterior I can insinuate my hand between the
swelling & the the swelling & the costal margin & if so I
costal margin & I can reach the upper can't reach the upper
border border
-Posterior- - Can be pushed to renal angle Can't be pushed to renal angle
-
Percussion Band of resonance Dull all through

- -j Bossy Smooth
-Surface
Edge Rounded I Sharp
Palpation of Gall Bladder
Anatomy
• Shape: pyriform-shaped. • Capacity: 30 - 50 ml.
• Size: 8 - 12 cm length X 3 cm width. • Power of concentration: 10 times.
• Site: fossa for gall bladder on the • Parts: funds, body and neck.
inferior surface of the right lobe of
the liver.
Normally GB cannot be felt, felt only if enlarged
Examination of GB is palpated for swelling& tenderness
1. Tenderness:
Murphy's sign acute cholecystitis :
Compress your right fingertips below the right costal margin at the site of the GB
& ask the patient to take deep inspiration & observe his face & breathing:
• Continue breathing: normal
• Pain & can't continue inspiration : cholecystitis
2. Swelling:
Site: Rt. hypochondrium
Method: Single handed method by deep palpation as liver
Comment on gall bladder swelling:
Intra-abdominal, moves up & down with respiration, in Rt. hypochondrium,
pyriform or rounded, cystic or hard mass (hard in malignancy)
Painless swelling of gall bladder:
• Tumors of GB
• Cancer head of pancreas
• Courvoisier's sign : Palpable distended gall bladder in pancreatic cancer
Painful! swelling of gall bladder:
• Cystic duct stone: mucocele, pyocele
• torsion
• pericholecystic abscess
Riedel's lobe (accessory hepatic lobe)
•
DD:
Palpation of Urinary Bladder
Normally UB is not palpable, felt only in retention.

Site: middle line, never cross umbilicus
Method:
Deep palpation from the umbilicus downwards
by tips of fingers or by radial aspect of index
finger of left hand
Comment distended UB "retention of urine":
Urtl!lral
Pelvi-abdominal swelling i.e. Has no lower ~noter
ffluldll
border
Oval in shape, smooth, firm, regular.
Direct pressure on it produces a desire to
micturate, Immobile, in suprapubic region,
Positive fluid thrill, Dull on percussion
Differential Diagnosis:
• Gravid uterus
• Ovarian cyst
• Any uterine mass e.g.-mesenteric cyst
Palpation of Colon
Method:
Method: Using both hands on each other (feel by the dominent hand and
press by the non dominent hand) rolling method in perpendicular directions
(Horizontal & Vertical)
Cecum:
Site rolling technique in right iliac fossa
Normally Cecum may be felt
Characters of Cecum:
Soft, rounded swelling with indistinct borders
Differential diagnosis: Tumors of Cecum
Sigmoid:
Site: rolling technique in left iliac fossa
Normally the pelvic colon may be palpable in thin patient or irritable bowel
syndrome (spastic colon)
Characters of pelvic colon:
Oblong sausage-shaped (about 12 cm length)
Does not move with respiration, parallel to the inguinal ligament
Movable from side to side (but not vertically)
Gurgling sensation on pressure
Differential Diagnosis; mass in left iliac fossa:
Commonest in children iliac adenitis
Commonest in middle age : Bilharzia! pericolic mass
Commonest in old age: cancer colon
•
Palpation of the Abdominal Masses
► Palpation of the Bilharzia I pericolic mass :

Site: Lt. iliac fossa
Method: rolling technique
Characters:
Moves from side to side but not up down, Oval in shape, Firm & may be tender.
Pathogenesis:
heavy deposition of ova in the subserous area ➔ Bilharzia! reaction ➔ large subserous mass (pericolic mass)
If deposition of ova submucous Bilharzia! reaction intestinal polypi
Clinically the mass can't be felt by per-rectal examination
No need for excision of the mass because: It is not precancerous & does not cause obstruction
Significance : Associated with bilharzia! polyposis :
J
DD: mass in left iliac fossa
► Palpation of Para Aortic Lymph node:
Method: Rolling technique
Site: umbilical & epigastric regions along lateral ► N.B.: Palpation of the ascites:
border of aorta i.e. on the left of a line extending from Transmitted thrill (fluid thrill) in tense ascites see
xiphisternum to umbilicus ascites
Comment on: site, size, shape,
Significance: if felt in malignant cases, signifies
preoperative inoperability
► Palpation of abdominal aorta :

Technique: by deep palpation using two handed method to the midline above & lateral to umbilicus.
Significance: Aortic anurysm
► Per Rectal Examination (PR) :

Patient position: left lateral position (best), Knee-elbow Value of PR:
position • Sphincter: Loss of tone and patulous. (Cauda
Inspection: separate buttocks carefully inspect perianal equina syndrome).
area and anus for: • Contents: Hard impacted stools, Foreign body.
• Pruriti s ani (signs of External piles or fistula or • Rectal wall: Pelvic masses (Ovary, Uterus) in
inflammation) women .
• Anal warts, fissure • Mucous membrance: Irregular, Mass. (Cancer),
• External Haemorroids piles (complicated) .
Palpation: • Prostate in men:
• Put a lubricant on gloved index finger of Right hand • Smooth, large, firm and non-tender. (Benign
• Ask patient to relax & introduce your finger gently enlargement)
& Rotate finger 360° in anal canal searching for : • Hard, irregular nodule or fixed hard mass.
• Thickening or irregularity in wall (Cancer, Stone, Chronic prostatitis).
• Tone of anal musculature & sphincters • Large, boggy and tender. (Acute Prostatitis) .
• Then pass finger into rectum with left hand placed • Stools:
on patient Right hip & latter in suprapubic position • Bloody: (Hemorrhoids, Bleeding rectal
• On withdrawing finger look at it for blood, mucou s, lesion).
pus • Black: (Upper GI bleed, Iron, Some Antacids).
It's not funny at all. PR in internal medicine is not Public

Relationship; it's Per Rectal examination dear...
e
Percussion 0
Simple roles: Abdominal percussion:

• The percussing finger: middle finger of the right hand. 1. Ascites.
• The movement: from the wrist joint. 2. Liver borders: liver span.
• The percussed finger: middle finger of the left hand 3. Spleen: for splenomegaly.
4. Kidneys.
5. Bladder: for enlarged bladder or pelvic mass.
6. Masses.
► Percussion For Ascites :
Knee elbow position

>3000 50 - 1500
Technique:
First step:
• Direct percussion is done over the abdomen,
from the umbilicus to the flanks.
• The location of transition from tympany to
dullness is noted.
Usually in ascites:
percussion note is tympanitic over the umbilicus
and dull over the lateral abdomen and flank
areas (U shape dullness).
The tympany over the umbilicus occurs in mild
or moderate ascites, because bowel floats to the
top of the abdominal fluid . Transmitted thrill (fluid thrill)
Shifting dullness:
• Place one hand on the patient flanks.
• Percuss from the mid line to the flanks on both • With the other hand briskly tap the other flank.
sides: • A third hand (Patient hand) is placed in the mid-
Place the finger parallel to the expected edge. abdomen with sufficient pressure applied to
Percuss from resonance in the mid-abdomen to dampen any wave that may pass through the
dullness in the flanks. anterior abdominal wall.
• The patient rolled to the opposite side and wait • Positive test: a shock wave be felt with palpating
for 30 seconds. hand.
• The previous area of dullness should now be If the percussion of the abdomen is resonent allover
resonant. the abdomen and failed to detect minimal ascites use
• It does not matter which side one chooses to the following tichnique:
start with. Knee elbow position
If the percussion of all abdomen is dull and no Place the patient in knee elbow position and
tympany, use transmitted thrill to examine ascites ... percuss the umbilicus area.
► Percussion Of Liver :
Aim: For detection of the liver span
-
Liver span:
The distance between both upper and lower borders of the liver in the right MCL.
About 8 - 12 cm in a normal adult.
The upper border (heavy percussion):
• Percuss downward from the chest in the right mid clavicular line until you detect
the top edge of liver dullness. (See cardiology)
• The upper border of the liver is normally in the right 5th intercostal space.
The lower border:
• By palpation (see before)
• light percussion: Percuss upward from the abdomen in the same line until you
detect the bottom edge of liver dullness.
• An alternate method of estimating liver size is the scratch test: Put the diaphram
of stethoscope just below Rt. Costal margin in MCL, by a sharp object scratch
from the Rt. iliac fossa upwards till you hear the sound way much loader.
► Percussion Of Spleen :
• Percussion of the spleen is more difficult as this structure is smaller and lies quite
laterally under completely under ribs.
• The two most useful methods are percussion over Traub's area and Castell's sign.
• Percussion should be carried out at one or more levels of Traub's area from medi-
al to lateral (See Chest)
• Castell's method:
Technique:
• Percuss the lowest intercostal space (8th or 9th) in the left anterior axillary
line. With the patient in full inspiration and then full expiration.
• Positive sign: if the note changed from resonant on full expiration to dull on
full expiration.
• Explanation: (when the patient inspires, the spleen moves inferiorly along the
posterolateral abdominal wall. If the spleen is enlarged enough that the inferi-
or pole reaches the 8th or 9th intercostal space).
► Percussion Of Urinary Bladder :

• Percuss the upper border of the urinary bladder (Just above symphysis pupis
• In 3 longitudinal lines (the midline and 2 para-median lines).
• The upper border of the urinary bladder (or any pelvic swelling) noticed as con-
vex (n shape) line.
•
Auscultation
Auscultation of the abdomen has a relatively minor role and used for:
1. Intestinal sounds.
2. Vascular sounds.
3. Scratch test.
4. Succussion splash.
5. Buddle sign.
6. Friction rubs.
1. Intestinal sounds:
The diaphragm of the stethoscope should be placed on the abdomen, as least initially in theright lower
quadrant near the ileocecal valve. Specifically listen for the pitch & frequency of the bowel sounds.
• Normal: gurgling, 5 - 35 per minute.
• Rushing {Borborygmi): loud and easily audible - normal in diarrhea.
• Tinkling: high pitched, (raindrops in a barrel): intestinal obstruction .
• Decrease sounds:_ (none for a minute) decrease gut activity. After abdominal surgery, abdominal
infection (peritonitis) or injury.
• Absent sounds: no sounds for 3 minutes: ileus.
2. Vascular sound:
I Arterial lbruits ·
.~ - ~ - - • --i .. - ,-~- ' Ve~~u~ hu~~
Timing Only during systole Continuous
By Diaphragm Bell
f--
Chracterized by High - pitched Low - pitched
Increased by -- Inspiration
• Venous hum:
Best heard overlying the portal vein in an area approximated by an elliptical shape between
the umbilicus and the mid-clavicular line where it crosses the right subcostal margin.
• Arterial bruits:
Begins at or just to the left of the xiphoid process and bifurcates at the level of the
umbilicus.
Midway between the xiphoid process and the umbilicus and within 2 cm of the
midline.
M id-way between the umbilicus and the mid inguinal point (MIP).
Just above the inguinal ligament (MIP)
3.Scratch test:
Technique: ► N.B.:
• Place the diaphragm over the area of liver/spleen Blood flow through the aorta itself usually does not
• Then scratch parallel to the costal margin until generate any appreciable sound.
the sound intensity drops of marking the edge of
the liver.
• Different patterns of scratch may be used (e.g.
5. Buddle sign:
spokes of a wheel). see picture before
• In knee elbow position.
4.Succession splash:
• It is useful for detecting small amounts of
• Called auscultation of the stomach
ascites as small as 120 ml (shifting dullness and
• Detected in gastric outlet obstruction e.g. pyloric
bulging flanks typically requires 500 ml).
ulcer or neoplasm.
• Technique: 6. Friction rubs (rare)
• Place the stethoscope on the epigastrium. • Right and left upper quadrant.
• Then shake both iliac crests. • Grating sound with respiratory movement.
• Indicates inflammation of peritoneal surface of
• While shaking, listen to splash from retained
an organ.
fluid.
•
► N.B.:
Auscultation over the liver:
• Friction rub (grating during breathing) peritonitis.
• Bruit (cancer).
• Scratch.
Auscultation is sometimes done before percussion and palpation, unlike in other examination.
It may be performed first because vigorously touching the abdomen may disturb the intestines, perhaps
artificially altering their activity and thus the bowel sounds.
Additionally, it is least likely to be painful - invasive; if the person has peritonitis and you check for rebound
tenderness and then want to auscultate you may no longer have a cooperative patient.
LONG ABDOMINAL CASE
► History: ► General Examination :

Personal history: Female patient, xxx, 47 years old, • Patient with an average general condition, average
from AI-Fayoum, house wife, married 29 years ago and built.
has 3 sons, the youngest is 19 years old, she has no • Patient is fully conscious, oriented for time, place and
special habits of medical importance. persons ....
Complaint: She is complaining of abdominal swelling of • Patient lies in semi sitting position .
2 weeks duration.
Head and face examination:
• Orange yellow jaundice, wasted temporalis, with
The condition started 15 years ago by an active attack
endemic parotitis.
of haematemesis of sudden onset with 2 cups of
• No pallor or cyanosis.
dark brown blood preceded by nausea and followed
• No puffy eyelids with normal eye brows.
by melena for 3 days, she admitted in Aldemerdash
• Bad oral hygiene with normal tongue size.
hospital, investigated by upper endoscopy & treated
by enodscopic sclerotherapy without blood transfusion
Neck examination:
and this attack is not recurrent until now.
• Congested pulsating neck veins, JVP = 4 cm above
• No appetite changes, dysphagia, heart burn or
sternal angle with normal waves.
halitosis.
• Palpable carotid pulsation without thrill.
• No changes in bowel habits or bleeding per rectum.
• Central trachea - no lymph node enlargement or
• 10 years ago, patient suffered from lower limbs
thyroid swelling.
oedema with gradual onset and progressive course,
• Spider nevus in root of the neck.
responds to diuretics.
• Followed after 2 years by ascites with gradual onset
Upper limb examination:
and progressive course with several paracentesis
• Pulse: 75 beats/ minute, regular, big volume, .....
process of about 3 liters of clear fluid and not followed
• Blood pressure: 130 / 50 mm Hg.
by any complications.
• Palmar erythema : are present in both hands.
• Lower limb oedema & ascites are associated with
jaundice and pruritis with dark urine and low grade .._,,
Lower limbs examination:
fever & progressive mild loss of weight.
• Shows bilateral, painless, pitting oedema.
• No abdominal pain or urinary symptoms.
• Echymotic patches: are present in lower limbs,
• No gynaecological symptoms.
upper limbs and trunk.
• No symptoms of other system affection.
• Systems examination: no abnormalities were
..,
• Patient is investigated by CBC, liver function tests and
detected are regard C.V.S., chest & C.N.S.
abdominal ultrasonography then treated by vitamins &
examination.
diuretics .
Past history:
History of bilharziasis at age of 13, manifested by
dysentery, investigated by urine & stool analysis and
treated by praziquantil.
No history of other chronic diseases, surgical
operations or drug intake.
•
Family history: Irrelevant.
All AM'S CLIN ICAL EXAMINATION ABDOMEN:
► Local Examination :
Inspection:
• Symmetrical enlargement of the abdomen with full
'---,( flanks, wide subcostal angle, and abdomen moves
freely with respiration.
• No gynecomastia, epigastric pulsation.
• There are divercation of recti, umbilicus is shifted
downward, everted with umbilical hernia, no pig-
mentation, discharge or nodules.
• No striae, scar or hernia neither dilated veins.
• No swelling in renal angle or back deformity.
V
Palpation:
A. Superficial
No superficial swelling or tenderness.
B. Deep palpation
• Right & lower lobes of liver are not palpable.
• Spleen: swelling in the left hypochondrium in-
tra-abdominal, 5 fingers below the left costal
V margin with notch, sharp edge firm in consistency,
l.; smooth surface, not tender & not pulsating.
• Kidney are not palpable.
• No any palpable mass.
Percussion:
• Moderate ascites is detected by shifting dullness.
• Dullness on Traub's area-.
Auscultation:
• Normal intestinal sounds.
v • No vascular sounds, rubs or splachs.
► Proper Diagnosis :
V
A case of shrunked liver with splenomegaly for D.D.
most propably due to mixed bilharzia! & hepatitis
cirrhosis, with vascular and cellular decompensation.
V
\J
V
ALLAM'S CLINICAL EXAMINATION NEUROLOGY:
INTRODUCTION
'-'
► Classifications of Nervous System:
A- Functional classification (Neurophysiology):
1- Motor
2- Sensory
3- Psychological
B- Structural classification (Neuroanatomy): F-+- - , - - -- Cerebellum
1- Central Nervous System (CNS) in stem
2- Peripheral Nervous System (PNS)
• t-+- - -- - Spinal Cord
► Central Nervous System (CNS) :
- -- - Spinal Nerves
'-' Brain:
1- Cerebrum
u 2- Cerebellum
u 3- Brain Stem: Midbrain, Pons & Medulla oblongata

4- Diencephalon
Spinal Cord { 31 Segments ):
8 Cervical
12 Thoracic
5 Lumbar
5 Sacral
1 Coxygeal
► N.B.
v Conus: last 3 segments of spinal cord .
Epiconus: 4 segments above conus.
\,,..,i ► Peripheral Nervous System (PNS):

Cranial nerves
Number: 12 pairs
Origin: brain & its stem
Exit: skull
Supply: head and neck
V Spinal Nerves:
Number: 31 pairs
Origin: spinal cord
Exit: vertebral column
Supply:
Cervical: upper limb
Thoracic: trunk
Lumbar: lower limb
Sacral: lower limb
Coccygeal: perineum
N.B.
Cauda equlna:
last 10 spinal nerves (lumbosacral) because spinal
cord is shorter than vertebral column .
V
•
Al.LAM'S CLINICAL EXAMINATION ► NEUROLOGY:
U.M.N. , L.M.N.
(Pyramidal (ll.) -~ Extrapyramidal tracts) .
Consist of Pyramidal tract(~): From AH Cs to the effector muscles:

A- Cortico spinal tract: AHCs » roots > > P.N. » neuromuscular
from cerebral cortex to the anterior horn cells junction >> muscles.
(AHCs) which present in the spinal cord. Or from cranial nerves nuclei to the effectors .,
B- Corticobulber tract: muscles:
from cerebral cortex to cranial nerves nuclei Cranial nerves nuclei >> cranial nerves >>
which present in the brain stem. neuromuscular junction >> muscles.
Functions 1- Initiate the voluntary movements. 1- Perform the voluntary movements.

2- Inhibits AHCs . 2- Vitality of muscles & their surrounding ~
3- Skillful movements . structures (skin - hair - nails) .

4- Control the sphincters (micturation and ..J
defecation) .
- ' ~
.1
~ '--
U.M.N.L L.M.N.L.
Weakness Paresis. Paralysis.

Distribution (the degree of weakness): Distribution:
Distal> proximal. for example Peripheral neuropathy:
Abductor> adductor. L.Ls. > U.Ls.
Progravity > antigravity. Distal > proximal.
Extensor> flexor.
±adductor> abductor.
-·
Tone Hypertonia (no inhibition of AHCs) . Hypotonia.

Distribution :
Adductor> abductor.
Antigravity > progravity.
-
Reflexes Superficial: absent (below level). Superficial: absent (at level).
Deep: hyper-reflexia. Hypo-reflexia.
Pathological reflexes: ± . Planter flexion or absent (equivocal).
Clonus: ± .
Planter reflex : dorsiflexion.
-- -------- ·-
Wasting Absent: may present as disuse atrophy Present (early - marked - localized).
(late - mild - diffuse).
·------
Trophic Absent Present

changes
- - -
Fasciculations Absent Present (irritation of AHCs)
•
ALLAM'S CLIN ICAL EXAMINATION ► NEUROLOGY:
'--'
'-....,
pyramidal Cells
'-....,
upper motor neurone
85% of fibers cross

'--'
15% of fibers descend on
the same side
\,_/
Lower Motor Neuron
\.....,
'--'
'-....,'
► N.B.
Superficial reflexes take facilitator fibers from both U,M.N. & L.M.N. so, they are absent in both U,M.N.L.
(be low the level) & L.M.N.L (at the level)
Pathological reflexes: reflexes which are normally absent, its presence indicates U.M,N.L., as adductor, patellar
and finger flexion reflexes; (don't elicit them in patient w ith normo ot hypo reflex1a)
Clonus: rhythmic contraction of the muscles after sudden sustained stretch of the tendon. If t;>resent indicate
severe U.M.N .l. as {wrist and ankle clonus).
Fasciculation: an oscillatory movement of the muscles caused by an irritating lesion of the AHCs.
Causes of Fasciculation:
1- Motor neuron diseases
2- Thyrotoxicosis
'-../ 3- Cervica l spondylosis
4· Syringomyelia
5- Acute t;>oilomyelltis
6- Metabolic: Severe hyponatremia , severe hypomagnesemia
8- Drugs ( Clofibrate, lithium, anticholinesterase & Salbutamol)
•
ALLAM'S CLINICAL EXAMINATION ► NEUROLOGY:
Important concepts:
Muscle tone: continuous and passive partial contraction
of the muscles.It helps maintain posture.
Tendon Jerk:
A reflex contraction of the muscle to which a tendon is
attached when the tendon is struck sharply so as to exert
a sudden pull on the muscles. An exaggerated response
may indicate the absence of higher nervous control on
the reflex(UMNL).
Reflex Arc: signals travel along the following pathway:
1- receptors of muscles and tendons
2-Afferent
3- Anterior horn cell (Reflex center)
4- Efferent
5- Muscle fibers
► Transection in the Spinal Cord:
Gracile Cortico-Spinl (ti Teact)
Cuneate Rubro-Spinl
Lateral Spino-Thalamic
Spino-Cerebellar - - - - v estibulo-Spinl
Ventral Spino-Thalamic - - ...... - - - Reticulo-Spinl
._,,
Tecto-Spinl
Relation between vertebrae & segments:

·vertebrae Spinai •cord 'segments __
C 1- 3 +0
C4 - 7 +l
T 1- 6 +2
T 7 -12 +3
Ll or below Cauda equina lesion
-
•
ALLAM'S CU 1lfCAL EXAMINATION NEUROLOGY:
q
NEUROLOGICAL SHEET
1
1- History: Persona l history.
General 2- Examination: Complaint.
Local =:f"" 3- Investigations. History of present illness: Analysis of the complaint.
. . Past history Symptoms of the related system .
4 - D1agnos1s. F .1 h'
am1 y 1story. Other systems.
5- Treatment. Investigations and treatment history.
NEUROLOGICAL HISTORY
1. Name: Y4!1 <!.Up ~1

2. Age: ! a... rlS ~J.,;,&.
Hereditary spastic ataxia.

Baker's myopathy.
Peroneal muscle atrophy.
3. Sex:
Motor neuron disease (M.N .D.) is common in males.
Migraine is more common in females.
4. Occupation: !4!1 ~
persons in certain occupations are more susceptible to certain diseases e.g. disc prolapse is more common in
drivers while lead neuropathy is commoner in printers.
5. Marital state: ya..., r1S o..l.i&- ~µ1 ! r1S !~Y.31 ~..l.i&, Y~.3_;:;.o
for possible sterility or impotence.
6. Residence: !~ .)SL.,
e.g. migraine is commoner in urban areas, while nutritional diseases are commoner in rural areas.
7. Special habits:
!o..,..UI o.i.A. J'llb- ~ ~ !a... rlS l!JJ~ ! f~I ~ o;~ flS Y.:,..-~
!4!J o~I e,jl Yu4-o,l;J,I ~ Y.3 w...:., "!.P. Yul;Jio..o .3i op y ~
e.g. alcohol can lead to peripheral neuropathy, tremors, amnesia & confabulation (Korsacoff syndrome).
8. Handedness:
in right handed people the dominant hemisphere is the left.
► N.B
Left handed peoples:
1/3 of them: dominant left hemisphere.
1/3 of them: dominant right hemisphere.
1/3 of them: bilateral.
► Complaint:
On patient's own words+ duration Y.,...,...,, ~1 ~, 4.1~ Y ~ I ~~ ~14!! Y~u ~1 4!1
Example: Patient is complaining of heaviness of right UL and LL of 2 days duration.
► History of present illness (H.P.I}:

2. Symptoms of the related system. • As long as possible.
3. Systemic Review:. • Contains medical terms.
4. Investigation & treatment (related diseases). • In chronological arrangement.
5. DM and HTN (Usually considered as past History) • In the form of a story.
► N.B.
History of present illness is highly diagnostic in C.N.S. As:
Etiological Diagnosis: From only onset and course
Anatomical and pathological diagnosis: From analysis of symptoms of C.N.S
Trauma can be easily excluded from history (no history of trauma).
Inflammation is associated with fever, headache and malaise.
1- Anc1lysis Of The Complaint:

