Clinical Examination Dedication June, Daniel, Marc, Morris and Nancy (Owen Epstein) Harry, George, Josephine, Tom, Ted, Elsie and Ella (David Perkin) Anna, Alastair and Fiona (John Cookson) Dr Natasha Kapur, my wife and fellow physician My children Rohan and Karan (Roby Rakhit) Dr Natasha Arnold, my wife and fellow physician, who shares our passion for looking after the whole of the patient and is proud to be called a generalist (Andrew Robbins) Sioban, Calum, Kieran and Brendan (Ian Watt) To Rosemary, my wife for her loving support (Graham Hornett) Commissioning Editor: Laurence Hunter Development Editor: Janice Urquhart, Pru Theaker Project Manager: Nancy Arnott Illustration Manager: Gillian Richards Illustrator: Marion Tasker, MTG and Chartwell Clinical Examination Fourth Edition Owen Epstein MB BCh FRCP Consultant Physician and Gastroenterologist, Royal Free Hospital NHS Trust, London, UK G David Perkin BA MB MRCP Emeritus Consultant Neurologist, Charing Cross Hospital, London, UK John Cookson MD FRCP Dean of the Undergraduate School, Hull York Medical School, University of York, York, UK Ian S Watt BSc MB ChB MPH FFPH Professor of Primary Care, Hull York Medical School, University of York, York, UK Roby Rakhit BSc MD MRCP Consultant Cardiologist and Honorary Senior Lecturer, Royal Free Hospital, London, UK Andrew Robins MB MSc MRCP FRCPCH Consultant Paediatrician, Whittington Hospital NHS Trust, London, UK Graham A W Hornett MA MB BChir FRCGP General Practitioner with a Special Interest in ENT, Surrey Primary Care Trust, UK Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2008 © © © © 1992 Gower Medical Publishing 1997 Times Mirror International Publishers Limited 2003, Elsevier Limited All rights reserved 2008, Elsevier Limited All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the Publishers Permissions may be sought directly from Elsevier’s Health Sciences Rights Department, 1600 John F Kennedy Boulevard, Suite 1800, Philadelphia, PA 19103-2899, USA: phone: (+1) 215 239 3804; fax: (+1) 215 239 3805; or, e-mail: healthpermissions@elsevier.com You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com), by selecting ‘Support and contact’ and then ‘Copyright and Permission’ First edition 1992 Second edition 1997 Third edition 2003 Fourth edition 2008 ISBN 9780723434542 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress Note Knowledge and best practice in this field are constantly changing As new research and experience broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications It is the responsibility of the practitioner, relying on their own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions To the fullest extent of the law, neither the Publisher nor the Authors assume any liability for any injury and/or damage to persons or property arising out or related to any use of the material contained in this book Working together to grow libraries in developing countries www.elsevier.com | www.bookaid.org | www.sabre.org The publisher’s policy is to use paper manufactured from sustainable forests Printed in China Preface The fourth edition of Clinical Examination comes at a time of momentous change in medical practice Gone are the white coats with their dog-eared pockets overflowing with all the paraphernalia of bedside examination The stethoscope, once peeping subtly from a pocket, in now draped like a necklace, as much a fashion statement as a tool of the trade The spiral-bound notebook is giving way to the personal digital assistant, the pen for a stylus and keyboard, and the evocative sound of the bleep is making way for the ringtones and soundscape of the mobile phone In