1. Onset: : ~! ~1 ~ ~j o~ c,~ ~~ 15µ11 ?u~ .;,1,1,t1 ~I ~1 J~ j :~J.i;.J4 ~j o~ uiJ..? .;,1,1,t1
From beginning of symptoms until the establishment of the disease. It may be acute or gradual.
• Acute onset (less than 14 days):
Seconds: Sudden e.g. em bolus or trauma.
Minutes: Dramatic or Apoplectic e.g. hemorrhage.
Hours: Rapid e.g. thrombosis.
Days< 14 days: e.g. inflammation.
• Gradual onset {14 days or more):
In degenerative diseases, as diabetic P.N. or space occupying lesions (S.O.L.) as tumors.
2. Course: : u4_9-i J -:.~ jl: J~j &-1...,i 15 .1.o ,fa ~j ~J.i;.J4 c,~ .;,1~1,t1
From the establishment of the disease until recovery or complications. It may be progressive, regressive,
stationary, remittent or intermittent.
• Remittent: in attacks, patient in between attacks is diseased as multiple sclerosis.
• Intermittent: in attacks, patient in between attacks is healthy (symptoms free) as epilepsy & migraine.
Acute onset is always followed by regressive course while gradual onset followed by progressive course.
2- Symptoms of C.N.S.: (TNM 4S + hypothalmus)
1- 0 Increases lntraCranial Tention {ICT)
2- 0 Central Nervous System Symptoms
3- e M otor Symptoms
4- C, Sensory Symptoms
5- C, Sphincter troubles
6- C, Speech troubles
7- C, Systemic Review (usually considered as a seperate item)
8- 0 Hypothalamic Manifestation
NIAi
Bursting headache, projectile vomiting, blurring of vision± coma,± convulsions.
: ..::J.l&.j ~ ~ : •r.} clJ c,..1=, ~: u ~ ~ ~ y,:;.-,. ti""" d.i.... ~
2. Cranial nerves:
See later. -
---
._,,
ALLAM'S CLINICAL EXAMINATIO N ► NEUROLOGY:
3. Motor System:
1. Weakness .
2. Involuntar y movement .
3. Co-ordination.
1. Weakness Analysis: 13 points: (onset, course, duration+ 5 character + 5 distribution)
5 characters 5 distribution
1. Degree. 1. U.L. /LL.or both.! ~'ill 'i/3 , l!ll.rJ 'i/.9 d.1.!l
~JU 'i/.9 ua.o d~ lt11 2. Right/ left or both. , ~~I 'ii., Y! J~ 'i/.9 ~
2. Tone. ~~l-½,11 .:,.o ~.::..~~~' ii., ½l.. cl:i~ 3. Proximal or distal.
~ ~~ J.=- lo J>AI ~ ',/.9 • Upper limb. !d_,...:. t.1"" 'ii., .:,.-1 a.;~1 ;,:w jJAi
3. Wasting (onset - degree). • Lower limb. , ~,~'ii., .;-I~, E16:i
~\?J~ ~ ',/.9 ~ ~ c l ; ~ J.i, 4. Abductor or adductor.
4. Trophic changes. • Upper limb. ! cl»~.::...,.; ..,..1:.5 ~ ',/.9 J.i,ii ..:..S~I ~
~~ cl_,sU:>1 J.il>
5. Fasciculation .
'i .,
• Lower limb. Y J6..,i ltJ..:..i <P.J Js- <P.J .-;
5. Flexor or extensor.
~cl;~ J 4SJ cl~ J.i, • Upper limb., 4.lili 'ii., ~.i.11 ~ , J6..il 4..!!
• Lower limb. Y J6..,i ~ ~ J J.,al 'ii., .:,~1 ~
2. Involuntary Movement s Analysis: 13 points: (onset, course, duration+ 5 character + 5 distribution)
5 characters 5 distribution
1. Static or kinetic.! .;iµ1 ~ 'ii., 4S'p11 ~_,;Si~ 1. U.L. / L.L. or both., ~ J 'ii., I!!~!~
2. Regular or irregular5 ~ :r::i' 'ii.,~ 2. Right/ left or both., J'6.to 'ii.,~
3. Tone. 3. Proximal or distal., o,! 'ii.,~, ~u
'i .,
J.=- 1.o ui>AI ~ 'i/3 4-!'-½-'' .:,.o ~ u.Ll. ! ~ ½t... .:.u~ 4. Head and neck. Y ~J .,i 1!.1..IJ ~ o_;A ~
!~~ 5. Trunk.,~, ; 4-!JIJ! 'ii .:..is,~
4. Increased by.! 4-.!l! .I.!?.
5. Decreased by.! 4-.!l! JJi:.!
3. Co-ordinat ion:
Cerebullum Deep Sensation
Upper limb lower limb.. Upper limb lower limb
Shaking movement Or,
-
Drunken gait. !c!J-½,11 hi ~.,; .;~

-- - - ·-
Falling while closing eyes
tremors during eating Y.:i1µ1 \?j t ~ ',/.9 ~ ~ ~.)t......aJla...._,..J,iiiiJJ~ l!L!..9 ~ ..:..;1., ~ ~ , i
' ~ J.o~ J5~1 J5~ ~
'&-!
Be kind to your patient and use apropriate words when asking about symptoms. and try to
make history taking as smooth as possible. you should also be familiar to the different words in
each culture reflecting the same meaning.
r
• •
•
4. Sensory System:
l Sensation
~
1 ~ • Localization
Cortical
Superficial Deep • graphothesia

• Stereognosis
• Pain. • Position.
In cortical sensory loss:
• Touch. • Movement.
the patient recognize _,,
• Temperature. • Vibration.
familial things without
Superfacial sensory affection are two degrees: • Muscle sense.
seeing them.
• Nerve sense.
.;,..a. \::Jl.9 ..:1.1.!I J ~i.., cl....i U,
Irritation: Destruction: In deep sensory loss:
!~~_;a::;J~
• Pain • Hyposthesia the patient feels as he is
• Parasthesia • Anasthesia walking on a cotton.
• Tingllng , ~ , ,91 Ji ..,.l-:,~j JA ! ~ t ~Lo l!lil ~
• Numbness
,~,,~~
In superfacial affection ask about distribution:
eg; Gloves and Stokes.
,~ AP i.>"t-~1.:,1-1.a ,1 ~ t
Radicular, root or girdle pain: (with dermatome)

Special type of pain in neurology. increases by cough and straining and desreasde by rest and support.
Value
• Paraplegia (leveling). • Cauda equina.
5. Sphincter troub les : ! cl...A.i ~ J,F! ! J~I ~ ~U... ..:I.= JA
• Micturition ! f1-11 Jb-..u Lo .µ ~ J~I
• defecation ! J~ Lo J½ ~ J~J e1-lt Jb-.1..! U. _,;,.~ J~I
• sexual function ! 4r.9_;/I o_.,.!,lal,I ~ ~U... .:J.= JA
Centre: autonomic center (S2,3,4) ! ~! i,.rl;-,•JI ":-'t..:.l~I J~i
! ~,~1 .lo-~
► Neurogenic Bladder:
Innervation of the human urinary bladdr:
1. Parasympathatic like any vieceral organ of the body S2,3&4
2. sympathatic has no active role in human
Control of mlcturatlon :
• The wall of the bladder containes special receptors (Stretch and chemical) stimulated by streach of bladder wall
and the acidity of urine. signals are carried by sensory nerves to the micturation center S2,3&4.
Motor nerves emerges from the center to the bladder causing wall contraction and sphincter relaxation (in infants)
• Sensory fibers also reaching the center S2,3&4 ascend in the posterior column to the brain where the sensation
of fullness is percevied. Higher center of micturation (Paracentral lobule) send inhibitory fibers through pyramidal
tract to inhibit the the reflex.
• Micturation occures only when the inhibitory impulses is released.
Lesions:
LMNL (at the reflex arc}: • Motor lesion (Motor atonic bladder) charachterized
• Sensory lesion (sensory atonic bladder) by:
charachterized by: • Intact fullness sensation (painful!)
• Loss of fullness sensation (painless) • Inability to evacuate the bladder
• Retention of urine with huge size bladder • catheter is usually used to evacuate
• Dribbling of urineevery now and then because of
overflow
• Both sensory and motor lesion (Autonomic bladder) charachterized by:
• Incomplete, irregular, Involuntary evacuation.
•
• Evacuation depends on the bladder myogenic action
ALLAM'S CLI NICAL EXAM INATION ► NEUROLOGY:
Summary of bladder affection in neurology:
Unilateral UMNL:_No effect LMNL:

Bilateral UMNL: Efferent lesion
• Acute: (shock) Motor Atonic Bladder
Retention with overflow Painful retention
...
\ .,/
• Gradual:
• Patial : Percipitancy Afferent lesion
• Complete: Automatic bladder: Sensory Atonic Bladder
(loss of upper control) Painless retention
as infants:
Involuntary, Complete, regular Afferent and Efferent lesion
Autonomic Bladder
lnvulantary, Irregular, Incomplete
'--...,I
► Erectile Dysfunction (lmpotance):
Definition: Inability of male to maintain an adequate erection sufficient for satisfaction of his female partner.
May be partial or complete.
Causes:
Causes
7
Psychogenic 30 % Organic 70%
J
Iatrogenic Vascular Neurogenic
'--'
B Blockers Le Riche Syndrome PN
Approach for diagnosis of impotence:
1. Ask about sexual function.
2. Ask about morning erection.
• If absent : organic.
• If intact : psychogenic.
3. Drugs history (anti hypertensive drgus) for iatrogenic organic impotence which is reversible.
4. Testicular sensation which is absent in neurogenic impotence but intact in vascular causes.
► N.B.
Le Riche syndrome:
Aorta-iliac block with occluded both internal Iliac arteries occlusion of median sacral artery which supplies
nerve erigent (S2, 3) which is responsible for erection .
•
6. Speech troubles :
There is speech troubles or no without details. ~ f)ISJI J JS'Ll:..o cl.i.:... J.c>
7. Systemic Review:
Usually considerd as a separated item ... see next
8. Hypothalamic Manifistation :
• The hypothalamus is the control center for several endocrine functions. Endocrine systems controlled
by the hypothalamus are regulated by anti-diuretic hormone (ADH), corticotropin-releasing hormone,
gonadotropin-releasing hormone, growth hormone-releasing hormone, oxytocin, all of which are secreted
by the hypothalamus.
• Numerous dysfunctions manifest as a result of hypothalamic disease. Damage to the hypothalamus
may cause disruptions in body temperature regulation, growth, weight, sodium and water balance,
milk production, emotions, sleep cycles, neurogenic diabetes insipidus, tertiary hypothyroidism and
developmental disorders.
~~lcl..~~3"
~J:?S JS'~~
~.@ f ~ I J:,-~
~J:?S rl;-1,1 j uWAi ~
3- Systemic Review:
. ·- ~
·Vaules;~f.C.V.S.,l}istory and examination in C.N .S.

Cause Result Association
• Mitral stenosis may be compli- Silent myocardial infarction in Herdiofamilial ataxia and ........
cated by atrial fibrillation which diabetic P.N. myopathy may be associated with
causes embolic hemiplegia. cardiomyopathy.
• Hypertension may cause throm-
botic hemiplgeia.
Vaules of respiratory·system ,hist_o ry and examination in C.N.S.

- - - - - -Cause Result
T.B. >> port's disease which cause extramedullary Static pneumonia in patients with prolonged rest in
compressive paraplegia. bed as patients in shock stages.
Causes of fever in C.N.S.: 1. Meningitis.

2. Encephalitis.
3. Encephalomyelitis.
4. Poliomyelitis.
5. Peripheral neuritis.
6. Myositis.
7. Subarachnoid hemorrhage (low grade).
4- Investigation & treatment (related diseases) :

What you exactly write should be like:
patient investigated by CT, MRI, MRI with diffusion and treated by clexan, etc
if all are negative:
no symptoms suggest other systems affection.
5- D1\.1 and HTN :

DM ans HTN are usually considerd as past history, but they better be considerd as present history as they are
highly important and never cured (controled not cured).
• Diabetes Mellitus: ~ u~t..:.o \?1 J-- ~ tlS .:,is _,s...,, ~ ; i ~ 4:! ~1 =,.
~ 4:! r~ u~i ~ _,;:.,) c>-" ~ _,s...,, cl.i.:...
• Hypertension: J-- ~ tlS .:,is~,~ •.,.. ;1 ~ 4:! ~1 =.P. ~ <t:! r~ .::,j_p.i ~ _,;:.,! c>-" ~ ,6.;,..;, cl.i.:...
._,,,
► Past History:
1. Similar attacks. ! I.IS'~ uJfal .s.,U,1
2. Chronic diseases as D.M ., hypertension and T.B.
• Diabetes Mellitus: ! .:.1.u-1.io.o o§i .;-. ! ris .:,is .,s- ~;I!~! ->l ~,. ! ~! r£~ u..tbl ! u""! ;,.o ! .,s- d..u&.
• Hypertension:! .:,Lu-1.io.o o§l .;-. , ris .:,is J.iwiJI ~ o.,.. ;1 ! ~! ->i ~,., ~l ~~ .:..1.-i, u""l i>" ! J:,a.o d..u&.
• T.B.: ! 41'_,1, uljlA/ ~~ .:,.!bl., J........,, ~ ij O.::,~I ! ,.;; 4!)U.I ~., ~ ~ ,:;.;,S ! F--' r->, w .)l,,j cl.11:r
• Hepatitis: ! ul:!-11 .:-J ! #I J~I .:,_,J ! .,.i,.,1 ~ ~ _,,
• D.V.T.: ! rJJJ .:,~ cll_,->1, o..lS' ~ ~ I i ; d,.r.-- ! ~_,_, ..:.OJ-' ~ J
3. Trauma. ! o§.,lill ->,-II .,I l!L.iJ .,i ~ ~ .:,~t.oJ ~f .,1 ! o..lS' ~ o.>1.,... ~
4. Major operations. (complications of general or spinal anasthesia).
t CP.11 i; .!i,U .,l .:.Lu-1.io.o la.IA! J.-- ! '-'""I ;,.o ! ~l ~ t o..lS' ~ ~"- ..::.~ ~
5. blood transfusion. ! r-> .:.w
6. Fevers.! I'-'! ris dt.u .:.,......1 ! o..lS' ~ a.;. a, .:.:r Ja
7. Drug allergy and intake: ! .,,-> o§i.:,... ~"- d..u&. ! o.,.._.. ~ 4!,->i .lb'-!
• P.N.: caused by isoniazide.
• Myopathy: caused by steroids, chlorquine and vincristine.
• Ataxia: caused by phyntoin (toxicity)
► Family History:
Some diseases in neurology has hereditary factors:
........ • autosomal recessive: Friederich's ataxia
• autosomal dominant: Hereditary spastic ataxia & peroneal muscle atrophy
• X-linked: Pseudo hypertrophic myopathy
, ':-'!,.,; rY'' . ,. Y, ! .s.,u,1 ..,.JJ .:,... ~ , an1a1, ~ .11>-
\._.,·
•
ALLAM'S CLINICAL EXAM! ATIO NEUROLOGY:
NEUROLOGICAL EXAMINATION
Don't get lost: Examination: General and Local:

1. General examination. 6. Reflexes.
2. Mentality. 7. Sensory system.
3. Speech. 8. Back.
4. Cranial nerves. 9. Gait.
5. Motor system. 10. Other systems
1. General Examination:
e rli.,i Vitals: Blood pressure. pulse. Respiratory rate. Temperature.
G Complexion: pallor, jaundice and cyanosis:
4!) Decubitus or position see pictures later in inspection section
Neck vein (H & N)

C,
0
E
fa
Clubbing (upper limb) & Flapping tremors in respiratory failure (CO2 retention)
Lower limb edema (lower limb}
Mentality: Disturbed level of consciousness (see later)
Face + general lock.
2. Mentality:
1. Consciousness level (fully conscious, semi-conscious or comatosed and if comatosed assess GCS).
2. Orientation (time, place and persons).
3. Mood (average, depressed, euphoric).
4. Memory (old and recent) .
5. Behavior (co-operative or not).
6. Intelligence.
► Glasgow Coma Scale (GCS):

This is an objective score of consciousness.
Repeated testing is useful for judging whether coma is deepening or lifting.
Note that the lowest score in each category is 1, meaning that the lowest possible GCS = 3 (even if the patient is
dead). and the highet score is 15.
Eye open ing

(max 4 points)
4 Spontaneously open
Open to (any) verbal in (moves hand toward
3 t disorientated
stimulus !
Open in response to Withdraws to pain (pulls hand away
2 Inappropriate words
painfl.11 stimulus from stimulus)_ ~ - - - - - -
1 No eye opening at all (random words, no Abnormal fl exion to pain (decorticate
conversation) posturing)
Incomprehensible sounds Abnormal extension to pain
(moaning, etc.) (decerebrate posturi_n~)
No response at all
Example: The patient is fully conscious, well oriented to time, place and persons, with good mood and memory,
he is co-operative with an average intelligence .
• -
ALLAM'S CLlNKALEXAMINATION NEUROLOGY:
3. Speach:
Communication with others via verbal, writing or movement.
► Development of Speech
When the baby is born:
• he received sensations from the surrounding in the Visual Sensory area (area 17) in the occipital lobe.
• Repetetion of these sensations leads to insertion, storage and recognetion in Visual Psychic areas ( areas 18 & 19).
Similary in the Auditory impluses
• Sensations ➔ Auditory Sensory area (area 41 & 42 ) in the Temporal lobe.
• Repetetion of these sensations leads to insertion, storage and recognetion in ➔ Auditory Psychic areas ( areas 22 ).
Example: when he see his mother, see (area 17 ), recognize (area 18) hear her voice (area 41, 42 ).
\......, at the age of 1 : 1.5 years:
Broca 's area (area 44) in frontal lobe is developed so, he can imitate sounds he has perceived.
at the age of school:
• he starts to learn letters & numbers so, he begins to develop a special visual psychic area ( 39) in angular gyrus in
- parietal lobe.
• when he wants to write the stored image in are 39 ➔ it requires development of a special cortical motor center for
writing (Exner' s area).
• Association between visual & Auditory Psychic area allow him to correlate between the image he sees & the sounds
related to them.
• this requires associative area (37) in the parietal lobe.which also sends association fibers to Broca 's and Exner's
areas.
• impulses from the Broca 's area or from Exner's area reach the Motor area (area 4) descend in fl tract to reach the
nuclei of the cranial nerves (supplying the muscles of articulation) and the A.H .C (supplying the muscles concerned
with writing).
► Speech Disorders
1. Formulationl aphasia or dysphasia
• Sensory 2. Articulation: Dysarthria
• auditory agnosia: lesion in area 22 • fl tract >> slurred speech.
• visual agnosia: lesion in area 18 and 19 • Extra fl tract >> monotonous speech.
• Alexia : lesion in area 39 • Cerebellum » staccato speech.
• Motor: • Basal ganglia » choreic speech.
• verbal aphasia: lesion in Broca's area (44) • Cerebellum + fl tract>> slurred staccato (scanning}.
= expressive aphasia.
• Agraphia: lesion in Exner's area (45)
• Jargon's aphasia:
lesion of the associated area (37) = salad word
4. Cranial Nerves: See later

5. Motor System Examination:
1. Inspection: muscle state.
2. Palpation: muscle tone.
3. Percussion: fasciculation and myotonia.
4. Power.
5. Co-ordination.
•
1. Position
1. Inspection : (muscle state):
1. Position (posture):
E 2.
3.
4.
Deformities
Wasting
Trophic Changes
• Semi flexed upper limb and hyper extended lower limb in

spastic hemiplegia.
• Adducted, hyper extended both lower limbs in spa stic
paraplegia.
• Dropped wrists & feet in P.N.
• Semi flexed, abducted both lower limbs in myopathy.
2. Deformity
Cause: Pott's disease causes paraplegia.
Result: Hyper Extended both LL Semiflexed UL &
• Pes-cavus in P.N. Hyper Extended LL
• Talipis equines in myopathy.
Association: Pes-cavus in herdio-familial diseases as ataxia and myopathy.
__,
3. Wasting (atrophy)
Comparison:
• Between both sides in unilateral diseases.
• Between the limb with itself in bilateral symmetrical diseases as inverted
champagne bottle in peroneal muscle atrophy.
Wasting landmarks:
• Upper limb • Lower limb
• Proximal: • Proximal :
Flat shoulder Flat buttock.
• Distal: • Distal
Flat thenar and hypothenar. Pes-cavus.
Prominent M .C.B. (Guttering) Prominent M.T.B.
4. Trophic changes
• Loss of hair in upper limb or lower limb.
• Brittle nails.
• Trophic ulcers.
•
2. Palpation (Muscle Tone): Ask the patient to relax first: ~ ':-':'.""'
Upper Limb Lowe Limb

Wrist: upside down shaking Ankle: side to side shaking.
-
..
Elbow: passive flexion & extension . Knee : passive flexion & extension .
··--
Shoulder: 2 methods.
c;roumdu<tion. I Gower method. Rolling For
hypertonia For
Hip: 3 methods.
j frog's sign Circumduction
For both hyper &
' Ihypotonia, hypotonia
Causes of hypertonia:
Causes of hypotonia:
1. t:. tract lesion : clasp knife spasticity (resistance in
1. Lesion of reflex arc:
beginning of movemen t only).
• Afferent= P.N . = Tabes dorsalis.
2. Extra t:. tract lesion: lead pipe rigidity (resistance
• Centre "AHCs" = polio, motor neuron disease
all over the movement ) or Cog-wheal rigidity
"M.N.D".
(interrupte d by tremors).
• Efferent= P.N. "motor"
3. Myotonia 4. Catatonia 5. Meningeal irritation .
• Effector= myopathy - myasthenia.
Spasticity Rigidity 2. Posterior column lesion .
Site of Lesion Pyramidal Extra Pyramidal 3. Cerebellar lesion except "Marie's"
Distribution
-----
Distal> Proximal
----- -!
Proximal> Distal
4. Extra {j, >> chorea.
5. Shock stage.
Flexors of UL Flexors of UL
Extensors of LL
Character ---- ---- -
Clasp Kn ife
Flexors of LL
Le ad Pipe or
Cog-wheel
Deep Reflexes Hyper-reflexla Hypo-reflexia
•
3. Percussion (fasciculation & myotonia):

► N.B.
Fasciculation: an oscillatory movement of the
Causes of Fasciculation:
muscles caused by an irritating lesion of the AH Cs.
may be physiological as with coffee, stress or
Myotonia: pathological as:
Delayed relaxation of skeletal muscle. 1- Motor neuron diseases
• Voluntary: ask the patient to catch anything or 2- Thyrotoxicosis
shake hand. 3- Cervical spondylosis
• Mechanical: by "percussion" 4- Syringomyelia
• On tongue: dimpling. 5- Acute poliomyelitis
• Thenar eminence : dimpling. 6- Metabolic:
• Electrical. Severe hyponatremia , severe hypomagnesemia
hener roi.poMe In m otonta 8- Drugs ( Clofibrate, lithium, anticholinesterase
& Salbutamol)
Medica l Research Council scale for muscle power

(degree of muscle power):
Routine Examination:
• Limbs. No muscle contraction visible.
• From distal to proximal. Flicker of contraction but no movement.
• Flexion then extension . Joint movement when effect of gravity eliminated.
• Abduction then adduction.
Movement against gravity but not against examin-
• Fix the joint that follow the joint examined .
er's resistance.
• Start without resistance then against resistance .
• Trunk. Movement against resistance but weaker than
• Ask patient to rise from bed. normal.
• Observe umbilical movement. Normal power.
► U er Limb Muscles Examination:
C3,4
Lateral movement of neck
IElevation of shoulder Supra and infraspinatus - ,,.
cs 1
Abduction of ~houi"der Deltoid
CS,6 Biceps & brachioradialis ....,,.

- - ~ -1- -
C6,7 Extension of elbow Triceps
.._J
C7,8 Extension of wrist Extensors of wrist

,__,
C8, Tl Flexion of wrist & movement of small ms of hands Flexors of wrist
Hand (C8, Th 1)
• Thumb: • Other fingers:
• Opponens pollicis: ask the patient to touch the tip • Abductors: dorsal interossei: patient abducts his
of his little finger with the tip of his thumb. fingers against resistance.
• Abductor pollicis brevis: it is the only muscle of his • Adductors: palmar interossei : patient grasps a
hand supplied by the median nerve than can be paper between 2 fingers.
easily tested (as in carpal tunnel syndrome). Ask • Lumbricals: patient puts his fingers in the writing
the patient to abduct his thumb at a right angle to position.
the palm of the hand, the muscle can be seen and • Flexors Digitorum: Flexion of fingers
palpated. • Extensor Digitorum: Extension of the fingers
Wrist (C7,8)
3. Flexors: anterior fibers of deltoid. Ask the patient to
• Flexor Carbi: Wrist flexion
raise his arm forwards against resistance.
• Extensor Carbi: Wrist extension
4. Extensors: posterior fibers of deltoid . Ask the patient
Elbow (CS,6,7) to push his arm backward against resistance.
1. Flexors: biceps, brachialis & brachioradialis. 5. Lateral rotators: infraspinatus & teres minor.
• Biceps: with the patient's arm extended by his side 6. Medial rotators: latissimus dorsi & subscapularis.
& the hand fully supinated. Ask him to flex his elbow 7. The serratus anterior: ask the patient to push his arm
against resistance. forward against resistance, paralysis of this muscle
• Brachioradialis: as for the biceps but with the hand leads to winging of the scapula.
semi-pronated.
2. Extensors: triceps, with the patient's elbow flexed ask
him to extend it against resistance.
Shoulder (mainly C4 - CS)

1. Adductors: pectoralis major & minor assisted by
latissimus dorsi & teres major.
Ask the patient to adduct his arm against resistance or
while patient presses his hands to his waist. Palpate
the anterior axillary fold for the contracted pectoral is.
2. Abductors:
• 0° - 15° supra spinatus.
• 15° - 90° deltoid.
• 90° - 180° trapezius.
► Lower limb Muscles Examination :

Root Action Muscle
L2
L3 -- Flexor of the hip
--·
Extensor of the knee
lleopsoas.
Quadriceps
---
L4 Dorsiflexion of the ankle Anterior tibial group
LS Dorsiflexion of the toes Anterior tibial group & glutei ._,

51 Plantar flexion of the ankle and toes Calf muscles & glutei
52 Flexor of the knee Hamstrings

$3,4,5 Anal contraction Anal and perianal muscles
Knee
Hip
1. Extensor: quadriceps (L2,3,4): ask the patient to
1. Flexer: ilio-psoas (Ll,2) : ask the patient to flex his hip
maintain knee extension while you try to bend the knee,
against resistance.
or bend the patient's knee & ask him to straighten it.
2. Extensor: gluteus maximus (LS, S1,2): with the patient
2. Flexer: hamstrings (S1,2): ask the patient to pull his
lying face downwards in bed. Fix his trunk with your
heel towards his buttock against resistance.
hands & ask him to raise his L.L. against resistance.
3. Adductor: adductors longus, brevis & magnus (L2,3,4) Ankle
assisted by pectineus & gracilis. Abduct the thigh & ask 1. Dorsiflexor: anterior tibial group (L4,S).
the patient to bring it towards the midline. 2. Planter flexor: calf muscles (S1,2): the patient moves
4. Abductors: gluteus medius & mininmus (LS, S1) while his foot upwards & downwards against resistance.
the thigh is in the midline. Ask the patient to move it 3. Inversion: tibialis anterior & posterior (L4).
outwards. 4. Eversion: peroneal muscle (LS): the patient inverts &
everts his foot against resistance.
5. Co-ordination:
Should be examine after power. Why?
Integration of
r-- Types of Ataxia
Cerebellum » open eye. Sensory Cerebellar Mixed

Deep sensation and cerebellum » closed eye. Co-ordinatio n Co-ordinatio n Co-ordinatio n
is impaired is impaired is impaired
Upper limb only when the in both in both
1. Finger to nose. patient close conditions; conditions, but
2. Finger to finger. his eys. either the much worse
3. Finger to doctor finger. patient is when the
4. Finger to moving doctor finger. opening patient close
Lower limb orclosing his his eyes
1. Heel to knee . eys .
2. Heel to doctor finger.
Rornberg's test:
Findings:
Ask the patient to stand with the heels together, 1st with
• Intention tremor.
his eyes open, then with his eyes closed .
• Decomposition of movement.
Note any swaying or loss of balance.
• Dysmetria.
If present:
• Only with closed eyes = sensory ataxia.
• With eyes open or closed = cerebellar ataxia or mixed
In rebound test doctors should remove his watch

and patient sould remove his glasses to avoid pa-
tient injury.
6. Reflexes Examination:
Reflexes Examination
Superficial reflexs l l
• Planter
Deep reflexs
r Pathological reflexs
1
• abdominal Upper Limb Lower Limb Upper Limb Lower Limb
• cremastric • Biceps C5,6. • Knee L2,3,4. • Supraspinatus C3,4. • Patellar L2,3,4.
• anal • Brachioradialis CS,6. • Ankle 51,2. • Finger flexion C8, Tl. • Adductor L4.
• gluteal • Triceps C6,7. • Hoffman's C8, Tl.
• Wartenberg' s C8, Tl.
1. Superficial reflexes :
1. Planter reflex (S1, 2 but mainly S1}
Technique: normally, stroking the sole of the foot ► N.B.
with a blunt object results in planter flexion of the In exam, the examiner
toes. observe your eyes, so you
Normal response: planter flexion. should look at the right
Abnormally: dorsiflexion = positive Babinski= place. This little body will till
Extensor planter= up going reflex. you where you should look
Causes of +ve Babinski : when electing the reflex
• {). tract lesion.
• Infant below 1 year. ...,,,
• Deep sleep.
• Anesthesia & coma
Other methods to elicit planter reflexes:
1. Strunski's method: sudden abduction of the little toe.
2. Gonda's method: the 3rd & 4th toes are passively flexed, then suddenly released.
3. Shaddock's method: a scratch is made on the lateral aspect of the dorsum of the foot from the lateral malleo-
lus to the little toe.
4. Barda's method: a scratch is made on the dead lateral aspect of the foot.
5. Gordon's method: the calf muscles are firmly squeezed.
6. Schaefer's method: the tendon Achilles is firmly squeezed.
7. Oppenheim's method: firm pressure is applied on the skin over the lower part of the shaft of the tibia, from
above downwards.
Causes of equivocal response:
1. L.M.N.L. at S1. 3. Total paralysis of big toe.
2. Hypothesis at S1. 4. Marked deformity of the foot.
► N.B.
• There is NOTHING called Negetive Babiniski.
• Fanning of the toes on electing the reflex = extra
pyramidal lesion specialy area 6
e _,.
Abdominal reflex (T6 - T12):

Technique:
Upper abdominal reflex (Th 6 - 10):
light stroking of the skin of the abdomen above the um-
bilicus, from the periphery inwards, using a pin .
Lower abdominal reflex (Th 10 - 12):
light stroking is done below the level of the umbilicus,
also from the periphery inwards.
In both cases, contraction of the ipsilateral abdominal
muscles can be seen.
Value:
• In hemiplegia: ½ lost.
• In paraplegia : level.
• In D.S.: early lost.
Cremasteric reflex (Ll): elicited by a stroke with a pin, along the upper part of the medial aspect of the thigh
resulting in visible contraction of the cremasteric muscle.
Gluteal reflex (L4,5): elicited by a stroking across one of the buttocks with a pin resulting in contraction of the
ipsilateral gluteal muscles.
Anal reflex {S3,4,5): elicited by scratching the skin of the perinea I region resulting in contraction of the external
anal sphincter
2. Deep Reflexes:
Deep Reflexes Response - -~
No response Normoreflexia Hyperreflexia

I
r reintorcement l
J,
Search for
pathological reflexes
Appeared Not appeared & clonus
Hyporeflexia Areflexia
Causes of hyper-reflexla:
l. t::,. tract lesion.
No reflex even by re-infrocement.
- -- 2. Thyrotoxicosis.
Reflexes obtained only by re-inforcement. 3. Tetany.
al hyporeflexia. 4. Tension.
gerated.
y. ------ ------ ----
► N.B.
Reflex is always as tone except in parkinsonism "hypertonia with hyporeflexia"
•
ALlAM 'S CLINICAL EXA MINATION ► NEUROLOGY:
In the upper limb:

1. Biceps reflex (CS,6):
Elicited by a tap upon the biceps tendon while the elbow is at 1200. the tap is done on your index finger placed
over the tendon. It results in mild contraction of the biceps with slight flexion of the elbow.
2. Brachioradialis (CS,6):
Elicited by a tap 3 - 4 cm above the styloid process of the radius. While the elbow is at 1200. it results in mild ....,
contraction of the brachioradialis and slight flexion of the elbow.
3. Triceps reflex ( CG, 7):
Elicited by a tap directly on the triceps tendon while the elbow is flexed at 900. It results in mild contraction of
the triceps with slight extension of the elbow.
In the lower limb: ........

1. Knee reflex (L2,3,4):
Elicited by a tap on the quadriceps tendon while the hip joint is slightly flexed and the knee joint is flexed and
supported from beneath by your hand. It results in visible contraction of the quadriceps and extension of the
knee.
2. Ankle reflex (S1,2):
Elicited by a tap on the tendon Achilles while the thigh is abducted and externally rotated, the knee is flexed at
900 and the ankle is dorsiflexed by the examiner. It results in mild contraction of the calf muscles with planter
flexion of the ankle
.__,
•
3. Patholgical Reflexes:
In the upper limb:

1. The supraspinatu s reflex (C3,4):
is done by tapping the supraspinatus muscle, in U.M.N .L. there is visible contraction of the muscles with
slight abduction of the shoulder.
2. The finger flexion reflex (C8,Tl):
is done by tapping the palmer surface of the middle 3 finger while they are slightly flexed, in U.M.N .L. there
is prompt flexion of the finger.
3. Hoffman (C8,Tl):
is done by tapping the nail or flicking the terminal phalanx of the middle or ring finger. in U.M.N.L. there is
flexion of the terminal phalanx of the thumb .
4. Wartenburge sign (C8,Tl)
5. Pectoralis (C3&4)
6. Deltoid (C4&5)
In the lower limb:

1. The patellar reflex (L2,3,4):
is done by pressing the upper border of the patella downwards with the examiner's index finger and then
tapping the finger with the hammer, in U.M.N .L. there is contraction of the quadriceps and displacement of
the patella .
2. The adductor reflex (L4):
is done by tapping the index finger placed just above the adductor tubercle, while the hip is externally and
slightly abducted, in U.M .N.L. there is visible contraction of the adductors with adduction of the thigh .
•
OOM,Wi
Rhythmic contraction of the muscle after sudden sustained stretch of its tendon.
1. Organic: denoting a definite U.M .N.L. in which case . It stops with release of the stretch of the muscle.
2. Hysterical: where it persists in spite of release of the stretch of the muscle.
• Upper limb clonus:
• Wrist clonus C8, Tl .
• Lower limb clonus:
• Patellar clonus L2,3,4.
• Ankle clonus S1,2 .
• Wrist clonus: .__

is obtained by sudden and sustained extension of the wrist .
• Patellar clonus:
is obtained by holding the patella and displacing it slightly upwards, this is followed by a sudden downward
displacement of the patella.
• Ankle clonus:
is obtained by passive planter flexion of the joint followed by sudden dorsiflexion .
► N.B.
Sure signs of fl tract lesion:
• Distribution of weakness.
• Hypertonia.
• Hyper reflexia.
• Positive Babinski.
• Pathological reflexes.
• Clonus (organic).
7. Sensory Examination:
Sensation
•
Superficial Deep Cortical
1. Pain . 1. Vibration. 1. Tactile localization.

2. Touch . 2. Position. 2. 2 points discrimination.
3. Temp. 3. Movement. 3. Streognosis .
4. Muscle sense. 4. Graphosthesia .
5. Nerve sense. 5. Perceptual rivalry.
e
► Dermatomes:
----~
"---"
Cl
'-·
cs
'-...,·
CB
TI
'....-- n
n
T4
~
TS
T6
~
T7
T8
'---'
T9
.._,, no
TII
Tl2
L1
.,_,,, 1.2
L3
'- l4
LS
--- Sl
S2
53
._.., S4
ss
Cl Angle of jaw, lateral neck.

C3,4 Shoulder, down manubrium.
cs Lateral aspect of arm.
C6 Lateral aspect of the forearm, thenar eminence & thumb.
C7 Middle aspect of the forearm middle of the ealm, middle 3 fingers.
C8 Medial aspect of forearm, hypothenar eminence & little finger.
T1 Medial asRect of arm.
T2-T7 Thorax (T4 is at nipples).
T8-T12 Abdomen (TlO is at umbilicus). (T12 is at inguinal ligament).
Ll
._ Upper 1/3 front of thigh.
L2 Middle 1/3 front of thigh.
L3 Lower 1/3 front thigh.
~
L4 Anterolateral aspect of thigh, front of knee, anteromedial aspect of leg, medial aspect of foot & big
toe.
-
LS Lateral aspect of thigh, lateral aspect of leg, middle 1/3 of dorsum of foot & middle 3 toes.
S1 Posterolateral aspect of thigh & leg, lateral 1/3 of dorsum of foot & little toe.
52 Posterior aspect of thigh, leg & sole of the foot.
53,4,5 Anal, perianal & gluteal region (saddle shaped area) in concentric manner.
e
► Site of lesion in each pattern of sensory loss:
Pattern of sensory loss Site of lesion

Mononeural. "--·
Stock & glove. Peripheral nerve.
Maculo-anaesthetic (leprosy).
Radicular sensory loss. Root.
Saddle area loss. Conus.
Dissociated sensory loss lUnilateral cord lesion (brown sequard syndrome )
Extramedullary lesion.
Sensory level.
Jacket sensory loss (dissociated) lntramedullary.
Crossed hemihyposthesia Lateral medullary syndrome.
Hemihyposthesia · Capsular & brain stem lesion .
Cortical sensory loss Area (1, 2, 3) of parietal lobe.
Dissociated sensory loss (brown Unilateral cord lesion.
sequard syndrome )
Sensory level Extramedullary lesion .
Jacket sensory loss (dissociated) lntramedullary.
Crossed hemihyposthesia Lateral medullary syndrome.
Hemihyposthesia
Cortical sensory loss
ICapsular & brain stem lesion .
Area (1, 2, 3) of parietal lobe.
1. Superficial Sensations:
Before Examination:
Expose the patient
ask the patient to Close his eyes~ JAsl}
Steps for Examination:
'--'
l. Compare right with left at (face - upper limb - lower limb) in hemiplegia; superficial sensation are lost on
one side
2. Compare the same side at (face - upper limb - trunk - lower limb)
• Jacket of sensory loss in intramedullary compression paraplegia.
• Decrease sensation in both lower limb in extramedullary Compression paraplegia .
3. Compare proximal with distal (P.N.}.
4. Level (P.N.}.
5. Circumferential. (check distrubtion of dermatomes)
► N.B.
Superficial Sensations: are pain, touch and temprature assend in anterior spinothalamic tract except fine touch
ascends with deep sensation in posterior column pathway.
•
ALLAM'S CLINIC.1\L EXAMINATION NEUROLOGY:
'-..I
• Face Rt and Lt All the left side: In both sides:
.Si 11..A> ..,....1:,
2 l..A> Face, Trunk, UL and LL • UL proximal and distal (so
• Trunk Rt and Lt 7 LlA> .sj 5 LlA> 15j 3 LlA> .Si 1 LlA> ..,....1:, proximal and so distal)
4 l..A> .sj 3 L.a ..,....1:, 2 LlA, .Sj 1 LlA> ..,....1:,
• Upper Limb Rt and Lt Then all the right side: If proximal is better do the next
6 L.a .Sj 5 L.a ..,....i.,. Face, Trunk, UL and LL steps to determine the level
• Lower Limb Rt and Lt 8 LlA> .Sj 6 LlA> .Sj 4 LlA> .sj 2 LlA> ..,....i.,. • LL proximal and distal (so
8 LlA, .Sj 7 LlA> ..,....1:, proximal and so distal)
4 LlA> 15j 3 LlA> ..,....i.,.
If proximal is better do the next
steps to determine the level
.,__,,.
Determine theLevel (P.N.). in both Go circular to (DD roots affection

UL and LL = not all dermatomes affected)
J_,i ~ .91 ~~ ..,..i.-~I Lol.9 ~ !~.sj
•
2. DeeP- Sensations~ •.
1. Vibration:
Check vibration sensation from distal
The bony prominences that you
to proximal by using tuning fork 128
should use arranged from distal
placed on bony prominences. Ask the
to proximal:
patient if he feels the vibtration. If
deep sensation is impaired distally go
proximal untill the patient feels the
vibration. ..._,,.
!4-!~ ..,.....,b-
J,s Ju~ u...
Value of Examining Vibration in Neu rology:

1. In PN: Vibration is lost distaly and is intact _-:..-\----.i 2. Tibial tuberosity
above the level. 3. ASIS
2. In Posterior Column injury: Vibration is
lost below the level of injury (e.g. lost in all
lower limb and intact in all upper limb)
3. In thalamic lesion: Vibration is lost in all
body even in forehead
._/
2. Muscle Sensation:
Squeeze the calf muscle while the patient is closing his eyes and ask the patient if he can recognise the
sensation.
Loss of muscle sense called abadie's sign as in diabetic P.N.
► N.B.
Tender calf muscle in:
• Diabetic P.N.
• G.B.
• Nutritional P.N.
• D.V.T.
• Myositis.
e
3. Position & movement: (joints sense):

first show the patient with his eyes open, the position
of his big toe (dorsi-flexed), then with his eyes closed,
move the big toe and ask him if he feels it moving and
if so in which direction .
The big toe should be caught gently, from the sides
and sou Id not touch the other toes during movement.
4. Nerve sense:
By pressing the ulnar nerve and the lateral popliteal
nerve against the bones. Normally, it results in an
electric like sensation .
3. Cortical Sensations:
They are only examined when the superficial and deep sensation are intact.
1. Tactile localization:
ask the patient to close his eyes, then prick his finger & ask him to localize the site of the prick.
2. Two-points discrimination:
with the patient's eyes closed, deliver 2 simultaneous pricks, e.g. on the finger (5mm apart) or on the legs
(4cm apart). Normally the 2 pricks are felt distinct from each other.
3. Stereognosis:
with his eyes closed, the patient is asked to recognize a familiar object placed in his hand.
4. Graphosthesia:
with his eyes closed, the patient is asked to recognize a number or letter drawn over his palm.
5. Perceptual rivalry:
normally if you deliver 2 simultaneous pin pricks at 2 corresponding sites of the body, both pricks are felt; in
cortical sensory loss, only the prick on the healthy side is felt.
.. ~
Tactile localization then 2 points

discrimination
~~ ~
~~l~soJ.=>-lj ~
•
8. Back and Cranium:

Back Examination for:
• Scar. ► N.B.
• Deformity. To count the vertebrae from the back.
While the patient is standing then sitting to • The most prominent bone in back at C7.
observe lumbar lordosis. • The angle ofthe scapula at T7.
• Tenderness.
• Cafe au lait patches "neurofibroma".
• Tuft of hair in spina bifida. .._,,,.
Cranium Examination for:
• Size, shape, sutures & fontanelles.
• Bony bosses & tenderness.
• Dilated veins, bruits & naevi. ..._,,
• Mc Ewen's sign in brain tumor.
1. Hemiplegia: circumduction . 7. Parkinsonism:

2. Paraplegia: scissoring . • Short steppage.
3. P.N .: high stepping . • Shuffling .
4. Sensory ataxia: stamping . • Festinant.
5. Friedreich's ataxia (archicerebellum): drunken. 8. Chorea: dancing .
6. Marie's ataxia (Neo cerebellum): 9. Myopathy: wadling
• Unilateral: deviation to one side.
• Bilateral: Zigzag.
drcumduction scissoring shuffling high stapagr waddling
10. Other systems:

Rapid Examination of the other systems
•
CRANIAL NERVES INTRODUCTION
Cranial Nerves:
1. Olfactory nerve (I}
2. Optic nerve (II)
3. Oculomotor (Ill}
4. Trochlear (IV}
5. Abducent (VI}
6. Trigeminal V
7. Facial (VII)
8. Vestibulocochle ar (VIII)
9. Glossopharyngeal (IX)
10. Vagus (X}
11. Accessory (XI}
12. Hypoglossal (XII)
Group:
• occulo cranial (Ill IV VI)
• bulbo cranial (IX X XI)
Cranial Nerves - - - - - - - - - - - .
Special Senses Mixed Motor

I, II, VII V, VII, X • Ill, IV, VI
• XI , XII
► N.B.
All cranial nerves have bilateral fl tract supply Except :
1. Lower facial nucleus.
2. Hypoglossal XII "50%".
3. Spinal part of XI.
Which are supplied from the opposite side only, so these nerves are affected in unilateral lesion as hemiplegia.
CRANIAL NERVES HISTORY AND EXAM INATION
Assessment of Cranial Nerves - , - - History.

L Exam;aation ~ Inspection.
Power.
Sensation.
Reflexes .
► N.B.
• In children and infants: Examine cranial Nerves as possible regarding the compliance and age.
• Oral discussion in clinical examination
• Anatomy.
• Physiology "function".
• Examination "technique".
•
ALLAM 'S CLINICAL EXAMINATIO N ► NEUROLOGY:
I. Olfactory nerve:
History: ~ ..::.~1 ~1 a...t:. J.a>
Examination:
Ask the closed eyes patient to identify the smell of
substance: Familiar and Not irritant e.g. coffee.
....,,
Each nostril is examined separately with closed eyes.
► N.B.
Anosmia
• Unilateral: neurological disease as fracture
base of the skull, meningitis or olfactory bulb
tumor "Foster kennedy syndrome".
• Bilateral: E.N.T. cause
II. Optic nerve:
History:
1. Acuity of vision ~ ~ l!!p J.a>
2. Colored vision ~ 01~~11 .s;J J.a>
3. Field of vision ~ ~Lo c.;l.9 J.;,olj»,ll.9 ._..,w1 ~ ~ J.a,
Exmaination:
1. Acuity of vision: using Snellen's chart or finger
counting from a distance of 6 meters. In case of
failure to count the finger at this distance repeat
at a shorter distance. If at a distance of 30 cm the
patient still fails to count the finger test for vision
use hand movements. If the patient does not see
the movements, test for light perception using the
torch. If there is no P.L. (perception of light) then
the patient is blind . Each eye should be examined __,,.
separately.
2. Colored vision: See ophthalmology.
3. Field of vision: the confrontatio test:
• Sit in front of the patient at a distance of 60 - 100 cm. keep your eyes at the level of the patient's eyes.
• Let the patient close one eye and you close the opposite eye. Insist that the patient looks into your eye and
nowhere else.
• Examine for the field of vision of the patient's open eye by bringing your finger slowly from the periphery
inwards. Test for the whole field by bringing your finger from above, below, left and right.
• Move the fingers till the end to insure ther's no scotoma
• move fingers upside down and ask the patient if he can see it moving.
• Compare the visual field of the patient to your own visual field (normal) .
•
Reflexes:
1. Light reflex "afferent: 2nd".
Separate the eyes by your hand, move the tourch
from lateral to medial. look for miosis in:
• the same eye: direct reflex
• the other eye: consensual reflex
2. Accommodation reflex "efferent: 3rd".
Ask the patient to follow your finger by his eyes
while moving it twords his nose.
Normal response:
• Convergence.
• Miosis.
• Accommodation.
Significance
Argyell Robertson pupil: Small, irregular, unequal which
doesn't react to light but reacts to accommodation.
Causes:
• D.M.
• Neurosyphilis.
• D.S.
• Encephalitis.
Ill, IV & VI Occulo cranial nerves: Occulomotor, Trochlear, Abducent:

Introduction
Muscles of the eye: Extra ocular muscles and Intra ocular muscles.
Extra ocular muscles: Intra ocular muscles:

1. Superior rect~ 1. Dilator pupillae: sympathetic supply.
2. Inferior rectus. (Ill Occulomotor) 2. Constrictor pupillae: (Ill Occulomotor)
3. Medial rectus 3. Ciliary muscles: (Ill Occulomotor)
4. Lateral rectus (VI Abducent)
5. Superior oblique (IV Trochlear)
► N.B.
6. Inferior oblique (Ill Occulomotor)
All muscles of the eye are supplied by
History Ill Occulomotor except 3 muscles:
• Ptosis ~ ,bJi.., ~ ~ 1. Superior oblique by IV trochlear S04
• Squint ~ .:J"'"i ~ ~ 2. Lateral rectus by VI abducent LR6
• Diplopia ~ ~1~w11..9~ ~ 3. Muller Muscles: sympathetic supply.
Examination:
Inspection:
1. Ptosis: which may be due to:
• Occulomotor nerve paralysis where the ptosis is
• complete and there is associated mydriasis and
divergent squint.
• Sympathetic paralysis "Homer's syndrome"
where the ptosis is partial and there is
associated miosis, enophthalmos and
anhydrosis.
2. Squint.
3. Pulpils: they should be equal, round and reactive
to ligh (RRR).
• The light reflex: see above
• The accommodation (near) reflex: see above
• Cilio-spinal reflex:
pinching the skin on one side of the neck results in dilatation of the ipsilateral pupil. This reflex is absent in
cervical sympathetic lesion "Homer's syndrome".
4. Nystagmus. See below
Power:
1. Each eye separately: 2. Both eyes together:
The patient close the other eye & the examiner fix the The examiner also fix the patient head If both eyes are
patient head . normal to examine the conjugate eye movements:
Ill (Oculomotor): J_jA)~~I~
Superior rectus J_jA) ~ .::-...!~~,~
Inferior rectus .::-...1 ~ ~~~,~
Medial rectus o~ ~ Jl.,.WJ ~~ I ~
VI (Abducent): lateral rectus o~ ~
IV(): superior oblique clA:;S:J ~
Significance:
In ophthalmoplegi a
internuclearis in median
longitudinal bundle
(M.L.B.) lesion that may
occur with multiple
sclerosis.
► Nystagmus:
Definition: Oscillatory movement of the eye ball.