the consulting room, the fraying patient file, with its often illegible testimony of the patient’s medical journey, is making way for the electronic patient record, displayed in legible type, and instantly retrievable from cyberspace The modern era is also blurring the traditional boundaries which once clearly demarcated the doctor-patient relationship Where once the nurse primarily tended for patients’ physical and emotional needs, highly trained practice nurses and nurse specialists now carry stethoscopes and undertake clinical roles previously considered wholly doctor owned With improved telecommunication, fax, Internet and email, even medical receptionists and secretaries have to learn to respond to patients’ questions, concerns and needs To all this is added the panoply of new investigations including MRI, spiral CT scanning, virtual colonoscopy, virtual bronchoscopy and coronary angiography, wireless capsule endoscopy, minimal access surgery and a whole new frontier of genetic profiling and targeted biological therapies Where does this leave Clinical Examination? In this new edition, the authors have reasserted the centrality and importance of the face-to-face consultation in this fastchanging medical landscape Perhaps it is more important than ever for all those engaged in direct patient care to remain closely connected with the patient’s story and physical examination There is no debate about the value of skilled history taking and physical examination and its importance in directing the patient journey and problem solving Indeed, as patients become more knowledgeable about health and illness, communication skills and the ability to engage in a professional two-way discourse become increasingly important The changing emphasis in the clinical encounter is recognized throughout this edition with the first two chapters emphasizing the CalgaryCambridge schema of gathering information, examining the patient, explaining, planning and closing the consultation For the first time, each chapter has been peer reviewed by both a primary care and hospital doctor and two general practitioner authors have contributed chapters to the book Where necessary, changes have been made to reflect the increasing primacy of general practice and the emergence of overlapping roles in modern healthcare practice The principles that underpinned the first edition remain intact Each of the systems chapters is introduced with an overview of clinical anatomy and physiology This provides a backdrop for describing history taking and the normal and abnormal examination, and the book spans the age range from infancy to old age The text is lavishly illustrated to provide a multimedia reading experience and the use of colour coded icon boxes, including a new ‘red flag’ box, provides quick access to summarized information and a revision resource for the ‘night before’ exams The first two chapters introduce the reader to history taking, the general examination and the principles of problem-orientated records The subsequent chapters are systems-based and include the skin, nails and hair, ears, nose and throat, respiratory, cardiovascular and abdominal systems, the female and male genitalia, bones joints and muscle, neurology and finally, the examination of infants and children Over a decade, Clinical Examination has established its position as a leading text for medical students, postgraduates, nurses, physiotherapists and a range of other healthcare professionals Clinical tutors have found the book and its illustrations a particularly helpful source for teaching and learning This latest edition consolidates its position as a rich resource