Character of nystagmus in cerebellar lesion :
1. On fixation.
2. Horizontal.
3. Biphasic (jerky).
4. Rapid phase toward the fixation point.
5. Bilateral.
Examination of Nystagmus:
Ask the patient to fix his eyes laking at your finger twice right side and left side
(both eyes together). observe if ther's any osicillatory movement of each eye.
V. Trigeminal:
It is mixed cranial nerve:

• Motor: muscles of mastication.
• Sensory: the main for the face, except skin overlying angel of the mandible which is supplied by C2.
Anatomy
the trigeminal nucleus lies in the upper part of the pons which bilateral f::. supply and 3 sensory nuclei in the
brain stem (see written notes).
e
History
• Motor: ! ~1 ~ 4-!-""" ~~ ~
• Sensory: ! ~., ~ ~ .,i ~ .,; ~., ~~ ~
! ~1.,i Ji~.,~ 1.1"~~1 ~
Inspection:
Wasting above or below zygoma.
• Above: temporalis.
• Below: masseter.
Power:
Muscles of mastication.
• Temporalis & masseter: cliL:..., .fa. P.
To touch the temporalis & catch the masseter.
• Pterygoids: Ask the patient to open his mouth
Not deviated • _ _ ·Deviatec!., _

Normal Bilateral weakness The same side of the lesion
Examine against resistance But the mouth is opened by gravity
• Both together. (D.D. between bilateral UMNL and
• Each one separately. LMNL by reflexes}
Sensation: 3 steps (Close your eyes~ Jill)

1. Compare between each corresponding parts (affection of sensation in one side occurs in hemiplegia).
2. Compare the 3 parts at the same side with the area supplied by C2.
• Value : compare face with body sensation
3. Compare central part with peripheral, upper with lower part of the face.
• Value: to detect the site of the lesion in the nucleus.
Ophthalmic division Rt and Lt Compare whole side with c2 Compare central and Peripheral
2 LlA> 15j l LlA> ..,...1.:,- 4 LlA> 15j 3 LlA> 15j 2 LlA> 15j 1 LlA> ..,...1.:,- 2 l,lA, 15j I LlA> ..,...1.:,-
Maxillary division Rt and Lt
4 LlA> 15j 3 LlA> ..,...lP-
Mandibular division Rt and Lt
6 LlA> 15j 5 LlA> ..,...1.:,-
Reflexes:
1. Jaw reflex "afferent: 5th" "efferent : 5th"
(Pathological refiex)
(temporalis masseter refiex)
place your thumb on the mentum and gentally tap
over it.
Significance: Accurate Anatomical Diagnosis
• Bilateral.
• UMNL.
• Above the pons. (leveling refiex).
2. Corneal reflex "afferent 5th" " efferent 7th in both
sides" ( Normal refiex)
Significance: Absent in:
• Brain death.
• Deep coma.
• G.A.
3. Palatal reflex "afferent 5th" "efferent 10th"
@11¥tiffll
It is mixed Cranial nerve:
• Motor: the main for the face.
• Sensory: taste sensation from the anterior 2/3 of the tongue.
Anatomy:
• The nucleus lies in the pons.
• Its upper half is bilaterally supplied by!:,. tract.
• Its lower half is unilaterally supplied by!:,. tract from the opposite side only.
-....../
Lesion .........
Unlateral Bilateral
UMNL LMNL UMNL LMNL
History, Inspection & Power: ~ items in upper part and ~ items in lower part
History Inspection Power

1. ! 4 J.---½! .:,~i....JI JA, 1. Wrinkles "frontalis" 1. ~l.t"'~JI
2. !o~'-!j~..ll!4JA> 2. Blinking. 2 . ..1.ol.r 4 Jill
----------
1. ~ l!W ~ ~ JS'',11 JA, 1. Nasolabial fold . 1. Orbicularis oris l!.W ~1
2. ~ J~ ~ J JA, 2. Drippling of saliva. 2. Orbicularis oris )..;,
3. ~ l!W t~! JA, 3. Mouth deviation . 3. Retractor anguli l!llL...i ~J-'
•
Reflexes:
1. Glabellar reflex "afferent: 7th" " efferent: 7th"
Gentally tap by the hummer between eye braws
Normally: blinking 4 - 6 times, then stopped due to habituation.
Significance: Accurate Anatomical Diagnosis
• Present: UMNL (exaggerated) .
• Absent : LMNL.
• Persistent (no habituation) : parkinsonism.
2. Corneal reflex" afferent 5th" " efferent 7th in both sides"
See before
Significance: Absent in:
• Brain death.
• Deep coma.
• G.A.
Sensation:
Taste sensation for the anterior 2/3 of the tongue .
VIII. Vestibuloc ochlear:

History:
: .)l_;;i:Jl3 ~ I J JS"l.;.o -'-'r~ J.0
Examination:
A. Cochlear part: test for the acuity of hearing using:
• The watch test: if there is diminution of the patient's
hearing do the following:
• Rinne's test: using the vibrating fork, compare air
conduction (fork placed in front of patient's ear)
with bone conduction (fork placed on patients
mastoid process).
• Weber's test: place the tuning fork in the middle of
the forehead.
Normal The acuity of the patient's Air conduction is better The vibrations are heard
hearing is similar to that of than bone conduction. in the middle of the fore-
the examiner. head.
Nerve deafness The patient's hearing is less Both air and bone conduc- The vibrations are heard in
than that of the examiner's tion are diminished. the normal ear.
- --
Conductive deafness The patient's hearing is less Bone conduction is better The vibrations are heard in
than that of the examin- than air conduction. the affected ear.
er's.
B. Vestibular part:
Caloric test, rotating chair tests and
electronystagmography (E.N.T.).
ALLAM 'S CLINICAL EXAMINATION ► NEUROLOGY:
IX, X & XI Bulbar cranial nerves: Glossopharyn geal, Vagus and Cranial part of Accessory :
They supply the palate, pharynx & larynx
History:
! ~ I cl.J-4' Ja
Palate 2
i clA.1 I>" iur~ oU,I Ja
i ~I ~ <½j,11,,"' ~,! Ja
Pharynx 2
m.(iSJ~Ja
m ~1.:1:;,..,Ja
Larynx 2
~ !'~I J a...,_ ~~ Ja
Power:
By using a tongue depressor and ask the patient to say ah & observe the uvula.
- No movement
Slightly elevated upward Deviated to the healthy side
(base of the uvula)
. . . . . D.D. b reflexes.
Reflexes:
1. Palatal reflex "Afferent : 5th" " Efferent: 10th" _....,,
2. Pharyngeal reflex (gag reflex) "Afferent 9th " " Efferent: 10th".
Value:
Normal LMNL UMNL"'
Slightly elevated uvula . No movement at all. • The uvula rapidly jumbed upward.
• Gagging.
• Vomiting.
ns ectm~ the uvel.-1 rlectmg palate I reflex and harynge,11 reflex

► N.B.
Bilateral LMNL: true bulbar palsy.
Bilateral UMNL: pseudo bulbar palsy.
XI. The Spinal Part Of Accessory:
It supplies sternomastoid & trapezius.

History: ~ J,.a.., l!lliS Ja
Examination:
Movement against resistance:
Trapezius from behind the patient: l!lliS E9;I "----
Sternomastoid muscles: ask the patient to push
against you by his chin and feel the sternomastoid on
the other side ,s~t J.- JJ
•
ALLAM 5 CLI NICAL EXAMINATION NEUROLOGY:
XII. Hypoglos sal:
It is a purely motor for the tongue

History: , ~J i!liw ~
Inspection: Look for wasting and fasiculations
Power: O.J! i!liW ~
- ~
- - -
Deviated Central
The diseased side Normal Bilateral affection
do against resistance UMNL I LMNL
-
--
No wasting l
Wasting
Tasting the power of 1hc tongue
► N.B.
Tongue:
1. Parklnsonism (tremors).
2. Chorea (jerky movement).
3. Myotonia (dimple sign).
u
~ - - -- Nerve Supply of Tounge - - - - - - .
Motor
Sensory
Hypoglossal XII
rt
Post 1/3
Glossopharyngeal IX r 7
Ant 2/3
General sensation Taste
Trigeminal V Facial VII
\.....;
......_.,
•
ALLAM'S CLI NICAL EXAMINATION NEUROLOGY:
SUMMARY OF NEUROLOGY SHEET

*Don't get lost; Unlike most of this book, the folowing summary is organized in 2 columns ...
Personal history: 2. Cranial nerves symptoms.

• Name • Olfactory: anosmia
• Age • Optic: (acuity - color vision - visual field )
• sex • 3rd. 4th and 6th cranial nerves (ptosis - squint - ...._,,
• Occupation diplopia)
• Marital status • 5th cranial nerve ...._,,
• Residence • Motor
• Special habits • Sensory
• Handedness • 7th cranial nerve
.....__,,
• Sensory
Complaint:
Patient own words + duration
•
• Motor (UMNL or LMNL)
8th cranial nerve
-
(deafness - tinnitus - vertigo)
• 9th and 10th cranial nerves
History of present illness: Palate, Pharynx and Larynx
1. Analysis of complaint. • 11th cranial nerve
2. Symptoms of the related system. • Cranial part of accessory
3. Other systems. • Spinal part of accessory
4. Investigation & treatment (related diseases) • 12th cranial nerve
5. DM & HRT
3. Motor system.
1. Analysis of the complaint • Weakness
• Onset: • Onset, course and duration
• Acute onset (less than 14 days): • Degree
Seconds: Sudden e.g. embolus or trauma. • Distreburion
Minutes: Dramatic or Apoplectic e.g. hemorrhage. • Upper limb/ lower limb or both
Hours: Rapid e.g. thrombosis. • Right/ left or both .____,,
Days< 14 days: e.g. inflammation. • Upper limb (proximal/ distal)
• Gradual onset (14 days or more): • Upper limb (adductor/ abductor)
degenerative diseases • Upper limb (flexor / extensor)
• Course: • Lower limb (proximal/ distal)
• Remittent: multiple sclerosis. • Lower limb (adductor/ abductor)
• Intermittent: epilepsy & migraine. • Lower limb (flexor / extensor)
• Tone
2. Symptoms of C.N.S. • Wasting
(T.N.M + 4 Ss + Hypothalamus) • Trophic changes
1. Symptoms of increased intracranial tension. ( I.C.T.). • Fasciculation
2. Cranial nerves symptoms. • Involuntary movement
• Static/ kinetic
...._,,
3. Motor system.
4. Sensory system. • Regular/ irregular
5. Sphincter troubles. • Increased by/ decreased by '-"
6. Speech troubles . • Proximal/ distal
7. Systemic Review • Head, neck & Trunk
8. Hypothalamic Manifestations • Co-ordination
• Cerebellum
1. Symptoms of increased intracranial tension. 11.C.T.). • Upper limb: shaking/ tremors.
• Headache • Lower limb: drunken gait.
• Projectile vomiting • Deep sensation
• Blurring of vision • Lower limb: falling on closing both eyes
---
0
ALLAM S CLINICAL EXAMINATION ► NEUROLOGY:
4. Sensory system.
• Superficial (pain - touch - temperature)
• Onset+ course+ duration
• Irritation: pain/ parasthesia
• Destruction: hyposthesia / anaesthesia.
• Distribution: Sites & sensory level '
• Deep sensation
• Cortical sensation
5. Sphincter troubles.
(Micturation - Defecation - sexual function)
6. Speech troubles.
7. Systemic Review.
• CVS
• Respiratory
8. Hypothalamic Manifestations
3. Other systems (Systemic Review) e.g. CVS and

v Resp.
4. Investigation & treatment (related diseases)
patient investigated by CT, MRI, MRI with diffusion
and treated by clexan etc ...
5. DM&HTN
Past history:
• Similar attacks
• Chronic diseases as D.M., hypertension and T.B.
• Diabetes Mellitus:
• Hypertension:
• T.B.:
• Hepatitis
• D.V.T
• Trauma.
• Major operations. (complications of general or spi-
nal anesthesia).
• blood transfusion
• Fevers
• Drug allergy and intake
Family history:
Similar condition
\.._
•
AllAM'S CLINICAL EXAMINATION NEUROLOGY:
PARAPLEGIA
■ •ffl@iJM•i Paralysis or weakness of both lower limbs below the level of CS,
It may be due to: - . - tract lesion (spastic).

fl
L-.. LMNL (flaccid).
Causes of flaccid paraplegia:
• Sho.ck stage. • Severe myopathy.
• Cauda equina lesion. • Subacute combined degeneration.
• Bilateral ..oliom,itis. • Ferdrich's ataxia.
E·HiitlitENM+=
Paralysis or weakness of both lower limbs due to bilateral pyramidal tract lesion most commonly in the spinal cord
(Spinal Paraplegia) and less commonly in brain stem or cerebral parasagital region (Cerebral Paraplesia)
Causes of spastic paraplegia
Spastic
Spinal Paraplegia Brain Stem Cortical

• Syringobulbia 1. Traumatic: Subdural he
• Brain stem Tumors 2. Vascular: Sup. sagittal sinus
thrombosis.
3. Inflammatory: encephalitis. ,... _
4. Neoplastic: Parasagittal meningioma __.
5. Degenerative: Cerebral palsy - •
,....
Focal Causes Systemic Causes Dissiminated
I • Heridofamilia: • DS
I • Heradatory Spastic Paraplegia • DEM
'-,/
lnflama~on Compression Vascular (HSP)
• Heradatory Ataxias: Friedreich's
• Transverse Myelitis Ant. Spinal A.
and marie's
• Myelomeningitis Occlusion
• Symptomatic:
'-..,/
• Pellagera
• subacute compined
degeneration {SACO)
lntramedullary Extramedullary
• Idiopathic:
• Syringomyelia I Motor Neuron Disease (MND)
• Glioma
Vertebral Meningea·I
•
•
Fracture
Dislocation
• Epidural: leukemia deposits
• Dural: Meningeoma ---
• Disc Prolapse • lntradural: neurofibroma
• Spondylosis
• Neoplasms "'-./
Clinical Picture: Clinical Picture of Focal Parapledia
At the level Below the level

I
l l
Vertebral Radicular in extra Motor Sensory Sphincteric
med. Compression Only.
ALLAM'S CLINICAL EXAM INATION NEUROLOGY:
At the level of the lesion: paraplegia inflexion :

• Vertebral manifestation {in verteberal causes) : progression of the lesion to the extra pyramidal
Localized pain or tenderness fibers; the hyper tonia will be in flexors more than
Localized sewlling extensors
• Radlcular manifestation (in extrapyram idal this last stage maybe associated with the mass
compression only) reflex: spontaneous urination and defecation on
• Posterior root affection scratching the inner side of the thigh
girdle pain then hypothesia and anasthesia of the Pierre Marie foix :
affected dermatome Test is done by firm passive planter flexing of the toes
• Anterior root affection: and foot, this will result in spontaneous "withdrawal
localized LMNL in the muscles supplied by the reflex" i.e. spontaneous flexion of the hip, knee and
affected root dorsiflexion of the ankle if the paraplegia is passing
from extension to flexion.
N.B. 2. sensory manifestation:
• in para plegia below cervical segments the • extra medullary compression:
LMNL Is not clinicaly detected sensory level below which all types of sensation are
• in lesion above the cervical region, ther's lost with early affection of saddle shaped area (s2,3&4)
quadriplegia with evidence of LMNL in the UL • intra medullary compression:
jacket sensory loss of dissociated nature i.e. pain and
below the level of the lesion:
temprature are lost but touch and deep sensation are
1. Motor manifestation:
• acute causes e.g. inflammatory, vascular or trumatic
perserved with sacral spare
the paraplegia passes by 2 stages: 3. sphincteric manifestation:
1. shock stage (flacid paralysis) immediatly folowing • in acute lesion: retention of urine in shock stage
the cause and last for 2 : 6 weeks followed by percipitancy of urine
2. recovery stage (spastic paralysis) • in gradual lesion: perceptancy of urine which may
• gradual causes e.g. neoplastic terminate with automatic bladder
the shock stage is abscent. these changes start early in intra medullary and late in
paraplegia in extention: extra medullary
the weakness affects distal more than proximal ·and
flexores (pro gravity) more than extensors (anti gravity)
the hypertonia affects extensors (anti gravity) more
than flexors (pro gravity)
GhJ•\•fUM Aetiological, level, stage and organic or hysterical

Aetiological: Aetiological
j 1
spinal cereberal brain stem
rare ...
cereberal or brain stem manifestation
Focal systemic dissiminated

MS
HSP
SACO
inflammation Vascular MND
Tran sverse Myelitis Ant. Spinal A. Occlusion
Compression
l
Extra medullary intra medullary
disc prolapse Syringomyelia
pott's disease
•
I tra medullary CO":!P!es~l~R -~~ ~ -=---- -- . Itrtr_a,!_ll~dullary compression

Painless onset. Painful (girdle pain).
Symmetrical. _ _ _ _ _ _ _ _ _ A~ymmetrical.
Jacket sensory loss (Dissociated ) Sensory level ( usually asoociated).
Early sphincteric affection. Late or no sphincteric affection.
Late or no affection of saddle shaped area. Early affection of saddle shaped area.
History of girdle pain. Plain X-ray.

The sensory level. Myelography.
The abdominal reflex (T6 - T12). C.T. Scan.
Beevor's sign (TlO). MRI.
From scar or tenderness at the back (vertebral column).
Stage:
• Acute:
• Flaccidity (shock stage) with retention of urine.
• Spasticity (recovery stage)
• Gradual: Spasticity from the start.
Organic or Hysterical:
By:
1. if sure signs oft:. tract lesion are present. (Organic)
2. by hoover test (see later).
Hoover test: OOW!J' S test

• Hoover's sign is a motor sign . l
• The patient is placed in a supine/recumbent position. The examiner places his hand
under the patient's heel.
• The sign based on the principle of synergistic contraction of muscle groups.
Involuntary extension of the "paralysed" leg occurs when flexing the contralateral leg
against resistance.
• To perform the test, the examiner should hold one hand under the heel of the
"normal" limb and ask the patient to flex the contralateral hip against resistance,
asking the patient to keep the weak leg straight while raising it.
• If the patient is making an honest effort, the examiner should feel the "normal"
limb's heel extending (pushing down) against his or her hand as the patient tries to flex (raise) the "weak" leg's
hip. Feeling this would indicate an organic cause of the paresis.
• If the examiner does not feel the "normal" leg's heel pushing down as the patient flexes the hip of the "weak"
limb, then this suggests functional weakness (sometimes called "conversion disorder"), i.e. that effort is not
being transmitted to either leg.
•
HEMIPLEGIA
--......_
i-fflfflNM,N
Paralysis of one side of the body due to 6 tract lesion at any point from the cerebral cortex down to the 5th cervical
segment (origin of brachia! plexus).
kMi41
1. vascular causes:
a. thrombosis: Virchow's triadE vessel wall disease (Cerebral atherosclerosis, vasculitis)
increased blood viscosity (Polycythem ia, Thrombocytosis )
stagnant circulation (H eart Failure, Systemic hypotension)
b. embolism: the sources from heart:
I •
•
•
from
•
•
mitral stenosis with AF
sub acute bacterial endocarditis on the airtic or mitral valve
mural thrombosis after Ml
distal vessels
Arterial: detatched atheromatous plaque
venous: DVT with ASD or VSD
c. heamorrhage: lntracereberal : most common cause is lenticulo striate A
E Subarachenoid
Subdural
2. infective causes: encephalitis and brain abscess
3. neoplastc causes: meningioma and glioma ► N.B.
the causes of intracranial hge: HAT HAT
4. demyelinating causes: MS
1. hypertention: 4. anticoagulants
5. teumatic: cereberal laceration
intracerebral 5. trauma
6. conginital : cereberal palsy 2. haemorrhagic blood 6. tumor
7. hysterical diseases
3. aneurysm rupture:
Clinical Picture: subarachenoid hge
Diagnostic approach: Aetiological, level, stage and organic or hysterical.

UMNL at one side involving UL & LL with Circumduction Gait
level:
Level
cereberal brainstem spinal

Crossed hemiplegia • lpsilateral hemiplegia .
• Hemiplegia (UMNL) on the • lpsilateral deep sensation.
opposite of the lesion • Contralateral superficial
• Cranial nerve paralysis sensory affection.
(LMNL) on the same side of
the lesion
Contralateral hemiplegia.
±Coma Contralateral hemianaesthesia.
± convulsions Contralateral cranial nerves affection
± cortical sensory loss (lower facial - hypoglossal - spinal
± aphasia & agraphia part of accessory).
•
ALLAM'S CLINICAL EXAMINATION NEUROLOGY:
....._,;
Site of the lesion
· ICord.
1 . S pma { DS Wound
stab '-.-/
the lesion is on one side of the cord & is situated between Cl & CS segments, it is caused by: Disk prolapse
resulting in ( Brown Sequard Syndrome) Characterised by: tumor
1. at the level of the lesion: 2. Below the level of the lesion:
• lpsilateral Localized LMNL of the Muscles supplied by • lpsilateral Hemiplegia.
affected segments. • lpsilateral deep sensory loss and fine touch.
• lpsilateral loss of all sensations in the area supplied by • Contra lateral superficial sensory loss for pain,
the dorsal roots of the affected segments. Temperature and simple touch, so touch diminishes
on both sides :)
2. Brain Stem.
the lesion is on one side of the brain stem resulting in the picture of crossed hemiplegia Characterised by:
-
1. Hemiplegia on the opposite side of the lesion.
2. Cranial nerve paralysis of LMN nature on the same side of the lesion.
the nerves affected depend on the site of the lesion: ' -"
• Mid-Brain Lesion • Pontine Lesion
Weber's Syndrome Millard Gubler Syndrome
• Hemiplegia (opposite side) • Hemiplegia (opposite side)
• 3rd Cranial nerve paralysis ( same side) • 6th & 7th Cranial nerve paralysis ( same side)
Benedict's Syndrome Faville Syndrome
• Hemiplegia (opposite side) • Hemiplegia (opposite side)
• 3rd Cranial nerve paralysis ( same side) • loss of Conjugate deviation of the eyes ( same side)
• Hemiataxia (opposite side) due to lesion in the medial Long. bundle (MLB).
(intention Tremors ) due to affection of the Red Nucleus. ...._,,,
• Medullarv Lesion
Avellis Syndrome
• Hemiplegia (opposite side)
• 9th & 10th Cranial nerve paralysis ( same side) '-.../
Jackson's Syndrome
• Hemiplegia (opposite side)
• 11th & 12th Cranial nerve paralysis ( same side)
3. Cerebral
the lesion in the cerebrql hemisphere results in hemiplegia asociated with UMN facial and hypoglossal paralysis '-.../
on the opposite side of the lesion, but without any cranial nerve paralysis on the same side of the lesion.
Cortical : Characterised by one or more of the following:
• Coma if the lesion is extensive
• Convulsions ( if the lesion is irritative)
• Contralateral cortical sensory loss ( if parietal lobe is involved)
• Aphasia & agraphia ( if the lesion is in the dominant hemisphere)
• Homonymous hemianopia ( if the lesion involves the parieto-occipital region )
Subcorical : it is indistinguishable from cortical hemiple- Capsular: Characterised by the following: ...._,,,
gia except that the paralysis is more extensive. • Complete hemiplegia associated with UMN facial and
hypoglossal paralysis ( on opposite side) '-"'
• Hemihyposthesia ( on opposite side)
• Hemianopia may occur
• No Convulsions, aphasia or coma .
Stage: organic or hysterical:
• Acute: Organic: if sure signs of /1 tract lesion are present.
• Flaccidity {shock stage) with no affection of Uri Hystrical: by Hoover test (see page 178)
Bladder.
• Spasticity (recovery stage)
• Gradual:
Spasticity from the start.
investigations & treatment See Theoretical Book
• '--"'
ALLAM 'S CLINICAL EXAMINATION ► NEUROLOGY:
DIABETIC PERIPHERAL NEUROPATHY

Sheet of Diabetic patient:
► N.B.
History:
Ne.urologkal complication of OM
• History of D.M. since ......
• Comas.
• Manifested by .. ..
• Argyll Robertson's pupil.
• Investigated by .... .
• Diabetic lateral sclerosis.
• Controlled by .... .
• P.C. lesion .
• Complicated by .. ..
• P.N.
Examination:
1. General:
• Head: eye (any disease), teeth (lose of teeth).
• Foot: diabetic foot. ► N.B.
• Blood pressure: Charcot's joint:
• Hypertension. Lost deep sensation leads to destruction of artic-
• Postural hypotension (so, B.P. should be measured ular cartilage which lead to increasing range of
twice, during standing and in flat position). movement.
• Pulse: conditions of the blood vessels.
2. Skin examination in a diabetic patient: 3. Heart examination in a diabetic patient:
• Increase incidence of infection. • lschemic heart disease.
• Trophic changes "neuropathic manifestations" . • Cardiomyopathy.
• Vascular manifestations "ischemia".
4. Abdominal examination in a diabetic patient:
• Effect of treatment: insulin injection "lipo dystrophy". • Liver:
fatty.
• Specific: • Kidney: Kemilestile Wilson's syndrome "diabetic
• Necroboiesis lipodica diabeticorum (NPLD). nephropathy".
• Bullus diabeticorum.
5. Chest examination in a diabetic patient:
Increase infections particularly T.B.
Clinical picture of peripheral neuropathy:
Motor, sensory and autonomic:

summarized in the next table
• Wasting. Distribution: Gloves & stocks • Early parasympathetic loss: fixed sinus
• Trophic changes. tachycardia.
• Irritation • Vibration.
• Hypotonia. ECG: absent respiratory sinus rhythm .
• Pain. • Position.
• Hyporeflexia . • late sympathetic loss: postural hypotension,
• Parasthesia. • Movement.
• difference should be more than 20 mm Hg in
Muscle.
Distribution: systole & more than 10 mm Hg in diastole.
• Destruction • Nerve.
(bilateral/ symmetrical) If no postural hypotension: B.P. while lying
• Hyposthesia.
• L.Ls. > U.Ls. equal to it while standing.
• Anaesthesia.
• Distal > proximal. Genital: impotence.
(Gloves& stockes)
• Extensor > flexor. GIT:
• ±adductor> abductor Gastroparesis diabeticorum: " delayed
emptying : dyspepsia, vomiting & distention"
Effect: Diabetic enteropathy " change in bowel
• Lost ankle , preserved habit".
knee. Sweat:
• High stapping gait • Anhydrosis.
• Wrist, feet drop • Gustatory sweating.
Gait:
Cranial nerves
• High steppage (P.N.) .
3rd, 5th, 7th & 8th may be affected .
• Stamping gait (sensory ataxia) .
•
Al_LAM'S CLINICAL EXAMINATION ► NEUROLOGY:
IMPORTANT NOTES
Causes of Thickened Nerves:

• Acromegaly • Neurofibroma
• Interstitial Hypertrophic • Refsum ' s Neuropathy
P.N. • Leprotic Neuropathy
• Myxedema
• Amyloidosis.
Causes of Sensory P.N: Causes of Motor P.N:
1. Diabetic neuropathy 1. Lead neuropathy
2. Alcoholic neuropathy 2. Diphtheritic neuropathy
3. Vitamin deficiency neuropathy 3. Acute infective polyneuritis.
4. Arsenic neuropathy 4. Porphyria.
5. Leprotic neuropathy
Causes of Lost Ankle with Preserved Knee Causes of Absent Ankle. Exaggerated Knee reflex
1. Epiconus lesion 1.Subacute Combined Degeneration.
2. Cauda equina lesion affecting 51 root. 2. Pellagra (Lateral sclerosis+ PN .)
3. Peripheral neuropathy 3. Friedreich's ataxia.
4. Subacute combined degeneration
5. Friedreich's ataxia .
CAUDA EQUINA
Defenition:
The collection of lumbo-sacral roots in the lower part of the spinal canal is known anatomically as the Cauda Equina .
The lowermost three segments of the spinal cord (53,4,5) are known anatomically as the Con us Medullaris. The above
four segments (L4,5 51,2) are known anatomically as the Epiconus.
Causes of Cauda Eqina Lesion
,,
1. Congenital: Spina bifida . • Vertebral:
2. Traumatic: • Primary: osteoma, haemangioma
• fracture dislocation of the lumbar vertebrae. • Secondary: metastatic.
• Post traumatic disc prolapse • Meningeal: meningioma
3. Inflammatory: Pott's disease of the lumbar vertebrae. • Radicular: neurofibroma.
4. Neoplastic: 5. Degenerative: Lumbar Spondylosis.
Clinical Picture:
I. Motor Manifestation: Ill. Autonomic Manifestations:
• There is motor weakness or paralysis in one or both 1. Sphincteric manifestations are usually late unless the
lower limbs. lesion is bilateral and affects mainly 52,34 roots (roots
• The weakness or paralysis is of a L.M .N. nature i.e. it of innervation of the bladder). The sphincteric distur-
is associated with wasting,hypotonia and hyporetlexia . bances are in the form of:
• The motor weakness or paralysis will affect the muscles • Sensory atonic bladder.
which are supplied by the affected root (See before) • Motor atonic bladder or
II. Sensory Manifestations: • Autonomic bladder.
• Cauda equina lesions usually have a painful onset. The 2. Vasomotor changes and trophic ulcers may occur in
pain is radicular and is referred to the lower limbs the L.L
• either along the femoral distribution when the lesion
affects the upper lumbar roots or along the sciatic
► N.B.
distribution when the lesion affects the lower
The cauda equlna consists of nerve roots while the
• lumbar. and sacral roots. Later on there is hyposthesia
conus and epiconus forrn part of the spinal cord.
or anaesthesia in the dermatome supplied by the
affected root.
• The sensory impairment affects both superficial and
deep sensations.
-
•
I. Motor Manifestation:
Root Action Muscle
L2 Flexor of the hip lleopsoas.
L3 Extensor of the knee Quadriceps
~-- ---
L4 Dorsiflexion of the ankle Anterior tibial group
LS i Dorsiflexion of the toes Anterior tibial group & glutei
-- - --
S1 Plantar flexion of the ankle and toes Calf muscles & glutei
S2. Flexor of the knee Hamstrings
53,4,5 Anal contracti0n Anal and perianal muscles
► N.B.
I
LS
CUnical Picture Of Canus Medullaris Lesion : (S34.5
Segment) l3 l4
1. Early urinary incontinence (autonomic bladder)
and faecal incontinence.
2. Impotence.
3. Impairment of sensation in the saddle-shaped
1\
area, (usually of a dissociated nature)
4. No motor or sensory disability in the lower
limbs. 1
S 3,4,5
l
52
l
51
II. Sensory Manifestations:
Ll Upper 1/3 front of thigh.

L2 Middle 1/3 front of thigh.
L3 Lower 1/3 front thigh.
L4 Anterolateral aspect of thigh, front of knee, anteromedial aspect of leg, medial aspect of foot & big
-
toe.
LS Lateral aspect of thigh, lateral aspect of leg, middle 1/3 of dorsum of foot & middle 3 toes.
-
51 Posterolateral aspect of thigh & leg, lateral 1/3 of dorsum of foot & little toe.
52 Posterior aspect of thigh, leg & sole of the foot.
S3,4,5 Anal, perianal & gluteal region (saddle shaped area) in concentric manner.
► N.B.
CinicaJ Picture Of Epiconus Lesion~ (L4.5 $1,2 Segments):
1. Weakness or paralysis in the lower limbs, in the muscles supplied by L4s and 51,2
2. (dorsiflexors and plantar-flexors of the ankle and toes, the flexors of the knee and the
3. extensors of the hip).
4. The ankle reflex is absent while the knee reflex is intact.
5. Sensory loss from L4 to 52 segment (usually of a dissociated nature).
6. Bladder disturbances may occur in the form of precipitancy
•
SUBACUTE COMBINED DEGENERATIONl S.C.D.)

~
Components : iii'hii
1. pyramidal tract lesion. 1. vitamin B12 (mainly).
2. Posterior column lesion. 2. D.M.
3. P.N.
► N.B.
Subacute means the onset within days.
Combined means affection of different parts as /J. tract, P.C. and P.N.
S.C.D. + cerebellar lesion= Friedreich's ataxia.
S.C.D. - P.C. = pellagra
ATAXIA
Defenition:
Inca-ordination of voluntary motor activity in absence of motor weakness± disequilibrium .
.._,;
ifMJM 1. Cerebellar.
2. Sensory.
3. Mixed ataxia =cerebellar+ sensory
4. Vestibular.
5. Hysterical.
► N.B.
cerebellum is divided into:
1. archi cerebllum (equilibrium)
2. paleo cerebellum (not in human)
3. neo cerebellum (coorfination and increase tone)
So, in archi-cerebellar lesion (Friedreich's ataxia) the main complaint is the drunken gait
And in nee-cerebellar lesion (Marie's ataxia) the main compliant is inco-ordination.
In any cerebellar lesion there is hypotonia & hyper-relflexia.
Causes of cerebellar ataxia: I Friedreich's ataxia"• _ IV_l_arie's:ataxia
• Heredofamilial: Components Archi-cerebellar lesion. Nee-cerebellar lesion.

bilateral & symmetrical gradual /J. tract lesion. /J. tract lesion.
onset & progressive course as P.N. lesion.
Friedreich 's & Marie's ataxia. P.C. lesion.
• Symptomatic: 2ry to Tone & reflexes decreased increased
• Infection (encephalitis). S):>eech Staccato or scanning Slurred, staccato or sca nning.
• Vascular.
---
Gait Drunken gait Scissoring or drunken gait
• Alcohol or barbiturates intake. ------ =--- ~
Ataxia Mixed Pure cerebellar
• Tumors. - -- ---
Planter reflex Positive Babiniski Positive Babiniski
• D.S. (the commonest cause) .
• Idiopathic: in old age. Association Pes-cavus. No
Heart lesion .
D.M. (40%) .
.....,/
0
Clinical picture:
Archi-cerebellar lesion:
• Staggering gait ( wide based) • Swaying on standing.
Nee-cerebellar lesion:
• Nystagmus (Chr.). • Lower limb:
• Head nodding (D.D.). • Unilateral: deviation of the body toward the af-
• Trunk: titubation. fected side.
• Upper limb: • Bilateral: zigzag gait.
• Intension tremors.
• Dysmetry.
• Decomposition of movement.
Specific co-ordination test
Fingers:
• Finger to nose test.
• Finger to finger test.
• Finger to doctor's finger test.
Hand:
• Adiadokokinesia.
• Rebound "Holm's test".
• Buttoning and unbuttoning test.
Leg:
• Heal to knee test.
• Heal to doctor's finger test.
• Foot to foot "straight ling" :
tendon gait (the earliest sign).
► N.B.
D.D. of the head nodding
• A.R. (with pulse (yes .. yes )
• Parkinsonism (static). ( No .. No )
• Ataxia (kinetic).
► N.B.
Neurological diseases with intact sensation: In rebound test doctors should remove his watch
(Puerly Motor Neurological Diseases ) and patient sould remove his glasses to avoid pa-
• Muscles disease (myopathy, myotonia, M.G., tient injury.
myositis)
• M.N.D.
• Marie's ataxia. C)G
• Parkinsonism.
• Poliomyelitis.
• Chorea.
• H.S.P.
•
ALLAM'S CLIN ICAL EXAMINATION NEUf{OLOGY:
SENSORY ATAXIA
Defenition:
It is ataxia due to loss of the proprioceptive sensa -
tions at any point in their pathway.
CiiM4J
1. Peipheral nerve: PN specially Diabetic, alcoholic.
2. Post root: Tabes Dorsalis.
3. Post Column : SCD.
4. Medial Lemniscus : brain stem lesions.
5. Thalamus : Thalamic Syndrome.
6. Cortical sensory area: Parietal lobe lesions.
Clinical Picture:
1. Kinetic tremors ( tested by Finger to nose, Figer to
Finger only on Closure of the eyes)
2. Rhomberg's test: when the patient stands with his
feet close together & his eyes closed, his body sways
& he may fall if not supported.
3. Stamping Gait: heavy strike of the ground on walking
due to lost deep sensation.
4. Deep sensory loss.
5. Hypotonia & hyporeflexia.
MYOPATHY
Defenition:
Group of muscule diseases affecting skletal muscles characterized by gradual progressive degeneration of the
muscles, when the the degenerative process is genitcally determind it's termed progrwssive muscular dystrophy.
Clinical Picture:
History:
Complaint: inability to stand from sitting position.
Family history: positive in his male brothers as it is X-linked disease (females only carrier).
Past history: ± corticosteroids.
Symptoms:
I. Clumsy gait.
2. Inability to climb the stairs.
3. Protuberant abdomen
4. Weakness and wasting of certain muscles (shoulder and '--"
pelvic girdles and trunk)
Examination:
LMNL: weakness, hypotonia (frog sign), hyporeflexia and wasting (except in Duchenne = psuedo hypertrophy) taking
the following distribution:
• bilateral and symetrical
• proximal more than distal (pelvic and shoulder girdle)
• with sparing of the following muscles:
1- C, sternomastold.
2- 0 aplzys "upper ftbers",
3- 0 Pectoralls major "clavlcular head".
e
► N.B.
No sensory affection in myopathy
Effects of muscle weakness in myopathy: special type of myopathy: facioscapulohumoral
1. Abdominal muscles: pot belly abdomen. type i.e. weakness of facial muscles
2. Compensatory loardosis due to weak extensors
(disappear with sitting as it is a compensatory).
3. Talipes equinus with hyperkeratosis due to weak
extensors.
4. Gait: wide base+ waddling gait due weak glutei.
5. Gower sign.
Examination of muscles of the shoulder girdle:

1. Abductors:
0 - 15°: supra spinatus.
15° - 90°: deltoid.
> 90°: trapizus.
2. Sternal head of pectoralis major: Ask the patient to put his hands on his waist and palpate anterior fold of axilla
3. Lattismus dorsi: Palpate the posterior fold of axilla & ask the patient to put his hands on his waist and cough
4. rhomboidus: Ask the patient to push backward against resistance
5. winging of scapula: Ask the patient to push the wall and observe winging of scapula:
• I\ Serratus anterior.
• V Trapizus.
6. clavicular head of pectoralis maior: Ask the patient to hold both hands against each other (see the pie) : palpate
contraction of clavicular head of pectoralis major.
7. Sternomastoid and upper fibers of trapizus as cranial nerves
•
ALLAM'S CLINICAL EXAMI NATION ► NEUROL,OGY:
Muscle Diseases
Myositis Myotonia Muscle dystrophy Myasthenia Gravis

Toxic manifestation. • Positive myotonic i.e. My;opathy Descending mannner
Tender muscle. phenomenon. Diurnal variation.
'--"
• Sternomastoid must be
affected.
Shoulder Girdle Pelvic Girdle Others
Usually atrophic type I • Occular type.

1. Scapulo humeral myopathy. • Occulo - pharyngeal type.
2. Facioscapulohumeral myopathy. • Atrophic • pseudo hypertrophic. • Distal Gowers
rare Usually affect
(Ca lf muscles - deltoid muscle )
I
Ouchenne Bal<er
Age 1st decade. 2nd decade.
Course Very progressive & Benign.
end fatally.
Association Heart and skeletal. No.
Treatment: '--"
Investigations (very important) :
• Serum creatin and creatinin. • high glycin in diet.
• Serum CPK (isozyme M.M.). • Physiotherapy.
• E.M.G. • Gene therapy.
• Muscles biopsy.
.._,
Causes of Pseudo-Hypertro phy of Muscles Causes of Pes Cavus
1. Duchenne Myopathy 4. Acromegaly. 1. Friedreich 's ataxia. 3. Peroneal Muscle atrophy.
2. Becker Myopathy. 5. Myxoedema. 2. Duchenne Myopathy. 4. Syringomyelia. ',..J
3. Myotonia Congenita.
-...__..,
'-../
A
• '--"
ALLAM 'S CLIN ICAL EXAMl l'l! ATl'ON ► NEUROLOGY:
MULTIPLE SCLEROSIS (M.S.)

A demyelinating disease in which the insulating covers of nerve cells in the brain and spinal cord are damaged.
if)·til Aetiology:
1. Remittent relapsing. • unknown but may be:
2. Primary progressive. • Auto-immune: antigen sheath Ab in C.S.F.
3. Secondary progressive. • Infection: viral, Chlamydia.
4. Progressive relapsing. Precipitating factors:
• Trauma. • Infection.
Clinical Picture: (MSC, MSC) • Operations. • Psychic trauma.
• Stress.
1-e M entality .... Euphoria or depression.
2-0 Speech .... Slurred. staccato or Scanning.
3-G Cranial nerves .... 2.3.7.8 plus MLB leads to ophthalmoplegia internuclearis.
Optic nueritis is a common Presentation.
4-e M otor .... Pyramidal tract lesion. Mono > para > hemi > quadriplegia.
with signs of UMNL (Hypertonia, Hyperreflexia, +ve Babinski).
vAcute onset but spastic from the start.
s-0 Sensory .... P.C. (L.Hermitt's sign). - - - - on flexion of the head there is sudden
elctric like sensation radiating to the back
6-G Cerebellar ..... ataxia. and limbs due to post. column involvement
in the cervical region.
7- Autonomic Disturbance: Precipitancy & Impotence.
• Criteria of M.S. with good prognosis:
Female, young age, remittent relapsing type.
Treatment:
Investigations:
During attack:
• MRI. • Methyl prednisolone 1 gm vial/ day for 3 - 5 days.
• C.S.F. In between attacks:
• Visual evoked response. • B interferon.
• Vitamin B.
• Physiotherapy.
PARKINSON ISM (SHAKING PALSY)
Defenition
It is a condition in which there are static regular rhythmic tremors associated with hypertonia of the muscles of the
body and bradykinesia.
Causes
1. Idiopathic: Parkinson's disease (paralysis agitans).
• The cause is unknown
• There is degeneration of the pigmented cells (neuromelanin) of the substantia nigra, which becomes pale. The
basal ganglia are also affected. This degeneration leads to deficiency of dopamine in the brain
• The age of onset is above 50 years.
• Both sexes are equally affected (tremors> Rigidity, with gradual onset & progressive course).
2. Symptomatic: There is a known cause which leads to deficiency of dopamine in the brain, but without structural
changes in the substantia nigra or basal ganglia.
• Inflammatory: Encephalitis. (Acute onset, regressive course, Tremors= Rigidity, acute onset and regressive course)
• Vascular: Cerebral atherosclerosis (with IHD > 40 yrs, Rigidity> Tremors) with remission and exacerbation (due to
opening of collaterals)
• Toxic: (Co & Mn poisoning, Rauwolfia drugs (Reserpine), Phenothiazines (Major tranquilisers)
• Neoplastic: Tumours of the basal ganglia.
• Traumatic: repeated trauma to the head as in boxers .
•
ALLAM'S CLI NICAL EXAMINATION ► NEUROLOGY:
Clinical Picture:
I. Tremors 3. loss of emotional and associative movements:
• Regular, rhythmic and occur at the rate of 4-8/sccond. resulting in:
• They begin unilaterally in the U.L. and spread to all 4 • Immobile face, with frequent blinking (mask face).
limbs • Monotonus speech.
• They give the hand the pill-rolling posture with the • Loss of swinging of the arms during walking.
thumb moving rhythmically back and forward on the
palm. 4. Other clinical manifestations
• Oculo-gyric crisis: sudden spasm of the conjugate
• They increase with emotional stress and fatigue and
movement of the eyes, mainly upwards
disappear during sleep and voluntary movements.
• Greasy face and sialorrhoea .
2. Rigidity & bradykinesia
• Diabetes insipidus.
• Affecting the proximal > distal
• Obesity.
• Affecting more the flexors of the neck, trunk limbs
• Impotence or amenorrh ocar ·- - --.::-::,...---,---::,-,...,..-,-,-,
resulting in the Flexion attitude.
• Glabellar reflex.
• It may be present throughout the act to the same
degree & is then described as lead pipe rigidity;
it may be interrupted by the tremors & is then
described as cog wheel rigidity
• Causing difficulty in starting the act of walking
leading to a slow, shuffling (festinant
• or short steppage) gait with propulsion
CHOREA
Defenition
Involuntary, static, irregular, dysrhythmic, sudden, jerky, pseudo purposive movement of any part of the body due to
lesion in caudate nucleus.
Causes '-./
1. H.F.: usually associated with Friedrich's ataxia athetotic movement.

2. Symptomatic:
• Auto immune: rheumatic chorea with other Rh. Criteria but never with arthritis, it lasts within 3 - 6 months
from its onset.
• Infective: post encephalitis.
• With pregnancy: chorea gravidarum.
3. Idiopathic: in old age.
Clinical Picture:
• Clinical picture of the associated disease as ataxia, asthetosis or rheumatic fever.
• choreic movement: tongue and facial muscles 1' with emotions and -J, with sleep.
• Hypotonia: specific tests for chorea.
• When the patient stretches his arms, there is flexion at the wrist and over-extension of meta carpo phalangeal
joint (MCP) and I.P. joints with fanning of the fingers "Scaphoid shaped hand".
• When the patient elevates and supinates his arms, they deviate downwards and laterally and become pronated. _,
• Pendular knee jerk (in dangling position).
• Emotional instability: a sudden laughing or crying is
observed in most cases.
• Speech: choreic speech.
Treatment:
• Phenothiazines.
• Haloperidol.
e
All AM'S CLIN ICAL EXAMINATION ► NEUROLOGY:
NEUROLOGY (LONG CASE)

► 1. History ► 2. General Examination
Personal History
• The patient with an average general condition, fully
Mr........... , 70 years old, driver, married and has four conscious, oriented by time, place and persons, with
children, the youngest is 26 year old, from Hadayik good mood and memory, co-operative with an average
Elqoba. He is a heavy smoker and right handed. intelligency.
G·l,,Hffli,ii • The patient with an average built for his age, he lies
comfortable in bed, no pallor, jaundice or cyanosis,
Patient is complaining of: weakness in the left upper &
no characteristic facies of medical important.
lower limbs of 24 years duration.
• Respiratory rate: 17 / min, pulse: 85 beats / min.
Present History regular, equal in both sides, temperature: 37.70 C.
blood pressure:140 / 90 mmHg (hypertension).
The condition started 24 years ago by sudden onset and
regressive course of weakness of the left upper and lower • Head examination:
limbs, the muscles were flaccid for 4 weeks then became no ptosis, oedema or subconjunctival hemorrhage,
stiff with weakness more distal than proximal, abductors there is deviation of mouth to right side & deviation
than adductors, flexors than extensors in lower limbs and of tongue to left side.
extensors than flexors in upper limb, there is no wasting, Neck examination: no congested neck veins, regular
fasciculation or trophic changes. carotid pulsation and no lymph nodes enlargement.
There is no involuntary movements or inco-ordination. Upper limbs: there is no tremors, deformities or
From the onset of the disease, there is accumulation of clubbig.
food in left side, deviation of mouth to right side, • Lower limb: there is no oedema or clubbing.
deviation of tongue to left side, no drippling of saliva. • Cardiovascular examination: elevated BP, signs of left
ventricular enlargement with heavig apex,
There is dropping of left shoulder and no other cranial
accentuated 1st and 2nd heart sounds with ejection
nerves affection. There is speech troubles with the onset of
click. (systemic hypertension).
the disease, but improved after 2 months.
• No abnormality detected in other systems.
There is hemihyposthesia in left side of the body and upper
& lower parts of the face. The patient feels as he is walking
► 2. Neurological Examination
on a cotton on left side. The patient denied that there is no
sphincteric troubles.
1. Speech:
There is no hypothalamic manifestations, no symptoms of no speech troubles.
increase ICT, no coma, no convulsion, no fever.
The patient used to suffer manifestations of systemic 2. cranial nerves:
hypertension which is controlled by ~ - blockers. There is I : no abnormality detected.
no other system affection. II : visual acuity & visual field: no abnormality detected.
intact light and accommodation reflex.
Past History
III, IV &VI:
Hypertension controlled by ~ - blockers, no other diseases • inspection: no ptosis, no squint, pupil: regular, round,
Family History reactive to light & accommodation, equal in both
sides. No nystagmus.
Family history is irrelevant. • power: the patient can move each eye separately and
MFMIHWI both eyes together in all directions. No abnormality
detected.
A case of organic spastic left side capsular hemiplegia due
V:
to thrombosis secondary to hypertension (atherosclerosis).
.inspection : no hollowness above or below zygoma .
power : muscles of mastication & pterygoids acting
normally.
reflexes : absent jaw reflex & intact corneal reflex.
• sensation: loss of sensation in left half of the face
(upper & lower parts+ area supply by C2).
e
ALLAM'S OJ !CAL EXAMINATION ► NEUROLOGY:
VII:
• inspection: left side : intact wrinkles of forehead,
absent nasolabial fold, deviation of mouth to right
side & no drippling of saliva. '---'
• power: upper part normal, patient can elevate his eye

brow & close his eyes.
• Lower part paralysed (weak orbicularis orison smil-
ing) indicated that contralateral lower facial nerve
affection.
VIII : no abnormality detected.
IX & X : normal uvula elvation intact gag & pharyngeal
reflex.
Xl (Spinal part of accessory):
• inspection: dropping ofleft shoulder.
• power: the patient can't elevate his left shoulder
against resistance.
Xll:
tongue: no wasting & fasciculation.
The tongue deviated to left side.
There is contralateral cranial nerves affection (lower
facial - hypoglossal - spinal part of accessory).
3. motor sm em
• Inspection: there is semi-flexed left upper limb and
hyper extended left lower limb, no muscles wasting,
no deformity, no trophic changes.
• Palpation: there is hypertonia ofleft side of the body
clasp knife type affects antigravity more than
progravity muscles.
• Percussion: there is no fasciculation or myotonia.
• Power: there is paralysis (weakness) ofleft side of the
body affects progravity more than antigravity and
distal more than proximal muscles.
4. Reflexes
• Planter reflex: positive Babinski sign.
• Abdominal reflex: lost on left side.
• Exaggerated deep reflexes in left upper and lower
limbs.
• Pathological reflexes appear on left side: (Hoffman -
wartenburg - finger reflex - patellar reflex - adductor
reflex).
• Loss of superficial reflexes in left side of the body.
• Ankle, patellar & wrist clonus are presented
5. Sensations
There is hemihypothesia on the left side of the body, loss
of deep sensation on left side & normal cortical sensation
on right side (not examined on left side).
6.Back
there is no scars, deformity or tenderness.
7. Gait
the patient has left circumduction gait. (Hemiplegia gait)
•
ALLAM'S CLINICAL EXAMINATION ► RHEUMATOLOGY:
RHUMATOLOGY INTRODUCTION
► Important terms:
Arthralgia: Bursitis:
Pain arising in joints without signs of inflamation ( ie. inflamation of bursa (with Rhd . A.)
No limitation of movement). Enthesopathy:
Arthritis: inflamation at points of muscle & tendon insertion
Joint with redness, hottness, tenderness, swelling & (in sero - ve Arthritis).
limitation of movement . Myositis:
Mono arthritis: inflamatory disease of the muscle.
One joint inflamation as Acute Gouty Arthritis. Synovitis:
Oligo (paucilarthritis: Synovial joint inflamation.
2- 4 joints inflamation as Psoriatic Arthritis. Teno Synovitis:
Poly arthritis: Tendon sheath inflamation.
affection of more than 4 joints As Rheumatoid Centripetal arthritis:
Arthritis. polyarthritis starts at peripheral small joints
(inerpharyngeal, metacarpopharyngeal or wrist) then
spreads proximally to involve a larger joint (knee, hip
or axial) e.g. Rh. A.
Centrifugal arthritis:
s_..._buno polyarthritis starts at a large joint (knee, hip or axial)
then spreads proximally to involve peripheral small
joints (inerpharyngeal, metacarpopharyngeal or wrist)
e.g. Ankylosing spondylitis.
'--'
Types of Joints
synovial cartilaginous fibrous
Venebral
body..._
lntervertebral
disc
freely movable. Slightly movable. No appreciable movement.