to help learn and teach clinical skills in a rapidly changing modern era v Acknowledgements vi We wish to thank the following individuals and organisations for generously providing illustrative material: The figures listed below were derived with permission from the following sources: Dr Philip Bardsley, Dr Russell Lane, Dr Mike Morgan, Dr P H McKee and Dr John Wales; Joan Slack, Dept of Clinical Genetics, Royal Free NHS Trust (Figs 2.3–2.7, 2.9–2.16); Dr Les Berger, Dept of Radiology, Royal Free NHS Trust (Figs 2.36, 2.37, 7.16a); Dr Malcolm Rustin (Figs 3.12, 3.15, 3.23–3.26, 3.30, 3.31, 3.70–3.72); King’s College Hospital (Figs 3.13, 3.14, 3.16, 3.37, 3.39–3.43, 3.45–3.47, 3.54, 3.65, 3.73, 3.74) for slides reproduced from Anthony du Vivier: Atlas of Clinical Dermatology (Gower Medical Publishing UK, 1986); Professor Tony Wright (Figs 4.9, 4.12, 4.13); Dr James Entwhistle for Figs 5.5–5.10; Dr C Richards for Fig 5.13; Dame Margaret Turner-Warwick et al (Figs 5.2, 5.11, 5.12, 5.14, 5.20, 5.29) for slides reproduced from Clinical Atlas of Respiratory Diseases (Gower Medical Publishing UK, 1989); Professor Robert H Anderson and Dr Sally P Allwork (Figs 6.4, 6.6, 6.7) for slides reproduced form Cardiac Anatomy (Gower Medical Publishing UK, 1980); Dr James S Bingham (Figs 8.37, 8.43–8.46, 9.14, 9.15, 9.29) for slides reproduced from Sexually Transmitted Diseases (Gower Medical Publishing UK, 1984); Dr Paul A Dieppe et al (Figs 10.8, 10.9, 10.38, 10.42, 10.50–10.52, 10.64, 10.66, 10.69, 10.75, 10.77, 10.78, 10.80, 10.81, 10.91) for slides reproduced from Atlas of Clinical Rheumatology (Gower Medical Publishing UK, 1986); Mr David Spalton et al (Figs 11.24–11.28, 11.30–11.39, 11.52, 11.62, 11.64, 11.65) Atlas of Clinical Ophthalmology (Gower Medical Publishing UK, 1984) Fig 11.13 from R B Strub and F William Black: The Mental Status Examination in Neurology (F A Davis Co); Figs 11.16, 11.17, 11.19, 11.24–11.26, 11.28–11.41, 11.43–11.45, 11.50, 11.52, 11.62, 11.65) from David Spalton: Atlas of Clinical Ophthalmology (Gower Medical Publishing UK, 1984); Fig 11.41 (right) from Haymaker, Webb: Bing’s Local Diagnosis in Neurological Diseases, 15th edn (St Louis, The C V Mosby Co, 1989); Figs 11.46 and 11.47 from J S Glaser: Neuro-ophthalmology (Harper & Row); Figs 11.48 and 11.49 from R John Leigh and David S Zee: The Neurology of Eye Movement (F A Davis Co); Fig 11.106 from Drs J W Lance and J G McLeod: A Physiological Approach to Clinical Neurology (Butterworths); Fig 11.103 from Lord Walton of Detchant: Introduction to Clinical Neuroscience, 2nd edn (Baillière Tindall Ltd); Fig 11.96 from Professor R S Snell: Clinical Neuroanatomy for Medical Students, 2nd edn (Little, Brown & Co); Figs 11.104 and 11.105 from Dr V B Brooks: Neural Basis of Motor Control (Oxford University Press); Fig 11.134 from ‘Somaesthetic Pathways’ Br Med Bull, 33, 113–120, 1977; Fig 11.142 from Professor Ian A D Bouchier CBE and J S Morris; Clinical Skills, 2nd edn (W B Saunders); Figs 11.150–11.152 from Dr F Plum: Diagnosis of Stupor and Coma, 3rd edn (F A Davis Co) Figs 12.1, 12.15–12.26 and 12.27 from Dr Caroline Fertleman, UCL Medical School; Figs 12.3a and b, 12.29, 12.30a–12.30j, 12.30l–12.30n, 12.31, 12.32, 12.35–12.37 from Dr Heather Mackinnon, Whittington Hospital Growth charts reproduced with kind permission of Castlemead Publications, Welwyn Garden City; Figs 12.11 and 12.33 with kind permission from Dr T Lissauer: Illustrated Textbook of Paediatrics (Mosby); Figs 12.42 and 12.45 from Clement Clarke Contents Consultation, medical history and record-taking Ian Watt The consultation Gathering information: the history Systems review