Separated by articular cartilage. Contain fibro cartilaginous discs Consists of fibrous tissue or
Lubricated by synovial fluid. that separate the bony surface. cartilage.
Surrounded by a joint capsule e.g.: vertebral discs. No joint cavity
e.g.: knee & shoulder. e.g.: skull sutures.
•
ALLAM 'S CLINICAL EXAMINATION ► RHEUMATOLOGY:
RHEUMATOLOGICAL HISTORY
.........
► Personal History.
► Complaint.
E General.
Articular.
► History of Present Illness: Extra articular.
► Past History.
► Family History.
► Personal History
NAS OMRH
Name
Age I Child: still 's disease and Rheumatoid fever. Occupation .
L Middle aged: gout, RA and SLE . Marital state .
Old : Osteoarthritis. Residence.
Sex --r- Female: SLE and RA. Habit.
L_ Male: Ankylosing Spondylitis Handedness.
&Reiter 's Disease. Menstrual in female.
W·h,MHMI
Painful ha nd joints, hotness, stiffness, limitation of movement ... etc
ffl@§ij■
Prodroma l manifestation: (Fever- Headache - Malaise - anorexia - weight loss)
Nlflffitl
1- Pain. 3- Stiffness . 5- Disability.
2- Swelling. 4- Deformities.
1- Pain
You have to diffrentiate between Articular & Non articular pain . and if articular (Inflammatory or Mechanical) .
Articular Non articu lar

~('-1 ~
-
Tender joint. Tenderness outside joint lines. dk,lA,. JA,
~~_w..l4 ~, 4<>1)4 -1:!.►-!
Disturbed active &
passive movement.
- ________________,,
Passive movement is better than
active. , ~---------- ------
Deformity.
RA
--~~-------
No deformity.
bursitis & tendonitis
► N.B.
Inflammatory Mechanicalcal Poorly localized hand & wrist pain + Numbness+
lncreased_b-'y'--r_e_s_
t. _ _ _ _ln_creased by activity. night
Decreased by activity. Decreased by res_t. pain = carpal tunnel syndrome.
Vertebral pain:
More in morning. More at night.
Upper: rheumatoid arthritis.
Lower: ankylosing spondylitis.
2- Swelling
Causes: ~J..,,;,. ~1 ~.::...i, dk,lA,. JA,
• Joints (signs of infl ammation). \,~., t-'~ ~, ~ r.i,11 JA>
• S.C. nodules. \ .&----- - -- - - - - - -- -- - - '
e
3- Stiffness
(morning stiffness) M.S.
Significant M.S. if >30 min.
But may improve by treatment so history of drugs
intake is important.
4- Deformities
See pictures of deformety in examination.
5- Disability
Functional Diagnosis.
► Extra articular
C.V.S.: Skin:
• Palpitation (A.R). • Alopecia .
• Pain (pericarditis). • Rashes .
• Thromboembol ic manifestation. • Urogenital ulcers .
J
Respiratory system: • Urticaria .
• pain (pleurisy - effusion). • Pigmentation. --._/
• Cough. • Cold peripheries. (Raynaud's).

• Dyspnea (1.P.F.). L.N.: __,
C.N.S.: • Swelling.
• Convulsion. Eyes: '-"
• P.N. - pain. • Dry, red eyes .

• Weakness. • Pain. '---,;
• Muscle pain. • Photophobia .

• Stroke.
Abdomen:
• Dysphagia.
• Abdominal pain.
• Kidney (LL. edema - urine changes).
► N.B.
Extra articular manifestations are:
Mild in Rheumatoid arthritis.
Marked in S.L.E.
Dont occur in Osteoarthritis.
► Past History
Trauma: suggests traumatic (or septic) arthritis and osteoarthritis.

skin manifestations of psoraisis: suggests psoraitic arthritis.
-
raynaud's phenomenon: suggests scleroderma.
► Family History
Familial mediterranean Fever runs in families.

Reumatoid Arthritis has familial factor.
ALLAM'S Cl'.'INICAL EXAMINATION ► RHEUMATOLOGY:
RHEUMATOLOGICAL EXAMINATION
'
Rheumatological Examination I General.
L Articular.
MIMii• Extra articular.
Temperature Blood pressure for vasculitis.

pulse (peripheral pulsation for vasculitis.) Face for cushinoid face (steroid therapy).
-
\....,
MIIFII
8 points:
( SM SM CD TT) 1- Skin: as erythema, ulcers and scar.
2- Muscle: as wasting of thenar, hypothenar and guttering.
3- Swelling: as effusion, synovium, bony and SC nodules.
4- Movement: Range of movement (active arid passive).
5- Crepitus:
Definition of Crepitus:
a gritty sound or sensation produced by friction between bone
and cartilage or the fractured parts of a bone.
6- Deformities & describe it: as:
Ulnar deviation (MCP)
Swan neck. / Grades of Tenderness:
Button hole. 1- Patient says.
Z shaped thumb 2- Patient winces.
7- Tenderness: in joints or surrounding structures. 3- Patient withdraws.
8- Special Test: as Carpal Tunnel syndrome 4- Patient refuse joint
Another method for joint Examination: touch.
Look - Feel - Move
Feel Skin for warmth Move - - Range of movement (ROM)

Look ~ Skin
M uscle Swelling active and Passive
Swelling Crepitus
Movement
Deformitie
► Extra articular
..___,
C.V.S.: C.N.S.: Abdomen:
• Effusion, H.F. & A.R. • P.N. H.S.M. (still's disease).
Respiratory: • Myopathy (from felty's syndrome = super RA.
• Effusion - Crepitation (I.P.F.). steroid therapy) . Skin:
• Caplan's syndrome • Pyramidal tract lesion • Alopecia, Raynaudes.
• (R.A. - lung nodules - (compression). • Nail fold infarction (psoriasis).
pneumoconiosis) L.N.: Swelling.
Eyes: Dryness & redness.
► N.B. severe Rheumatoid

felty's syndrome..f Huge spleen
Articular Examination super RA. [ Neutropenia
Periphral Axial Special

Upper limb & Cervical Tempromandibular joint.
lowr limb joitns Thoracic Sterno calvicular joints.
lumber Sacroiliac joints.
e
► Hands & Wrist Examination
1- Skin:
look for erythema, ulcers, 2- Muscle:
or scar. look for wasting (thenar, hypothenar and hand guttering)
3- Swelling:
look for effusion, synovium, bony, SC nodules.
► N.B.
Heberden's and
Boucherd's Nodules:
bony swilling (osteophytes)
present in PIP and DIP.
Occurs in osteoarthritis.
4 - Movement:
Examine Range of movement (ROM) (active & passive)
Fingers Extention Fingers nexkln Wrist 01!Kt10n WrM Extension
_.,
Opponents muscles Opponents muscles Opponents muscles Opponenu muscles

...,J
•
ALLAM 'S CLINICAL EXAMINATION ► RHEUMATOLOGY:
5- Crepitus: start from MCP and wrist

6- Deformities & describe it:
as the following:
• Ulnar deviation (at the level of MCP)
• Radial deviation (at the level of wrist)
• Swan neck:
Hyperextension at PIP joint, hyperflexion at DIP.
• boutonniere:
Hyperflexion at PIP joint with hyperextension at DIP
• Z shaped thumb:
Fixed flexion and subluxation at the MP joint and hyperextension at the IP joint.
• Trigger finger:
Flexion at both PIP and DIP due to nodule trapped behind the tendon.
• Fusiform finger: Swilling of the PIP
• Mallet finger:
injury to the tendon that straighten the PIP, Result in inability to straighten the last joint.
► N.B.
Deformity may be correctable if in soft tissue or
correctable in bone and cartilage.
7- Tenderness:
Examine for tenderness
in joints or surrounding
structures.
► Grades of Tenderness:
1- Patient says.
2- Patient winces.
3- Patient withdraws.
4- Patient refuse joint
touch.
8- Special Test: e.g. Carpal Tunnel syndrome:

Phalen's test: Tinnel's Test:
The patient is asked to hold their wrist in complete Lightly tap over the nerve to elicit a sensation of
and forced flexion (pushing the dorsal surfaces of tingling or in the distribution of the nerve.
both hands together) for 30-60 seconds
► Elbows & R.U.J Examination
1- Skin: as erythema, ulcers, sinuses or scar.

2- Muscle: waisting of the muscles.
3- Swelling:
In posterior triangle between 2 epicondyles &
olecranon.
search for effusion, synovium, bony, SC nodules.
4- Movement:
Elbow: R.U.J.:
full flexion & extension . shoulder adduction & elbow flexion do supination &
pronation.
5- Crepitus:
crepitus is felt on Radius head with shoulder '-'
adduction & elbow flexion do supination & pronation.

Flexion deformity.
Integrity of collateral ligaments with fully extended
elbow.
7- Tenderness: joints or surrounding structures.
8- Special Test: no special test.
-.......
► Shoulder (acromio-clavicular joint) Examination

2- Muscle: as wasting of the muscles
3- Swelling: as effusion, synovium, bony, SC nodules.
4- Movement:
Place behind neck {abduction+ external rotation) .
Place behind back (adduction+ internal rotation) .
Abduction in supination.
Abduction in pronation.
5- Crepitus:
6- Deformities & describe it: Abducboo m supmanon

8- Special Test: no special test .
► N.B.
Rotator cuff injury e.g. Supraspinatus tendonitis:
Pain on start of abduction till 45Q (active or passive)
Patient can continue abduction without pain by
deltoid.
► Ankle & feet Examination
1- Skin: erythema, ulcers, sinuses or scar.

2- Muscle: wasting of the muscles.
3- Swelling: effusion, synovium, bony, SC nodules.
4- Movement:
Ankle:
• Dorsi flexion (15° )
_. • Planter flexion (45°).
Subtalar joint:
• Inversion (20°) Planter
• Eversion (10°). flexion
5- Crepitus:
Hallux valgus, Hammer toe, Talipes equinus & Pes
cavus. Darsi flexion
the rest of examination is the same as previous ...

8- Special Test: no special test.
e
► Knee Examination

2- Muscle: wasting of the muscles.
3- Swelling: (Knee Effusion)
A- Front Examination:
Inspection: Lost depression around patella .
Palpation:
Bulge test: for mild effusion.
The suprapatellar bursa is first emptied by squeezing
15 cm above the patella. The medial compartment of
the knee join is emptied by pressing on the side of the
joint. The hand is then lifted away and then the lateral
side is sharply compressed.
If the test is positive, a ripple is seen on the flattened,
medial surface.
Patellar tap: for moderate effusion.
using the tips of the fingers of the free hand, the patella is hit squarely and with
force downwards.
If the test is positive then the patella can be felt striking the femur with a click and
bouncing off again .
Fluctuation test: for tense effusion.
place the webs of both hands 2cm above and 2cm below the patella
then proceed to alternately apply downward pressure with each hand (one hand
pushes, the other hand relaxes) .
B- Back Examination:
Inspection:
Popleteal fossa for Baker cyst.
Palpation:
semiflexed knee (900) & palms of both hands on
popleteal fossa.
4- Movement: exam in range of movement (active & passive)

5- Crepitus:
as: Genu valgus, Genu varus, genu recurvatum & Flexion deformity.
7- Tenderness: joints or surrounding structures .
•
8- Special Test: Examination of collateral liganments stability.

Hold the knee in smi-flexed position.
Apply medial and lateral stress on the knee joint.
Excessive movemnet suggests collateral ligament instability.
► Hip Examination

2- Muscle: waisting of the muscles.
'- 3- Swelling:
effusion, synovium, bony, SC nodules.
4- Movement:
Flexion, Extension.
adduction,abduction .
nternal and external rotation.
5- Crepitus:
8- Special Test: no special test .
•
LA v1 CL NICAL EXAM INATI N RHEUMATOLOGY:
mcmngocele
► Sp~(1~ Examination
,'.
1- Skin: as erythema or pigmenations.
•'
.
..... • ~~ ~ -.1
, ti'. '
' - > •
'
•
- •
•
2- Muscle: wasting of para-vertebral muscles.

3- Swelling:
soft (inflamation)
hard (SC nodule)
DD: meningocele (neural tube defect)
4- Moveme nt
Mid. Cervical
Flexion (chin to chest).
Extension (occiput to wall).
Atlanto-occipital: head nodding.
Atlanta-axial: lateral rotation.
Flexion Extension lateral rotation
Finger to floor test Extension Lateral tilting.
Thoracic
chest expantion by hand & tape meter.
Lumbo- sacral.
1.Flexion: Finger to floor test ( > 10 cm)
2.Extension : backward movemen t.
3.Lateral tilting.
4.Rotation
5.Schober's test see below
5- Crepitus.
6- Deformities: as:
flexion of cervical vertibrae
flexion of thracic veribrae (Kyphosis)
exageration of lumber lordosis Clordosis)
loss of lumber lordosis
lateral curvature of the spine {scoliosis)
pott's, fracture, malignant deposition.
Scoliosis Kyphosis Lordosis
e
7- Tenderness: ► N.B.
fist or medical hummer Question Mark sign
in Ankylosing Spondylitis:
flexion of thoracic vertebrae
and loss of lumbar lordosis
8- Special Test:
Original Schober Test
from standing position, mark a line on lumbosacral
► N.B.
Anatomical Land Marks:
llica crest= level of L4
PSIS= level of 52
•
Dimple of venus = Sacroiliac joint
level. A second line is marked 10 cm above it.
measure increased distance between the 2 points in
erect and flexion positions.
Modified Schober Index (also called short Schober test)
from standing position, mark a line on lumbosacral
level (between the dimple of venus) . A second line
is marked 10 cm above it. A third line is marked 5
cm below the first line . measure increased distance
between the 2nd and 3rd points in erect and flexion
positions.
Modified-modified Schober Test
from standing position, locates the inferior margin
of the PSIS with the thumbs and then marks the
intersections of the PSIS by drawing a horizontal line.
A second line is marked 10 cm above it. A third line is
marked 5 sm below the first line. measure increased
distance between the 2nd and 3rd points in erect and
flexion positions.
The idea of all of them
is to measure the increased distance between 2
points of the spinal cord which reflect the ability of
the spines to be flexed.
► Sacra iliac joint:
Springing of the pelvis:
Abduct pelvis by both hands from SIS leads to pain.
Pressure test:
Lateral and direct pressure
Faber test (patric test):
Flexion, Abduction, and External Rotation. ( to put
heal of the patient on the opposite knee & press on
flexed leg down to the bed leads to contralateral pain)
this test examine the contra lateral sacroiliac joint and the ispilateral hip .
•
Gaenslen's test:
the hip joint is flexed maximally on one side and
the opposite hip joint is extended, stressing both
sacroiliac joints simultaneously. This is often done
by having the patient lying on his or her back, lifting
the knee to push towards the patient's chest while
the other leg is allowed to fall over the side of an
examination table.
► N.B.
Sciatic Nerve Examination
signs of meningeal irritation:
Kernig's sign
is positive when the thigh is flexed at the hip and
knee at 90 degree angles, and subsequent extension
in the knee is painful.
Brudzinski's sign
Appearance of involuntary lifting of the legs when
lifting a patient's head off the examining couch, with
the patient lying supine.
Lassegue test
the patient is positioned in supine without a pillow,
the hip medially rotated and adducted, and the knee
extended. The clinician lifts the patient's leg by the
posterior ankle while keeping the knee in a fully
extended position.
The clinician continues to lift the patient's leg by
flexing at the hip until the patient complains of pain
or tightness in the back or back of the leg.
► Sternoclavicula rt Joint:
Ask the patient to flex the arm at the level of

,,,,,-
Ask patie nt to Open, close, protrude, retract the
shoulders mandible.
abduct and adduct the arm . Palpate for tenderness & crepitus.
feel the crepitus on the sterno clavicular joint.
e -
BABY STEPS FOR EXAM INATION OF TH E HAND
An illustration of hand examination in rhumatology in one page . Here is what you really need to master in
-._ rheumatological examination with understanding what behind the technique and being able to identfy the
abnormal findings and using them to reach to the diagnosis ...
Inspect Skin Inspect and pulpate fv'IL1Scles; thcncr hyM t hener Gutll!llng or na1
........
Se;irch for swilltng on extenso, surr
Op?onenrs musdes Oppone111s muscle< Opponents musc l115 _ Opponents muscles
-----
e
RHEUMATOID ARTHRITIS
► Definition:
Chronic connective tissue disorder charechterized by symmetrical poly-articular errosive manifestations

associated with extra-articular manifestations.
► Pathology:
Arthritis:
first: synovitis then: granulation (pannus) and errosive destruction .
lastly: fibrosis and deformity.
Subcutaneous Nodule: connective tissue with chronic inflammatory cells with central necrosis.
Vasulitis: usually small vessel vasculitis.
► Clinical Picture:
Type of patient: Extra-articular

F:M = 3:1- Age of onset 20-40 C.V.S: Pericarditis - Myocarditis - Endocarditis - IHDs
General symptoms: Chest: Interstitial pulmonary fibrosis and Caplan's
Fever, Malaise, Loss of body weight and Anorexia . syndrome: (R.A. - lung nodules - pneumoconiosis)
Articular (3Ds) Abdomen: Pancreatitis and Hepatosplenomegaly
Description: C.N.S: Psychosis, Chorea, Depression Epilepsy
Morning stiffness, Swollen, red, warm with limitation Skin: Subcutaneous nodule and Palmer erythema
of movement. eye:Conjunctivitis, Scleritis and scleromalacia
Distribution : Blood: Anemia
Symmetrical centripetal polyarthritis of the small
peripheral joint; wrist, MCP and PIP are involved
while DIP are usually spared,
Deformity: (erosion, destruction and fibrosis)
• Ulnar deviation.
• Boutonniere deformity.
• Swan neck deformity.
• Thumb deformity.
• hyperextension at the IP joint.
• Hammer toes.
• Flexion contractures.
• Triggered finger.
e
Diagnostic Criteria (ACR/EULAR) Disease Activity Score (DAS) 28

Symptoms Duration: (as patient report) 5 PIP X2
< Gweeks: Q 5 MCP
>6weeks: !
Joint Distribution: 2 wrist 2 Ankle
1 large joint: 0 2 elbow 2 Knee
2-10 large joints: 1
1-3 small joints: 1. Swellimg (SW 28)
4-10 small joints: 1 Tenderness (Ten 28)
...._,, >10 small joints~ Patient global assessment of disease activity over last
Serology: week (0-10)
-ve RF and -ve ACCP: Q
low +ve RF or ACCP (<3x lower normal value) : 1. Formula:
high +ve RF or ACCP (>3x upper normal value) : ~ (0.56 x vTen 28 +0.28 x vSw28 + ESR x7 + 0.014 x pt
Acute phase Reaction: assessment)
Normal ESR & CRP: Q Normal Activity= 3.2 - 5.1
Abnormal ESR & CRP: .! less than 3.2 = inactive
Score> 6 = RA More than 5.1 = very active
Criteria of Joint Activity: Diagnostic Criteria (American Rheumatism Association)

Swelling (4 or more of the following):
Tenderness 1. Morning stiffness (> 1 hour) for> 6 weeks
Erythema 2. Soft tissue swelling of 3 for > 6 weeks
Warmness 3. Arthritis in at least 1 of:
MCP, PIP or wrist for > 6 weeks
► lnvestigslions: 4. Symmetric arthritis for > 6 weeks
5. Rheumatoid nodules
Blood: CBC, ESR & CRP 6. Serum RF
Serological tests: RF, LE, ANA and Recentl anti CCP 7. X-ray changes: erosions or periarticular osteopenia
X-ray
Aspiration of synovial fluid
► N.B. Treatment:
Rheumatoid Factor:
NSAIDs: for relive of pain & inflammation
Mainly lgM directed again st Fe of lgG
Cortisone:
Positive in about 85% of RA patients, Nonspecific
Disease modifying anti-rheumatic drugs {DMARDs):
for RA but usually used for follow up & severity
sulphasalazine, Gold, Pencillamine and Chloroquine
evaluation
lmmuno suppressive:
Methods:
• Methotrexate
Latex (synthetic material - Rose-Welar (sheep RBCs)
• Leflunomide (anti pyrimidine)
Bentonite (clay)
• lnfliximab, Adalimumab ( TNF a blockers)
False positive:
• Anakinra (Interleukin -1 blocker)
5% of healthy people
Intra articular injection of cortisone
10-20% of people over age 65
Other sere-positive diseases
Bacterial and viral infections
Gammopathy, Granuloma &SBE
Anti CCP: cyclic citrullinated peptide
The most common tests for anti-cit rullinated
protein antibodies (ACPAs) are the anti-CCP (cyclic
citrullinated peptide) test and the Anti -MCV (anti-
mutated citrullinated Vimentin).
Recently a serological point of care t est (POCT) for the
early detection of RA has been developed. This assay
combines the detection of rheumatoid factor and
anti-MCV for
diagnosis of RA and shows a sens itivity of 72% and
specificity of 99. 7%
e
SYSTEM IC LUPUS ERYTHEMATOSUS
► Definition :
An autoimmune disease characterized by clinical manifestations affecting multiple organs, including the skin,
joints, kidneys and nervous system.
► Clinical
- . Picture;
- -
"
Type of patient: C.V.S: Pericarditis - Myocarditis - Endocarditis - IHDs
F:M = 9:1 - reproductive years, 14 - 40 Chest: Interstitial pulmonary fibrosis and Ca plan's
General symptoms: syndrome: (R.A . - lung nodules - pneumoconiosis)
Fever, Malaise, Loss of body weight and Anorexia. Abdomen: Pancreatitis and Hepatosplenomegaly
Articular C.N.S: Psychosis, Chorea, Depression Epilepsy
Arthritis and arthralgia: Skin: Subcutaneous nodule and Palmer erythema
Non-erosive, symmetric involving 2 or more small or eye:Conjunctivitis, Scleritis and scleromalacia
large peripheral joints. Blood: Anamia
Extra-articular (main manifestations) Skin:
Renal (Lupus nephritis): Photosensitivity, Malar (butterfly) rash,
immune complex-mediated glomerulonephritis. erythema, discoid lesions, alopecia, oral ulcers,
Proteinuria, haematuria, pyuria, or red cell casts telangectasia & Raynaud's phenomenon
Oedema and hypertension.
End stage renal failure in less than 5% of patients.
Stages of renal affection in SLE:
I: Normal Glumeruli -
Mild proteinuria
II: Mesangioprolferative GN Asymptomatic hematuria
or proteinuria
complete cure with
corticosteroid
Ill : Focal proliferative GN Responds to treatment
with high doses of
steroids (4 or more of these criteria)
1. Malar rash
IV: Diffuse proliferative GN Treated with
2. Discoid rash
corticosteroids and
3. Photosensitivity
immunosuppressants
4. Painless oral ulcers
V: Membranous GN
- Characterized by extreme 5. Pleurisy or pericarditis
edema and protein loss 6. Psychosis or seizers
7. Peripheral joints arthritis (2 or more)
VI: Sclerosing GN Significant renal 8. Pancytopenia
insufficiency (RF) 9. Proteinuria or cast
Not responding to 10. +ve ANA antibody
medical therapy 11. Immunological investigations: +ve anti DNA ab or
anti-sm ab
► lnvestigstions: ► Treatment:
Blood: CBC, ESR, CRP & KFT Modifications of lifestyle

Serological tests:_RF, LE, ANA, Anti-ds DNA, Anti-Sm, An- Use of sunscreen &Avoidance of estrogens
ti-RNP, Anti-Ro (SSA), Anti-La (SSB) and Anticardiolipin Combination of therapies that include
Complement levels: decreased NSAI Os, Coticosteroids, Chloroquine, Methotrexate,
lmmunoglobulin: increased Azathioprinem Cyclophosphamide
LE cell Plasmapharesis & intravenous immunoglobulins
ALLAM'S CLINICAL EXAM INATION ► RHEUMATOLOGY:
ANl<YLOSING SPONDYLITIS
, -,~
► Definition :
Type of the spondylo-arthropathies characterized by sacroilitis, spondylitis and marked fibrosis.
► Pathophysiology
v Enthesitis: Inflammation of ligament at the site of attachment then osteopenia then erosion then ossification
A- Articular
Axial Peripheral
Bilateral sacroilitis: Asymmetrical large joint peripheral arthritis, mainly
Pain: Mid-low back stiffness, pain at rest, partially lower limbs with centrifugal spread
improved by movement
On examination: painful sacroiliac joint B- Extra-articular:
Spinal affection: Genito-urinary: Prostatitis
Spinal restriction: Lumbar-thoracic- cervical spine in
Eye: Acute anterior uvetitis
flexion-extension-rotation
Kidney: amyloidosis and lgA nephropathy
On examination: GIT: IBDs (UC)
Postural changes: (Question Mark sign)
Neurology: atlantoaxial sublaxation
increased dorsal kyphosis, decreased lumbar lordosis,
forward protrusion of cervical spine (flexion)
Increased occiput-to-wall distance (flexion attitude)
,._,.,
Decreased chest wall expansion
Decreased Schober test (decreased forward flexion of
lumbar spine)
see the pictures of examination before ...
► N.B.
•
AS= 5 As
anterior uvititis, aortitis, amyloidosis, lgA nephropathy
and apical fibrosis
► fnvestigstions: ► Treatment:
X-ray: Physiotherapy:
Sacroiliac joint: Exercise (e.g. swimming).
Early: Pseudo-widening of the joint due to erosion Pharmacological therapy:
Late: Joint sclerosis (bony fusion) NSAIDs
Spine: DMARDs
Early: for peripheral arthritis (sulfasalazine, methotrexate)
Square-shaped vertebra (due to erosion and sclerosis lnfliximab for axial involvement
- of the its corners)

Late:
Ossification of the outer fibers of annulus fibrosis
Symptomatic treatment:
as for extra-articular manifestations
Surgery: Hip replacement, Vertebral osteotomy for
(bridging syndesmophytes) marked deformity
Ossification of the longitudinal ligament producing a
bamboo spine or Dagger
Laboratory tests:
RF negative
Elevated ESR & C-reactive protein
•
ALLAM S CLINICAL EXAMINATION ► RHEUMATOLOGY:
PSORIATIC ARTHRITIS
► Definition:
The most commonly a seronegative oligoarthritis found in patients with psoriasis, with less common, but
characteristic, differentiating features of distal joint involvement and arthritis mutilans.
► Clinical Picture: ► lnvestigstions:
Skin and nail changes are typical findings Serology: RA -ve

erythematous plaques with silvery scale X-Ray:
Nail: pitting, ridging, discolouration, hyperkeratosis or Floating syndesmophytes
onycholysis Pencil and cup appearance
Joints: at IP joints '--./
5 general patterns Osteolysis, periostisis

1-Arthritis of DIP joints with nail changes
2- Destructive arthritis {5%) ► Treatment:
3- Symmetrical polyarthritis {similar to RA)
Treatment of the skin disease:
4- Sacroilitis and spondylitis {usually older, male
steroid cream, salicylic/retinoic acid, tar
patients similar to Ank. Sp.)
NSAIDs
5- Asymmetrical {most common)
Intra-articular steroids if NSAIDs fail to reduce synovitis
Other features (complications)
and pain
Eve: Conjunctivitis, lritis
DMARDS: methotrexate, sulfasalazine, cyclosporine,
Heart: Aortic insufficiency
gold, chloroquine,
Lung: Apical lung fibrosis
azathioprine, and TNF inhibitors {infliximab)
Neurological: Peripheral nervous system - Cauda equina
SCLERODERMA
► Definition :
Generalized disorder of connective tissue characterized by fibrosis and degenerative changes in blood vessels, viscer-
al organ and skin.
► Incidence:
F:M = 3-4:1 & Associated with HLA DRI, DR3, DRS
► Pathogenesis:
Fibrosis and degenerative changes in skin and viscera
Collagen deposition leading to atrophy and fibrosis
Blood vessels: intimal proliferation and medial degeneration progressive obliteration secondary fibrosis of tissue.
'-....,,
Cutaneous
Hand:
Bilateral symmetrical swelling of fingers, hands and feet
leading to skin tightening (scelerodactyly)
Characteristic face: Mask, Fish mouth, beak nose, Radial
Peri-oral furrows _,,
Other skin changes: Atrophy, ulcerations, Hypo -
and Hyperpigmentation, Telangiectasias, Calcinosis,
Periungual erythema, Pruritus
0
ALLAM'S CLINICAL EXAMINATION RH EU MATO LOGY:
Raynaud's phenomenon
Diagnostic Criteria
Abnormal response of
peripheral blood vessels (1 major or> 2 minor of the following)
a-Major criterion:
to cold which lead to
proximal scleroderma
specific color changes
b-Minor criteria:
and pain:
white: ischemia Sclerodactyly
then blue: increased Digital pitting scars or loss of finger pad,
metabolities Bi-basilar Pulmonary fibrosis
then red: vaso dilatation
due to vasodilators
Extra-cutaneous:
l)ii-t41
1- Localized
GI tract:
Distal esophageal hypo-motility (Dysphagia) Morphea and Linear sclerosis
Lower esophageal sphincter dysfunction (GERO)
2- Limmited (CREST)
Small bowel hypo-motility (Bacterial overgrowth, 1- Calcinosis: calcium deposits in skin
malabsorption, weigh loss) 2- Raynaud's Phenomenon: spasm of blood vessels in
response to cold
Large intestine hypo-motility (May cause constipation)
Kidneys: 3- Esophageal Dysfunction: decreased esophageal
Scleroderma renal crisis: (10-15%) may lead to motilits
malignant HTN, oliguria and microangiopathic 4- Sclerodactyly: tightening of the fingerss skin
hemolytic anemia 5- Talangectesia: dilatation of capilaries causing red
marks
Urine abnormalities: Mild proteinuria, creatinnine,
elevation and/or HTN
(commonest)
Lungs:
Pleural: pleurisy and pleural effusions
Lung: interstitial fibrosis - carcinoma
Vascular: pulmonary HTN
Extra thoracic: tight skin may lead to restrictive
hypoventilation.
CVS:
pericarditis, pericardia I effusion or constrictive.
3- Diffuse
Myo: left ventricular dysfunction, arrhythmias
Musculoskeletal: Widespread skin lesion & Early visceral(renal,pulmonary)
Joint: poly-arthralgia or -arthitis (both small and large
4- Systemic Sclerosis
joints) 5- Overlap
Muscle: Myalgia or myositis.
Resorption of distal tufts: radiological finding
Endocrine: May have hypothyroidism ► Treatment:
► lnvestigstions: General: Avoidance of exposure to cold
Blood: CBC, ESR, CRP & KFT Specific:
Serological tests: Penicillamine
• Anti-sci 70 Steroids
• Anti-topoisomerase 1 Others: methotrexate/cyclosporine
Symptomatic treatment:
• Anti-centromere (In limmited type)
Images • GERO:
• Hand: calcinosis of the fingers - resorption of Proton pump inhibitors
distal tufts • Intestinal bacterial overgrowth:
• Chest: IPF broad-specturm antibiotics (tetracycline,flagyl)
• GI: barium contrast • Raynaud's:
• Biopsy: from the skin Ca blockers, Vasodilators, Nitroglycerin cream,
systemic PGE2 inhibitors
• Renal disease or HTN: ACE inhibitors
• Myositis or pericarditis: steroids .
•
OTHER C.T. DISORDERS
► Mixed Connective nssue Disorder: .........

Clinical:
• Acrosclerosis
• Myositis
• Edema of joints (Articular) .........
• Raynaud's
Lab:
►
Anti Ribo Nuleo Protien (ARNP)
Overlap Syndrome:
-
Presence of more than one C.T disease
As:
RA + SLE = Rheubus
Scleroderma + Dermatomyositis
► Dermatomyositis:
(Dermato) Skin lesion (Myositis)Proximal Muscle:
• Heliotrope • Weakness
• Shawl sign • Pain
• Gottorn nodule • FAHM
..,,,
.._,
ALLAM'S CLINICAL EXAMINATION ► HAEMATOLOGY:
HAEMATOLOGICAL HISTORY
'--
1. Name: :"-:!1 ci:iP"" I'"'"'
2. Age: : .i.:.., ris <!I~
3. Sex:
Haemophilia & G6PD-D in male ( X linked)
ITP more common in female
4. Occupation: :"-:!1 ~
Lead exposure: Sidroplastic anemia
5. Marital state: :.i.:.., ris o~ ~µ 1: ris :~~.91 <!I~ :t.9rc
Sever chronic anemia ➔ Infertility
Treatment of Lymphoma or MM with chemotherapy or radio therapy ➔ Infertility
6. Residence: :~ .:,Sl...
mediterranean area ➔ Thalassemia
7. Special habits:
1' alcohol intake ➔ Megaloplastic anemia
8. Menstrual History:
Chronic blood loss ➔ ..J,Fe anemia
ITP ➔ Heavy period
► Complaint:
• Usually Headache, fatigue
• Sken lesion
• Swelling (LN, liver or splean)
• Abdominal Pain (HSM)
• Yellowish discoloration in HA
► History of present illness (H.P.I):

• Analysis of complaint as usual
• Analysis of haematological symptoms (see next)
• Other symptoms RBCs (Hb)
• Investigations & treatment ~WBCs
► Haematological Symptoms : ------- +-- Bleeding
Evidance of Haemolysis
Evidance of RES Hyperplasia
1- .,!,, RBCs (Hb) : Hyperviscosity manifestations
• Headache, Bluring of vision , dizziness & syncopal attacks
• Anginal pain, dyspnea & palpitations
• Fatigue & I.C
2- .,!,, WBCs (Number or function) :

• '1, Nomber as in aplastic anemia
• '1, Function as in leukemia
• Resulting in:
1' 1' Infection: 1= Sore throat
Stomatitis
Fungal Infection
0
ALLAM S CLI NICAL EXAMINATION ► HAEMATOLOGY:
3- Bleeding:
Due to: ~ Platelet disorder ( Number or function)
or blood vessel disease ( as Vasculitis)
or coagulation factor defect (as haemophilia)
Bleeding Per Orifices: Epistaxis Skin lesion: ~ Petichiae <2mm

Haematuria Purpurikc 2mm - 1 cm
Haematochezia Ecchymosis > 1cm
Bleedign gum
Haematemesis Skin manifestations my appear spontaneously or after
Haemoptysis trauma
4- Evidance of Haemolysis :
\......-
Jaundice, Haemolytic crisis & history of repeated BT
► Jaundice:
Definition:
yellow discoloration of skin & mucous membranes ► N.B.
due to increased level of bilirubin > 2.5 mg%. Jaundice may be:
Analysis of the jaundice: • Viral: acute- short- regressive .
1. Onset: • Calcular: acute intermittent.
• Acute: viral hepatitis, calcular obstruction. • Malignancy : gradual - progressive (2 months).
• Gradual: malignant obstruction, cirrhosis. • Chronic liver disease : gradual - intermittent (2V).
2. Course:
• Progressive: malignant obstruction, cirrhosis.
• Regressive: viral hepatitis.
• Intermittent: calcular obstructive jaundice, periampullary carcinoma, hemolytic jaundice, chronic active
hepatitis.
3. Duration:
V • Short: viral hepatitis.
• Long: cirrhosis.
• More than 2 years exclude malignancy.
4. Urine:
• Dark: hepatocellular & obstructive.
• Normal: hemolytic.
5. Stool:
• Pale clay: in obstructive.
• Dark: in hemolytic.
• Slightly pale in hepatocellular. 9. Pain:
6. Anorexia. nausea. vomiting: • Hepatocellular: dull-aching pain in right
Occur at the onset of viral hepatitis. hypochondrium in case of viral hepatitis.
7. Fever: • Hemolytic: bone pain and abdominal pain in
• Hepatocellular: pre-ecteric phase of viral hemolytic crisis.
hepatitis. • Obstructive:
• Hemolytic: during hemolytic crisis - malaria - • Biliary colic (calcular obstruction).
incompatible blood transfusion. • Epigastric pain radiating to the back
• Obstructive: Charcoat's triad. (malignant obstruction).
8. Bleeding tendency: from skin. orifices in: 10. Pruritis:
• Liver cell failure. • In obstructive jaundice.
• Obstructive jaundice. • Primary biliary colic.
► Haemolytic Crisis :
• Dizziness, blurring of vision ~ j J ~J~
• fever & rigors WJJ 4.1~
• Headache, Pain & co lors (Dark urine & deep jaundice) .:,1_,JI, f~I, ti"""
•
ALLAM 'S CLINICAL EXAMINATION ► HAEMATOLOGY:
5- Evidance of RES Hyperplasia:

The following cases maybe presented by abdominal pain or swelling:
• HSM & LN++ may occur in malignancies due to infiltration
• HSM may occur In chronic HA due to extra medullary haematopoiesis
• Splenomegaly occur in any type of anemia due to extra medullary haematopoiesis
6- Hyperviscosity manifestations:
as thromboemboil sm ..... as in multiple myeloma, leukemia, polycythemia .... .etc.
► Other Systems:
CNS:
• IC Hge in Purpura or Haemophilia
• lnfiltrarion in Blood Malignancies
CVS: Dyspnea, Palpitation & arrhythmia in Anemia
Chest: Pleural or lung infiltration in Blood Malignancies
Abdomen: See before
Others:
• Bone pain & Fracture : MM
• Joint Pain & Swelling: Haemophilia
► Past History : _►_ F~mily History :

1- Drug History: Similar Condition in the family: In Hereditary HA:
• Aplastic Anemia: • Hereditary Spherocytosis (AD)
• Antithyroid, Antiepilepsy • Thalassemia & Sickle cell anemias (AR)
• Antibiotics, Antidiabetics • G6PD-D & Haemophilia (X- linked)
• Anticancer
• Haemolytic Anemia: Alpha methyl dopa
• Bleeding: use of anticoagulants
2- History of radiotherapy: BM depression with
radiotherapy in malignancies
3- History of Chronic Diseases: as TB, DM, Tumors,
Hepatitis
HAEMATOLOGICAL EXAMINATION
0 ~19Jl Vitals : Blood pressure, pulse. Respiratory rate. Temperature.

•
•
• Temp.: Fever: E
Pulse : Big pulse volume & WHP : in Anemia (Hyperdynamic circulati on)
BP: Hypotention: in sever anemia
haemolytic crisis
Leukemia
'1,, WBCs (infections)
Lymphoma
• R.R.: Tachypnea: in anemia
0 Built: Short stature: In chronic haemolytic anemia since childhood
G Complexion:
Pallor: Anaemic.
Jaundice (Haemolytic)
Cyanosis: Never occur with anemia (why?)
•
AU AM S CLI NICAL E ' AM INATION HAEMATOLOGY:
G Decubitus or position
Orthopnea: in anemic HF
Mon oloid Face See below
Atroph sitis In -J, Fe Anemia
Beef in Megaloblastic anemia
Ble s see pictures below
(H & N): Con k vein: in H namic Circulation Anemic HF & LN+ Compress SVC
S ooni of nai ls Koilon chia in Fe anemia
0 UL & Skin:
-E Petechiae, Pu rpuric eruption or Ecchymosis See table and pictures below
Hyperpigmentation in thalassemia
lower limb: --r-

Leg Ulcer: In Sickle Cell Anemia
L- Lower limb edema ~ Hypoxia ➔ 1' Capillary permeability
Anemic HF
NB : tender sternum in leukemia -.1,GFR ➔ Salt & water retention
► Mongoloid face:
• Expansion of forehead (protrusion of frontal &
parietal bones)+ Widening of the medulla due to
hyperacrive bone marrow
• Depressed nasal bridges
• Prominent maxilla
• Protruding upper central incisors
Ecchymosis
lnteradermal Hge Subcutaneous Hge
sized< 2mm sized >lcm
not raised raised
No color changes color changes
not related to trauma related to trauma

Note: Pu rpura { 2 mm to 1 cm )
lnpo,nl Pet~chio
0 Other Systems:
CVS: LN:
• 1' Sl & S2 • Chronic HA
• S3: Volume overload • Leukemia or Lymphoma
• Haemic Murmur (Soft systolic over base of the Joints:
heart particulalry pulmonary area • Haemoarthrosis in
Abdomen: haemophilia
• HSM
• Evidence of splenectomy Scar & Percussion on
traub's area (resonant
•
ALLAM'S CLINICAL EXAMINATION ► HAEMATOLOGY:
~-
THALASSEMIA
An example of chronic haemolytic anemia Clinical pictures:

Pathophysiology: R.B.C.s life span. General examination:
1. Hepatosplenomegaly. • Pallor/ jaundice.
2. Hemoglobin: • Pulse ➔ hyperdynamic circulation.
• Heme: • Lower limb ➔ leg ulcers.
• Iron (bronze diabetes ➔ cardiomyopathy, skin Abdominal examination:
ulcers). • H.S.M. or scar of splenectomy.
• Blivirdin ➔ bilirubin ➔ pigmented stones in Heart examination:
G.B. 7. Hyperdynamic with haemic murmurs
• Globin. 8. D.D. with A.I.
3. Anemia: with mild pallor
1' anemia & pallor in : Investigations and treatment:
• Haemolytic crisis. CBC, Hb electrophoresis
• Aplastic crisis.
• Megaloblastic crisis.
• Hyper splenism.
4 . Jaundice: mild
1' jaundice in:
• Haemolytic crisis .
• Hepatitis (Blood transfusion).
• Incompatible blood transfusion (rare).
• Obstructive jaundice.
5. Bone marrow changes:
• Mongoloid face.
• Bone ache.
6. Haemolytic crisis:
• Fever - rigor - headache - dizzeness.
• Dark urine - bone ache.
SICl<LE CELL ANEMIA
Specific features:
• Autosplenectomy: from reccurent splenic infarction
Palpation of spleen in adult: never sickle cell anemia
• Vaso-Occlusive crisis: sudden ischemia
• Cardiac: Ml
• Chest: Pulmonary Infarction, Cor-Pulmonale
• Abdomen: Mesenteric occlusion: acute abdomen
• Genital: Priapism
• Neurology: Strokes (Focal lesions: Hemiplegia, sudden blindness)
• Limbs: lschemic ulcers and gangrene, Hand and foot syndrome (Chronic Dactylitis)
• General features of purpura

• skin examination: Purpuric eruption : generalized, ► N.B.
variable in size, not raised above the skin & don't Hess Tess
blanch with pressure • circleofScmindiame terismarkedintheant ecubital
• Spleen is not palpable, and if palpable it would never fossa then inflate the sphygmomanometer midway
be hugely enlarged between Systolic and diastolic BP for about S min.
• No history of blood transfusion, and if there, it would • count the numbers of petichae within the circle .
be just once • if more than 10 petichae ➔ +ve test.
Evan Syndrome: • it is +ve in all cases of purpura.
Autoimmune Haemolytic Anemia + Autoimmune
Thrombocytopenia
•
Definition:
A condition characterized by progressive and irreverable reduction of renal function . The clinical symptoms and
signs of end stage renal failure are known as uraemia or uraemic syndrome.
► Complaint:
On patient's own words+ duration Yy.s,.:;JI 4:!I ~, 41~ Y ~ I ~~ .;,1 4:! l Y~i;; .;,1 4:!I
Maybe Headache due to HTN or fatigue due to anemia
► History of present illness (H.P.1):
Pat hology, History & Examinations are explained in the next table:
Glumerular ➔ Na retention ➔ N
Tubular ➔ Na Loss ➔ 1
------
Extracellular shift due to acidosis J ~ 31 u'lLlwl J ua..:, l!l.u& Examine Muscles
➔ p !.;§.fill
failure of HCO3 reabsorption Observe for kaussmaul
I
breathing
!~_;;; 3 1a....s
- ~ !
Measure BP
-. -!J-~- ,-J- ~-,-J-+ Pericardia I Rub
!_,.,..cij U;S J kaussmaul breathing

!~IE"' J~I J ~I Rhonchi
Pleural Rub
! .I.! a....s
Mouth: Uremic odour !u~··1 l!W <k.... J Halitosis

tongue is dry and coated ! · 1 cllL..J White coated tongue
~
Stomach: ANV Yr~ E;:?riJ J Y-::.,.#1 JS'':.U ~
- -GIT
- bleeding ------------
Constipation, Diarrhea (Dysentry)
A Apathy. Astrixis !-::.1.~1 31 u ~ d

B Psychotic: lrretability !i.1"1...-~I J ua..:, J
-~ PN & Myopathy !u~I J ua..:, J hypothesis
r: Confusion
p Dementia {Dialysis)
rparathyroidism ➔
(Generalized bony pain)
Pallor+ Urochrome pigmentation ➔ Earthy look Earthy look ·

Pruritis ! ~_;11> J Scratching marks
ALLAM'S CLINICAL EXAMINATION ► RENAL:
.._,..
-
~8- 'slood~
I'- •. - - - "--
History Examination
Anemia (All Types) ~ul~~I , ~j , <1o-.9.), t_lJ..:> Pallor
~r~~.9~
+ CVS ( 1'Sl, S3 & haemic
murmur)
.J..1.41~ ~I
Bleeding (Toxemia interfere with platlet & coagula- ~ .91 0~ 151 13 ~y cl~ Petechiae or ecchymosis
tion factors functions) ~IS~
► Past History :
• Reccurent loin pain ( Pyelonephritis • Collagen disease & Gout
= the commonest in Egypt) • Renal stones
• DM (the commonest world wide) • NSAID
• HTN
► Family History :
• Polycystic Kidney (AD)
.J
RENAL EDEMA
U@Md ~.s abdominal sheet but focus on the following:

► personal history as before nephn::1tic syndrome:
► Complaint Puffiness of eyelids • Nephritic nephrotic.
• Collagen diseases e.g. SLE
IJl: Present History • Complication of atherosclerosis or renal failure
1. Analysis of the complaint: OCD, 1' '1,, associated • Steroids
symptoms
2. Symptoms of the same system: 2. Abdominal examiMi:ion:
1. Urinary symptoms: change in the amount or in colour • Generalized distention of the abdomen
Oliguria & hematuria in nephritic syndrome • Stretched skin, Visible veins
2. Headache (hypertension) : in nephritic syndrome • Divarication of recti
3. Symptoms of complications: • Wide subcostal angle
• Chest infection: fever, dyspnea • Tender& rigid abdomen suspect in peritonitis
• Skin infection • Ascites examination
• Urinary tract infections: dysuria, ... etc • Scrotal edema
• Abdominal: pain vomiting (peritonitis or GIT
Diagnosis _,,
congestion) & diarrhea
• Rash, arthritis (with lupus nephritis- Henoch A case of generalized pitting oedema (associated
Schonlein purpura) with moderate or tense ascites for investigation) most
4. Investigations & treatment: probably nephrotic syndrome in (first attack or in relapse)
• Steroids or immunosuppressive & hospitalization complicated by acute bronchitis.
3. Symptoms of other systems:
• Hepatic &cardiac to exclude other causes of edema ► Why Nephrotic?
Examination as general & local abdomen but focus on: 1. Character & distribution of edema.
2. edema started over eye "periorbital"
1 General examination: 3. Gradual onset.
• BP: normal in nephrotic & high in nephritic, 4. absent hematuria with normal blood pressure.
• Puffy eyelids
• Oedema start periorbital then face then sacrum
then genitalia then general
• Pallor
• Xanthomata (hyperlipidemia)
• Cushinoid features in long standing treatment with
steroids
• Lower limb edema: bilateral pitting not tender
reaching.
•
GH & ACROMEGALY
Hormonal Actions & Pathology History Examination