Recording the medical interview The general examination Owen Epstein General examination Formal examination Recognisable syndromes and facies Endocrine syndromes The thyroid gland The parathyroid glands The adrenal glands The pituitary gland Nutrition Clinical assessment of vitamin status Clinical assessment of hydration Clinical assessment of shock Colour Oedema Temperature and fever The lymphatic system Skin, hair and nails Owen Epstein Structure and function Symptoms of skin disease Symptoms of hair disease Symptoms of nail disease Examination of the skin, hair and nails Skin infections Skin manifestations of systemic disease Nail disorders 1 10 20 20 21 22 27 27 33 35 38 40 43 44 44 45 46 49 50 57 57 59 60 61 61 71 78 79 Ear, nose and throat Graham A W Hornett Structure of the ear Symptoms of ear disease Examination of the ear Structure of the nose and sinuses Symptoms of diseases of the nose and sinuses Examination of the nose and sinuses Structure of the throat Symptoms of diseases of the throat Examination of the throat The respiratory system John Cookson Structure and function Symptoms of respiratory disease General examination Examination of the chest Common patterns of abnormality The heart and cardiovascular system Roby Rakhit Structure and function Electrical activity of the heart Cardiac arrhythmias Blood supply to the heart The arterial system The venous system Clinical history Occupation and family history Clinical examination of the cardiovascular system Examination of the jugular venous pulse Palpation of the precordium Auscultation of the heart 82 82 83 86 93 94 96 98 100 101 105 105 112 120 125 133 139 139 144 145 148 151 152 152 157 157 164 166 167 vii Cardiovascular system and chest examination Cardiovascular system and abdominal examination Peripheral vascular system Peripheral vascular disease The abdomen Owen Epstein Structure and function Symptoms of abdominal disorders Examination of the abdomen Examining the groin Examining the anus, rectum and prostate Female breasts and genitalia Owen Epstein Structure and function Breast structure and function Symptoms of breast disease Examination of the breast Structure of the genital tract Symptoms of genital tract disease Examination of the female genital tract Examination of the abdomen Examining the external genitalia Examination of the vagina Examination of the cervix Internal examination of the uterus The male genitalia Owen Epstein Structure and function Symptoms of genital tract disease Examination of the male genitalia 10 Bone, joints and muscle G David Perkin Structure and function Symptoms of bone, joint and muscle disorders General principles of examination GALS Regional structure, function and examination Temporomandibular joints The spine The shoulder The elbow The forearm and wrist The hand viii 173 173 174 178 The hip The knee The ankle and foot Patterns of weakness in muscle diseases 290 295 299 303 11 The nervous system G David Perkin 307 The cortex Examination Clinical application 307 310 314 The psychiatric assessment Examination Clinical application 317 319 319 Headache and facial pain 320 The cranial nerves 321 The olfactory (first) nerve Examination Clinical application 321 322 322 The optic (second) nerve Examination Clinical application 322 323 327 The oculomotor, trochlear and abducens (third, fourth and sixth) nerves Examination Clinical application 332 337 340 The trigeminal (fifth) nerve Examination Clinical application 345 347 349 The facial (seventh) nerve Examination Clinical application 349 350 351 The acoustic (eighth) nerve Examination and clinical application 353 354 The glossopharyngeal (ninth) nerve Examination Clinical application 354 355 355 267 269 272 The vagus (tenth) nerve Examination Clinical application 355 355 356 274 274 274 279 282 283 286 The accessory (eleventh) nerve Examination Clinical application 356 356 357 The hypoglossal (twelfth) nerve Examination Clinical application 357 357 358 186 186 193 204 220 221 226 226 229 230 231 235 238 242 242 243 244 246 248 252 252 255 257 265 265 The motor system Examination Clinical application 359 362 370 The cerebellar system Examination Clinical application 371 372 374 The sensory system Examination Clinical application 374 377 380 The unconscious patient Examination Clinical application 382 383 385 12 Infants and children Andrew Robins Taking a history The examination Growth and development The newborn and very young baby Older babies and toddlers The preschool child The school-aged child Adolescents Index 390 390 392 393 397 407 412 414 416 421 ix Index Crepitus, 268 Cricopharyngeus, 187 Cricothyroid membrane, 100 Crocodile tears, 352 Crohn’s disease anus in, 222, 224 skin manifestations of, 80 Croup, 103 Cruciate ligaments, 295, 297, 297 Cryptogenic fibrosing alveolitis, 111, 137 Cryptorchidism, 260 Cullen’s sign, 207 Cushing’s syndrome, 36, 37 abdomen appearance in, 206–7 skin manifestations of, 80 Cutis anserina, 58 Cutis laxa, 58 Cyanosis, 46, 46, 122, 122, 123, 157–8 infants, 409 newborns, 398 Cystitis, 203 Cystocele, 244 D Dandruff, 68, 75 De Quervain’s tenosynovitis, 270, 271, 284 Deafness, 85, 354 cranial nerve symptoms, in elderly people, 18 tests for, 90–2 Death, brain, 387–9, 388 Decerebrate posturing, 385 Deciduous teeth, 99 Decision-making, 16–17 Decorticate posturing, 385 Decubitus ulcers, 81 Deep tendon reflexes, 365–7, 365–7 Deep vein thrombosis, 179–80 Defibrillation, 148, 148 Deformity finger, 269–70, 270 joint, 269–70 knee, 269 Dehydration, 44, 44, 63 Déjà vu, 318 Delirium, 318 Deltoid muscles, 42 Delusions, 318 Dementia, 310, 314, 314 in elderly people, 18 history taking, 10 Dentate nucleus, 372 Dependent oedema, 175 Depersonalisation, 318 Depression, 318, 320 general demeanour, 20 history taking, 10 Derealisation, 318 Dermal naevus, 76, 77 Dermatitis, 65, 68, 68 Dermatitis herpetiformis, 76, 76 Dermatomes, 375, 376 Dermatomyositis, 80 Dermatophytes, 74, 74 Dermis, 57–8, 58 Development, 396, 396–7 adolescents, 418 infants, 408 newborns, 397 preschool children, 412 school-aged children, 414 Di-iodotyrosine (DIT), 28, 28 Diabetes insipidus, 41, 193 cranial, 40 nephrogenic, 40 Diabetes mellitus characteristics, 9–10 ketoacidosis, 126 and peripheral vascular disease, 178–9 retinopathy, 330, 330 skin manifestations of, 80 Diagnostic tests, problem-orientated medical records, 14 Diaphragm movement assessment, 130 pain, 198 paralysis, 126 Diarrhoea, 190, 200 dehydration, 44 spurious, 200 Diarthroses, 266 Diastolic murmurs, 172, 172–3, 173 Digestion, 186–9, 189 Digestive enzymes, 187 Digestive organs, 186, 186–93 Digits see Fingers Dilatation, heart, 142 Dilated cardiomyopathy, 169, 182 Diplopia, 9, 336, 337, 338, 359 in Graves’ disease, 31 Discharge breast, 231, 234 ear, 84–5 nose, 95 Discoid eczema, 67 Discoid lupus, 80 Dislocation, 269 Dissecting aortic aneurysm, 155 Distributive shock, 45 Divarication hernia, 206, 206 Dix-Hallpike test, 92–3 Dizziness see Vertigo Doctor-patient relationship, Documentation history taking, 11 medical interview, 10–19 systems review, 10 see also Recording Dog-in-the-night-time syndrome, 123 Doll’s head manoeuvre, 338, 338, 385 Dopamine, 38, 39 Doppler ultrasound, 179 Dorsal column lesion, 381 Dorsal interosseus, 286, 289, 289 Dorsalis pedis pulse, 161, 161 Dorsiflexion, 271, 299, 302 Down’s