A-Mainl~ Metabolic Action:
CHO:
Diabetogenic (DM): ¥ ~# J~ r~' .po~~#~ y ~ Examin as a diabetic patient
1' Gluconeogenesis & ._I, Glucose ~iS~ J¥.I
uptake by cells
~
• 1' Lipolysis with loss of S.C. fat ~# J~ • wrinkling of skin of
• Excretion of fat with sebum + forehead
hypertrophy & hyper plasia of • Greasy sweating
sweat gland
Proteins:
B n · ~C>~I cl.;,..9 ~).Lo J.a, Big skull (See below)
•
• Face: coarse featurs ~~I J ..9~ clo-13 ..91 <!!~I J.a, • Spade like hand & big feet
• Feet & hands • Kyphosis
J.,.,l.iU,I J r~I J~
• Vertebral column • Osteoarthrosis
• Joints
• ~~I ui.1~1 ~ I l!.IJ..99 1 • Muscles Examination
• Early: 1' in power (Power as in neurology)
• Later on: Myopathy I
~Jlo.;..ll..9 ~I~ J JJi3 J • HSM (Examine liver &
• Liver & Spleen Liver & Spleen ~~j ..91 49_,.91 ol ~ a:,~ I!!~ J.a, spleen)
• Heart:Cardiomyopathy & HF • Exam in heart for chamber
~J~I eWI JSLl..o I!!~ J.a,
• Prostate: BPH enlargment
• Colon: Polyps ..9I l!JL...ol ..9I J~I ~jlfi.ll ~ J # l!.I~ J.a, • PR examination
a....:;
Electrolytes:
• Na retention lead to HTN ~~ ~..9.)I ~~ • Mean Arterial Blood
Pressure
~
• PN ~ul..,.b~I J ~ ..9I ~ ..9I ~I J • Examine for glove & stock
• Carpal tunnel syndrome of hypothesia
• Thick ulner nerve, tinnel &
phalen test
due to macroadenoma
Big Skull: Acrom~I~ face

• Thickening of the cortex
• Pneumanization of frontal air sinuses
• Prominent external Occipital Protuberance
• Big mastoid process
• Prognathism & wide separation of teeth
► N.8.
Cause of death in acromegalic patient:
• Sleep apnea (respiratory)
• Heart failure (Cardiovascular)
• DM ► N.B.
• Colonic Polyposis (Colon Cancer) Colonic Polyposis usually associated with skin tag
•
ALL.AM'S CLINICAL EXAMINATION ► ENDOCRINE:
--------------------------__,
► Gigantism :
Definition: Increased GH secretion before fusion of epiphysis (before puppetry)
Aetiology;
• Hyperplasia of acidophil cells
• Acidophil adenoma
dinical picture:
• Generalized overgrowth of metaphysis of long bones leading to disproportionate gigantism
(span > height)+ (lower segment >upper segment).
• Later on features of acromegaly develops.
• End stage or decline stage:-weakness, fatigue due to pituitary insufficiency.
Definition: Height above 97th percentile of normal individual for the same age & sex
- . --·
-
'.' -
ii ....... ::r. ...,:, : ( el lt'T:J'i.'I I
I -
Familial & Racial I Proportionate Normal GH

Gigantism
,__ _l Di~roportionate High GH level
Hypogonadism Disproportionate Feminine
Cerebral Gigantism (Soto's Syndrome)
----
in first 5 years of life only, MR, big
I
skull & normal GH level
-
Marfan's syndrome See Cardiology
Klienfilter's syndrome (XXV) Tall, Slim & underbuilt i
Homocystenuria I
I
II
Hyperthyroism
Sexual Preco Early aceelerated growth, later on shorter stature
► DD of Short Stature :
Definition: Height below 3rd percentile of normal individual for the same age & sex
Aetiology:
A. Familial: the commonest cause.
B. Genetic disorders:
1. Mongolism (Down syndrome): Trisomy 21
2. Turner's syndrome XO: ovarian dysgenesis, lry amenorrhea webbing of neck,increase carrying angle,
coarctation of aorta.
3. Microcephaly.
4. Progeria: premature senility.
C. Endocrinal:
1. GH deficiency: Levi-Lorain, Frohlich's & Laurence-Moon-Biedle syndromes. __,
2. T4 deficiency: cretinism & juvenile myxedema.
3. 1' Sex hormones: precocious puberty (tall child short adult).
4. 1' Cortisol: Cushing syndrome or excess steroid treatment (Cortisol block the ability of GH to produce
somatomedin).
5. -!, Insulin: Juvenile DM excess glucose inhibit GH release
D. Skeletal:
• congenital: • Acquired:
1. Achondroplasia: short limbs & normal trunk. 1. Rickets
2. Osteochondrodystrophy: limbs & trunk are short and deformed. 2. Paget's disease.
3. Osteogenesis imperfecta fragile bone, pathological fracture+ 3. Port's disease.
malfusion &
4. dwarfism, joint dislocation, blue sclera, deafness due to
otosclerosis.
E. Chronic severe illness during the childhood :
1. CVS: rheumatic fever, congenital heart disease. 3. GIT: malabsorption, lipoid storage, parasitic _,
2. Lung: polycystic lung. infestation, malnutrition, liver cirrhosis.
4. Kidney: chronic nephritis.
ALLA /Vl'S CL!NiC \:__ EX AM L\J/'\TION ENDOCRINE:
CORTISOL AND CUSHIKiG DISEASE

~
1- Metabolic: ~~ u"l~I ISi J • Signs of DM

• CHO: Hyperglycemia .::.lj~.9l~~lcl.;,.9~~ 1 • Moon face,
• Fat: 1' Lipolysis with abnormal distribution ~~ .:>Slol.9 .:>SLol J
Buffalo Hump.
• Protien: 1' Catabolism : Ms ➔ Weakness Trunkal Obesity
~u~IJ~J with thin limbs
Skin & BV ➔ Striae & Purpura
Bone ➔ Osteoprosis ~~ J l_,.o.:>' ..6_# J • Muscle Wasting
• Vitamins: Anti Vit. D ➔ Osteomalecia - - ~J~ J..=- .9I ~fU:WI J r~I J •

~~J
•
Striae Rubra
J ('J.9 J • Purpura
LL Oedema
Stress Search for skin infection
t Allergic
Inflammatory
3-Androgenic Like Action: ~Y~ ..,...,.- cllJ'&b • Acne Vulgaris

.9I JJ.411 .9I 4z~I J y:..;, cll.)&b • Hirsutism (in females)
(Females only) 10J.9JJI J ul~
1 - 1' Neutrophils
4- Bone Marrow: 1' RBCs (Polycysthemia) 1 ~ cl.;..9 Jbll ~ ' J • Plethoric face
~JJ~ .:,~I J ~ • cyanosis with cold
L -J, Lymphocyte, Monocyte,
eosinophils & basophils
5- 1' Sensetivity of Receptors to Catecholamines: ----------+I. Measure BP 11')

Causes of hypertention in
Cushing:
• Polycysthemia
• Salt & water retention
• 1' Sensetivity of receptors
to catecholamines
6- .J, Gastric Mucous Secresion: 1 o.u..1.1 J 01sp.9 ~I • Epigastric Tenderness
- ---- -·- - - - - - - - - - - + - - - - -- - - - - - - ; r - - - - - - - - - - - - - - - ,
7- Psychosis:
•
NI A E AW 1A I N ENDOCRINE:
i--
Cushing Types
~W.9.►-,J9 ~.9.)I ..:,.i..;..1 ~ [ •
pituitary causes :
do confrontation
-
~ J.o~ ti.Loa .:J...1,;s. (Pituitary)
1'1' ACTH .J,.J, ACTH
j flJ.91 .91 ~ j JSL;..o .s! j
test.
• Pituitary (Disease) • Supra Renal Disease • Suprarenal: as
~ wis:..
• Ectopic in para malignant$ • Steroids (Cushinoid) kidney exam
• Synacthen drug
ACTH is a darkening hormone
ADDISON DISEASE
Addison Disease
Primary Secondary
• Autoimmune Panhypopituitarism
• TB ( .J,ACTH)
• Drugs as Ketoconazole
• Surgical removal of the gland
• Truma or inflamation
_ Ex:amioation
Hypotention .J, Aldosterone & .J, Cortisol ~ ti.Loa .:J...1,;s. Measure BP .J, (110\70)
~ o.i...l.9 o_,.o I.Jill f ~ LI,
.
~ ~,~
Hypoglycemia .J, Cortisol ~µ,~~~~

~IJ.5'
Athenia .J, BP, .J, Glucose & .J, Androgen ~ ~ Ju,,;, .:J...1,;s. Apathetic look
Hyperpigmentation only in l 'Y ( 1' ACTH) .91 l!W .91 .:,~ j &. cl/~ Hyper pigmentation in:
~cl.iW • Exposed Areas (Face &
neck)
• Scars
• Areola
• Groin & Axilla
• M.M. in mouth &
tongue
._,.ill .91 ~..:.~, j Ju,,;, .:J...1,;s. I
~ _►.SPI
1' W ➔ Acidosis
& GIT disturbance
~ &t.iJ .91 w~ .91 o..u,.l,! j ~, j
j
l
-
-
ALLAM'S CLINICAL EXAMINATION ENDOCRINE:
HISTORY OF THYROID CASE
1. Name: 1~1 l!!Jp I°'""'

2. Age: t'""" ris d.i.:.s.
3. Sex:
Benign thyroid sewlling 9:1 male: female
Malignant thyroid conditions 3:1 male: female
4. Occupation: 1~1 ~
V
5. Marital state: t'""" ris o.i.:.s. ~.,;...,1 t ris ,~y,1 d.i.:.s. tv.;..o
\...I 6. Residence: ,~ <)St...
7. Special habits:
!oj<A/1 o.l.4. J~ ~ ~ !4.... rlS clll.at ! r~I ~ o;~ rlS !~~
J Y, ~ ~~ !ul;..IN ,1 O_,u- y ~
!~j oj46.ll tJl !u4'-L..l,I
8. Menstrual History:
2rv amenorhhea maybe due to pregnancy or thyrotoxicosis.
► Complaint:
On patient's own words+ duration t .,_.....,, ~1 ~, 411.at t ~ I ~~..)JI~! t -¥1.1..)JI ~1
V ► History of present illness (H.P.I): I
1. Analysis of complaint. ~ Pain

2. Other system affection~~+ L Swell ing C Pre_ssure ~anife_ st ations
3. Investigation & treatment. disturbance of function _ _.___ t oxic manifestati on s

a..Pain analysis: 11 point: 8+3
Onset, course, duration, association, what increase, what decrease, date of last attack, effect of treatment,
site, radiation & character
b. Swelling analysis:
Onset, course, duration+ swelling characters (site, size, shape,consistancy, surface, skin over it)
c. Disturbance of function:
1. pressure manifestations :
pressure manifestations
dyspnea dysphagia hoarseness of voice
-
..._,
ALLAM'S CLINICAL EXAMINATION ► ENDOCRINE:
...,,,
2. toxic manifestations:
• GIT: diarrhea 5e~J j o_,.. rlS r1--II J,;..u ~.,,....
• CNS: insomnia, fine trumors, irritability
• Urinary: polyurea 50...¢' J~J ~ JAi
• CVS: palpitation w~ .:.,~fa! ~
~ JAi • Skin: sweaty and worm ~.;it.s_,...9 JI~ .:1~ .:,1 ~
• Metabolic: recent heat intolerance ~ ci;I
• SC tissueu: peritibial myxedema 5~J J J.L;JI c.,,,;; eJii J
~,,,,.;1~,.;,...
• Muscles: myopathy ~cl.l.i,..!, t }Lo.9 u~I j ~ ~ JAi
• Eye: a. exophalmos ~1Y- ..::....t1 4 .:,1 ~ -
b. diplopia ~~1 ~w1 . ; ~
• bone: osteoprosis ~rll:utll J .:,1fa J JAi
2- other system affection:

a. Lung metastasis: cough, haemoptysis, chest pain
b. bone metastasis: boneache and pathological fractures
3- investigations and treatmen t:
Ask about investigations, operations and drugs
► Past History:
1. Similar attacks ~1JS ~ uJ.,S:,I 15µ1
2. Chronic diseases as D.M., hypertension and T.B.
• Diabetes Mellitus: ~ u~w... \?i J.=- ~ rlS ,:ilS §,..,, J.,.J.,,.:; pi~~! ~1 =-.rr ~ ~! i;:~ u~i ~ '-'"'°!.,.. ~ §,..,, .:1~
• Hypertens ion:~ u~w... \$1 J.=- ~ rlS .:,IS ~1 ~ •.,..pi~~! ~1 =-.rr ~ ~! i;:~ u~i ~ '-'"'°!.,.. ~ ~ .:1~
3. Major operations. (complications of general or spinal anesthesia).
~ ~I.; c,,_t; .9i u~W... ~~ J.=, ~ '-'"'°! .;.o ~ ~! '½W 5 oJS ~ ~Irr u~ c.w.
4. blood transfusion. 5 r~ ..:.1.1..i
5. Drug allergy and intake : 5.1.9~ \?i .;.o ~1-,,. .:1~ ~ o~ ~ 4-:!.9~1 ~~
► Family History:
consanguanity and history of similar conditions
~ ':-:!I~ r~l.9 y~l ~ 15µ1 ._....cl.; .;.o ~ I a!.\WI ~ ..1.:,
EXAMINATION OF THYROID CASE ._,,;
► General Examination:
0 els) Vitals: 1= Blood pressure: Hypertension

Pulse: Tachycardia _] In thyrotoxico sis
Temperature: Hyperther mia & heat intolerance
0 !!uilt: increased appetite & wight loss (thyroid paradox)
G Complexion: --C pallor: thyroid dysfunction

L cyanosis : in retrosternal goiter
jaundice: 1= liver metastasis
antithyroid drugs
DD: hypercarot enemia in myxedema
Decubitus or position orthopnia in heart failuire
head and neck

__c Neck: swelling
head: skull metastasis
upper limb - - - -- - - - - - -- - - + - -
§ clubbing (thyroid
acropacky)
Lower limb ~ LL edema in HF water hummer pulse
L-. Pretibial myxedema palmar erythema
fine tremors
0 fa Mentality & Face
► Local Examination:
1- Inspection:
ask the patient to swallow (for thyroid swelling) then to protrude his tongue for thyroglossal cyst and observe
the movement ...
2- Palpation:
lahey's method of thyroid palpation:

ask the patient to tilt his neck on one side support the thyroid on the tilted side by the hand and examine it by
the other hand on the other side
If swelling describe the following:
• wormth (from front) • edges
• tenderness (from front) • consistancy
• surface • relation to the surrounding e.g. skin, muscles and vessels
special tests:
1. Berry's sign
palpate the 2 common carotids : --r- both are palpated: Normal
L- one only palpated: Palpate both superfecial temporal A.
I
~
both are palpated : displaced carotid
one only palpated: infiltrated carotid
2. pemberton sign:
ask the patient to raise his hanf above the level of the head; If positve, face polethora occures.
pemberton sign is positive in SVC obestruction in retrosternal goiter.
3- Percussion:
Direct percussion on sternum; dullness in retrosternal
goiter.
4- Auscultation
Bruit over the lateral lobes in hyperthyroid ism (on

sup. thyroidal artery )
► Eye signs:
Non infiltrative:
increased thyroxin in the blood leads to retraction of
muller muscles which leads to
the following signs:
1. Stellwag sign: staring look+ infrequent blinking
2. Dalrymple's sign: rim of sclera above the cornea
3. Von Grafe's sign: lid lag on looking down
4. Rosenbach's sign: fine tremors on closure of eye
5. Slight exophthalmos: retracted upper lid
•
Infiltrative:
auto antibody called exophthalm os producing substance
(EPS) leads to infiltration with myxomatous tissue in retro
bulbar space and extra ocular muscles which leads to the
followin signs:
1. Exophthalmos: unilateral or bilateral. may occur before
-
thyrotoxicosis (ocular grave's),
the following tests is to DD true and false exophthalm os
• Naffziger test: to see the level supra and infra orbital
ridge with cornea.
• Frazer's test: to see the obliteratio n of sulcus of
orbital margin with slight closed eye.
• Ruler test: to see the level of supra & infra orbital
margin with cornea by a ruler. __,,
2. Injected conjunctiva
3. Swelling of eye lids and lacrimal glands
4. External Ophthalmplegia:paresis of oculomoto r
muscles which lead to:
• Mobius sign: lack of convergence due to weak
medial recti
• Joffroy sign: lack of forehead corrugatio n on looking
upward
Malignant exophthalm os with papiledema and corneal
ulceration may occur
investigations & treatmen t See Theoretica l Book
HYPOTHYROIDISM (MYXOEDEMA) 1
► General Examination:
5. Gonadal:
• A e@>I: Cold intolerance - history of hypertensi on. • Female: atrophy of breast, loss of libido, loss of hair
• B (built}: weight gain. & menstrual (menorrhagia, galactorrhea or 2nd
• C (color}: yellowish discolorati on. amenorrhe a).
• .E..;_ • Male: impotence - gynecomastia.
• slow celebration (myxedema madness). 6. Skin: dry, cold, pale, yellow, scaly & rough - loss
• bloated face (use old photo). of hair, thin, brittle nails with longitudina l ridges.
• Gonadal: Menorrhag ia, galactorrhea or secondary Hyperkeratosis of elbows and knees.
amenorrhe a. 7. Systemic review:
• Skin: dry hair and skin • C.N.S.: slow celebration - slurred speech-su spended
• Gland: thyroid swelling or mass. knee jerk± ataxia - P.N. - carpal tunnel syndrome.
• Others: Fatigue - confusion - weakness - constipatio n - • Heart: pericardia! effusion HB HF
dyspnea - deep voice. (cardiomyo pathy).
• Abdomen :++ liver (fatty).
1. Vital signs: • Chest: pleural effusion (cholesterol effusion).
• Hypotherm ia. • Abdomen: hypoactive bowel sounds (ileus),
• Hypertension . myxedematous ascites.
• Bradycardia.
2. Head and neck:
• slow celebration.
• Myxedema face:
• Expressionless, bloated & malar rash.
• Loss of outer 1/3 of the eye brow, puffiness± cataract.
• Thick lips, red glazed tongue (macroglossia).
• Yellowish skin without sclera icterus (carotenemia).
3. Trunk.
4. Limbs: myxoedematous oedema.
•
DIABETES MELLITUS
Diabetes mellitus is characterized by hyperglycemia due

► Examination :
to absolute insulin deficiency .
• There may be evidence of weight loss and
Types : C Type one ( Insulin deficiency )
dehydration.
• primary _ __.___ Type two (insulin resistance)
• In diabetic ketoacidosis the breath may have the
• Secondary
sweat smell of ketones.
e.g. cancer pancreas
• Skin infections with boils and abscess are common.
DIMMZW • Acnthosis nigricans (soft, velvety, brown skin ) is a
sign of hyperinsulinism and is seen frequently in the
As with other diseases, you should establish when the
axil la and groins of patients with insulin-resistant type
diagnosis was made (and how) and the course and
2 diabetes.
treatment of the disease. Additional questions relating
• Necrobiosis lipodica, due to collagen degeneration,
to disease monitoring and diabetic complications that
may occur on the shins of some patients with type 1
you should ask patients with diabetes are as follows :
diabetes and often causes chronic ulceration.
• When was it first diagnosed?
• Diabetic foot ulceration which caused by multi
• How was it first diagnosed?
factorial, including diabetic neuropathy, arterial
• How was it first managed?
insufficiency and increased susceptibility to infection .
• How is it managed now?
'-"' • Xanthomata their presence indicates significant
• If on insulin, when was that first started?
hyperlipidaemia. (See page 32 picture E2)
• Are they compliant with a diabetic diet?
• Lipohypertrophy at the site of insulin injection
• Are they compliant with their diabetic
medication?
• How often do they check their blood sugar? Complications of Diabetes mellitus:
• What readings do they normally get {if possible, Microvascular neuropathic
ask to see their monitoring booklet)? • Eye: Retinopathy, cataract (impaired vision)
• What is their latest Hb A 1 C (many will know • Autonomic neuropathy: postural hypotension,
this)? vomiting, diarrhea.
• Have they ever been admitted to hospital with • Nephropathy: protein loss, renal failure .
diabetic ketoacidosis {DKA)? • Foot disease: ulceration, arthropathy
• Do they go to a pediatrist? • Peripheral neuropathy: sensory loss, motor
• Have they experienced any problems with their weakness.
feet? Do they use any moisturizers or cream on Macrovascular
'-'
their feet? • Coronary circulation: myocardial ischaemia and
• Do they participate in a retinal screening infarction.
program? • Cerebral circulation: transient ischaemic attack
• Have they needed a referral to an (TIA }, stroke.
ophthalmologist? • Peripheral circulation: claudication, gangrene and
amputation .
► N.B .
In the newly diagnosed diabetic, ask about a history
of weight loss (will differentiate type 1 and type 2
diabetes).
Diabetes may present with the classical triad of

symptoms:
1. Polyuria: due to osmotic diuresis caused by
glycosuria.
2. Thirst: due to the resulting loss of fluid and
electrolytes.
3. Weight loss: due to fluid depletion and breakdown of
V fat and muscle secondary to insulin deficiency.
• Other common symptoms include tiredness, blurred

vision ( due to glucose-induced changes in lens
refraction ) and itching of the genitalia ( pruritus
vulvae in women or balanitis in men ) due to candida A
yeast infection ( thrush ) V

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"...

Allam·s Clinical Examination

134 Neur ology

191 Rheu mato logy

213 Misce llaneo us

Allam s Clinica l Exami nation

► Personal History: NASOM RH

Diseases common Diseases common

► N.B. Ask about number of cigarettes/day and duration + type

C~ est C.V.s G.I.T. Other complications

Ask about the amount/ day. ._,,

GIT CNS CVS

Please Write Personal History in a single paragraph as:

► N.B. In neurological sheet add handedness to personal history

► Complaint: C/O + Duration

Analysis Of The Compla int:

+ 3 variants + 3 for any excreta: + 3 for any pain:

Disease Operative ' Drugs

Don't Rush to examination before making a

GOOD DOC TOR ....

GENERAL EXAM INATION

1. Vital Signs: 3. Regions:

G Decubitus or position see pictures later in inspectio_n section

Neck vein (H & N)

.,S..s Mentality, Face + general lock.

Manuver of examining radial pulse (most commonly used): -..._/

Examine rhythm before rate if regular count in 15 or 30 sec. if irregula

Regular .....--- - - - - - - - - - Irregular

Extra systole Atrial Fibirilation

Small Pulse volume Big Pulse volume Variable Pulse volume

Causes of unequal pulse:

1. Water hammer pulse= collapsing pulse= bounding pulse :

2. Plateau pulse = pulsus tardus et parvus:

5. Pulsus bisferiens =bifid =double hump:

7. Pulsus bigeminus, Pulsus trigem inus & pulsus

Other peripheral arterial pulsations & capillary pulsation

Sup. Temporal Ant. & sup to tragus

Against the transverse process of 6th Ulner

Example of normal pulse:

Base Continuous Remittent Intermittent Relapsing

1. Continuous: {Gram negative sepsis, CNS damage)

► Temperature - Pu lse relationship:

► Temperature - Respiration relationship :

For meas urem ent of blood pressure you have to do:

1. Palpatory and Auscultatory :

Patient : The doctor:

Auscultatory Gap: (Silent gap)

2. Measure right and left :

3. upper limb and lower limb :

4. Measure blood pressure on laying flat and standing :

► Orthostatic Hypotention: ► N.B.

Uses of sphygm omano meter:

2. In some valvular disorder s:

Pallor, Jaundice, Cyanosis, Pigmentations & Skin rashes

Def.: yellow discoloration of skin & mucous membranes due

DD of yellow discoloration of skin & sclera:

Cyanotic lung disease : Generalized decreased blood Flow :

All the body: Skin of peripheral parts:

► N.B.: • Examination of under surface of tongue is better

• Haemochromatosis. • Malar rash in MS with PH++ due to:

• Orthopnea: Semi setting position

Internal jugular vein is preferred:

. Internal jugular vein - ~...... . External jugular vein