syndrome (trisomy 21), 23, 24, 24 Dress code, 2–3 Dressing, 309 Drug history, 6–7 psychiatric assessment, 319 respiratory disease, 120 Drug-induced coma, 386 Drugs associated with tinnitus, 86 causing impotence, 257 causing nausea, 196 illicit, history taking, photosensitive rashes, 66–7 porphyria of, 60 skin reactions to, 64, 66, 67 Drusen, 329, 329 Duodenum, 187 Dynamic lung volumes, 110, 110 Dysarthria, 311–12, 315, 359, 372 Dyscalculia, 315 Dysdiadokokinesis, 373 Dysfunctional uterine bleeding, 240 Dysgraphia, 309, 313 Dyskinesia, 369 Dyslexia, 309, 316 Dysmenorrhoea, 8, 241 Dysmorphology, facial, 403, 404 Dysmotility syndromes, 194 Dysosmia, 94 Dyspareunia, 241 Dyspepsia, 195 Dysphagia, 7, 9, 101, 187, 193–4 Dysphasia, 312, 315, 315–16 Dysphonia, 312, 315 Dyspnoea causes of, 113–14 duration of, 113, 114 in heart disease, 153–4 and hypoxia, 115 paroxysmal nocturnal, 114–15 in respiratory disease, 113–15 severity of, 114 systems review, variability of, 114 Dysprosody, 312 Dysthyroid eye disease, 345, 345 Dystonia, 369, 371 Dysuria, 203 E Ear, 82–93 disease symptoms, 83–6 elderly people, 103 examination, 56, 86–93 external see External ear inner see Inner ear middle see Middle ear structure of the, 82–3, 83 Early diastolic murmurs, 172, 172 Ecchymoses, 62, 410 Eccrine glands, 58 Echolalia, 316 Ectopic beats, 146, 147, 156 Ectopic pregnancy, 197, 241 Eczema, 67–8, 67–8 ear signs, 87 varicose, 68, 179 Edinger-Westphal nucleus, 332, 341 Education, 5, 14–15 Efferent pathways, 307 Effusions, 269, 270 elbow, 282 hip, 292 knee, 296, 297, 298 middle ear, 89 pericardial, 123, 183–4, 184 pleural, 47, 131, 133, 134, 135 shoulder, 279 Eisenmenger’s syndrome, 150, 151 425 Index Ejaculatory duct, 255 Ejection clicks, 169–70, 170 Ejection systolic murmur, 171, 172 Elastic cartilage, 266 Elastin, 57–8 Elbow, 282, 282–3, 283, 284 Elderly people abdominal examination, 225 bones, muscles and joints, 306 cardiovascular examination, 185 ear, nose and throat examination, 103 female breasts and genital tract, 250 history taking, 18 male genitalia and genital tract, 264 nervous system examination, 389 nutrition, 55 respiratory examination, 137 skin changes in, 81 Electrical activity of the heart, 144, 144–5 Electrocardiogram (ECG), 144–5, 145, 146 Electrolyte balance, 44, 192 Emphysema, 110 chest auscultation, 130 chest percussion, 129–30 lung volumes in, 111 surgical, 126 Employment history see Occupational history Encephalopathy, hepatic, 201, 212–13, 213 Endocarditis acute, 181 infective, 158, 181–2 postoperative, 182 subacute, 158, 181 Endocrine system disorders, 23–7, 61 history, 9–10 organs, 27, 27 (see also specific organ) syndromes, 27 Endocytosis, 28, 28 Endolymph, 354 Endometriosis, 241 Endometrium, 236 Endophthalmitis, 23 Enophthalmos, 124 Enterocytes, 187, 188 Enteroglucagon, 189 Enterokinase, 192 Enzymes cardiac, 177 digestive, 187 pancreatic, 192 Eosinophils, 116 Epicondylitis, 283 Epidermal cells, 57 Epidermis, 57, 58 Epididymal cysts, 261, 261 Epididymis, 252, 255, 255 palpation, 260, 260 Epididymitis, 262, 263 Epiglottis, 100, 100 Epiglottitis, 103 Epilepsy, 8, 156, 381 Epistaxis, 94–5, 98 Epitrochlear lymph nodes, 52, 53, 54, 55 Eponychium, 59 Erection, prolonged, 259 Erysipelas, 72, 72 426 Erythema, 62 in bullous pemphigoid, 75, 75 cellulitis-associated, 72 toxic, 65, 65 Erythema marginatum, 182 Erythema multiforme, 66, 66 Erythema nodosum, 59, 65, 65, 66, 80, 125 in respiratory disease, 124, 124 Erythema toxicum, 407, 407 Erythroderma, 65 Erythropoietin, 45, 192 Euphoria, 318 Eustachian tube, 82, 86, 89 dysfunction, 89 Examination children, 392–3 formal, 21–2 general, 20–1, 56 patient position, 22, 22 recording, 13 setting, 22 Exertional dyspnoea, 153 Exfoliative dermatitis, 65 Exophthalmos, 31 Expiration, 126 Exploration, 109 Extension, 271 ankle and foot, 299, 300 cervical spine, 275 elbow, 282, 282, 283 fingers, 283, 286 forearm and wrist, 283, 284, 285 hip, 293, 295, 295 knee, 296, 298, 299 lumbar spine, 275 shoulder, 279, 280 thoracolumbar spine, 276 thumb, 287 Extensor carpi radialis brevis, 284 Extensor carpi radialis longus, 284, 285 Extensor carpi ulnaris, 284, 285 Extensor digitorum, 286 Extensor digitorum longus, 299, 300 Extensor hallucis longus, 299–300, 300, 303, 303 Extensor pollicis brevis, 284 Extensor pollicis longus, 286 External ear examination, 87, 87–8, 88 pain, 84 structure of the, 82 Extrahepatic cholestasis, 201 Extraocular muscles, 338 Extrapyramidal system, 360, 368–70 disorders, 371 Extrasystoles, 146, 147, 155 Extrinsic allergic alveolitis, 120 Eye assessment for dehydration, 44 examination, 22–3 in Graves’ disease, 30–1, 31, 32 movements, 339, 372 disorders, 339, 341, 342 inspection, 337 saccadic, 334–5 in the unconscious patient, 385 muscle testing, 338, 338–40, 339 newborns, 402, 402 in respiratory disease, 124–5 Eye contact, Eyelid inspection, 337 retraction, 31, 31 F Face asymmetry, 350 dysmorphology, 403, 404 expression, 3, 20 movement disorders, 352, 352–3 numbness, 9, 359 pain, 95, 321 palsy, 74 paresis, 359 plethora, 45 weakness, 350, 350, 351, 352 Facial (seventh) nerve, 82, 349, 349–53, 350, 411 Facies, 22–7, 158 Faecal incontinence, Failure to thrive, 394 Fainting, 8, 156–7 Fallopian tubes, 237, 237 Fallot’s tetralogy, 150, 151 Familial hypercholesterolaemia, 23, 26, 26, 27 Family history, cardiovascular disease, 157 children, 391 psychiatric assessment, 319 respiratory disease, 120 Family trees, 5, 5, 391, 391 Farmer’s lung, 120 Farnsworth Munsell test, 324 Fasciculation, 269, 273, 352, 362 Fast twitch fibres, 267 Fastigial nucleus, 372 Fat digestion, 189, 189 Fat-soluble vitamin deficiency, 43 Female genitalia and genital tract, 226–51 anatomy, 235 blood supply, 235 disease symptoms, 238–42 examination, 56 abdominal, 242, 242–3 cervical, 246–8 external genitalia, 243, 243–4, 244 general, 242 uterine, 248–50 vaginal, 244–6 external, 236, 243, 243–4, 244 in infants, 411 newborns, 400–1 structure and function, 226–9, 235–8 symptoms of disease, 238–42 Femoral artery, 220 Femoral epiphysis, slipped, 294 Femoral hernia, 220, 221 Femoral neuropathy, 299, 299 Femoral pulse, 159, 160–1, 161, 178, 398, 398 Femoral sheath examination, 220–1, 221 Femoral stretch test, 276, 277 Femur fractures, 294 Fenestrae, 190 Fertility, male, 254 Fetal circulation, 149, 149–50, 397, 397 Index Fever, 50 dehydration, 44 in lung disease, 118 Fever blister, 73, 73–4 Fibrillation, 148 Fibroadenoma, 234 Fibroadenosis, 234 Fibrocartilage, 266 Fibrocartilaginous semilunar cartilages, 295 Fibromyomas (fibroids), 249 Fibrosing alveolitis crackles, 132 cryptogenic, 137 Fibrosis, lung, 110, 128, 131, 136, 137 lung volumes in, 111 Finger drop, 286, 286 Finger jerk, 366, 366 Fingernails see Nails Fingers clubbing, 31, 80, 80 deformities, 269–70, 270 extra, 406 movements, 287 reflexes, 366, 366 Fingertip bruising, 410 First heart sound, 168–9 First impressions, 20–1 Fissured tongue, 102 Fixed drug eruption, 66, 67 Flapping tremor, 213, 213 Flatulence, 7, 199 Flexion ankle, 300 cervical spine, 275 deformity, 271, 272 elbow, 282, 282, 283 fingers, 283–4, 287 foot, 300 knee, 295, 296 lumbar spine, 275 shoulder, 280 thoracolumbar spine, 276 thumb, 287 wrist, 285 Flexor carpi radialis, 284, 285 Flexor carpi ulnaris, 284, 285 Flexor digiti minimi, 286 Flexor digitorum longus, 299 Flexor digitorum profundus, 286 Flexor digitorum sublimis, 286 Flexor hallucis longus, 299 Flexor pollicis brevis, 286 Flexor reflex afferents (FRA), 361 Flow charts, problem-orientated medical record, 15–16, 17, 18 Flow meters, 110, 110 Fluency of speech, 312–13 Fluid balance, 44, 192 Focal tachycardia, 147 Folic acid deficiency, 43 Follicle-stimulating hormone (FSH), 38, 226, 227, 228, 252, 253, 254 failure, 40, 41 Follicles ovarian, 228, 228 thyroid, 28 Fontanelle, 402, 402 Foot, 299–303, 300, 303 deformities, 301 Foot drop gait, 305, 305 Forced expiratory volume in second (FEV1), 110 Forced vital capacity (FVC), 110 Forearm, 283–6 Forearm carrying angle, 282, 282 Foregut pain, 198, 198 Foreign body in the eye, 23 lung collapse, 135 vaginal, 241 Foreign travel, history, Foreskin see Prepuce Formal examination, 21–2 Fourchette, 236 Fourth heart sound, 169, 169 Fractures atlas, 279 cervicothoracic junction, 279 Colles’, 284, 285 femur, 294 humerus, 280 Pott’s, 301 scaphoid, 288 Smith’s, 285 vertebral body, 279 Fragile X syndrome, 23 Frequency of micturition, 8, 202–3 Frontal lobe, 307, 308 Frontal sinusitis, 98 Frontalis, 350 Frozen shoulder, 279 Functional mental states, 319–20 Functional residual capacity (FRC), 110 Fundoscopy, 326–7, 327 Fungal infections ear, 84 nails, 79 skin, 74 Funnel chest, 125, 125 Furuncle, 72 ear, 88 vulval, 244 Furunculosis, 88 G G-cells, 187 Gag reflex, 354, 355, 355, 388 Gait ataxia, 372 in cerebellar disorders, 374, 374 disorders, 305, 305–6 first impressions, 20 GALS, 272 Galactorrhoea, 39, 231 Gallbladder, 191, 191 pain, 198 palpation, 213–14, 214 Gallop rhythm, 169 Gallstones, 202, 214, 214 GALS, 272–4 Gangrene, 178, 178 Gas exchange, 110–11 Gasserian ganglion, 346 Gastric acid, 187 Gastric inhibitory polypeptide, 189 Gastric outflow obstruction, 219, 219 Gastric secretions, 187 Gastrin, 187, 189 Gastro-oesophageal reflux cough, 115 pain, symptoms, Gastrocnemius, 180, 299, 300 Gastrointestinal system, 186–93, 186–93 bleeding, 196, 201 diseases, 193–9 hormones, 189 newborns, 400, 400 review, 7–8 in the unconscious patient, 383 Gate control theory, 376 Gathering information see History-taking Gaze, 334–5, 336 in infants, 411 paresis, 341 Gegenhalten, 363 Geniculate body lesions, lateral, 331 Geniculate ganglion, 74, 349, 349, 352 Genital ulcers, 256, 259 Genital warts see Condylomata acuminata Genitalia see Female genitalia; Male genitalia Genu valgum, 269, 269, 295, 413, 413 Genu varum, 269, 269, 295, 413, 413 Geographical orientation/disorientation, 309, 311, 312, 315 Geographical tongue, 102 Gerstmann’s syndrome, 316–17 Gestation and weight at gestation, 403 Ghrelin, 189 Gibbus, 274, 274 Gigantism, 39 Gingivitis, 116 Glabellar tap, 314 Glands of Montgomery, 229, 235 Glandular fever, 102 Glans penis, 254, 254, 258 Glasgow coma scale, 383, 383 Glaucoma, 23, 330, 331 Glenohumeral joint, 279, 280 Global aphasia, 316 Globe, 335 Globus pallidus, 350, 360 Globus syndrome, 103 Glomerular filtration, 193 Glomerulus, 192 Glossopharyngeal (ninth) nerve, 186, 187, 354, 354–5, 411 neuralgia, 355 Glucagon, 189, 192 Glucocorticoids, 35–6 Gluconeogenesis, 36 Glue ear, 89–90, 90 Gluteus maximus, 291, 292 Glycosaminoglycans, 57 Goitre, 29, 29, 30, 30, 31 Golfer’s elbow, 282 Gonadotrophin-releasing hormone (GnRH), 226, 227 Goniometer, 271, 271 Gonorrhoea, 241, 259 Goose pimples, 58 Gout, 301, 302 pain, 268 swelling, 270 Gowers’ manoeuvre, 304, 304 Graafian follicle, 228, 228 427 Index Granuloma inguinale, 244 Grasp reflex, 314, 314, 317 Graves’ disease, 30–2, 31, 32 bruits, 29 Grey Turner’s sign, 207 Grip, 21 Groin examination, 220–1, 221 strains, 294 Grommets, 90, 90 Growth adolescents, 416, 416–17, 417 failure, 21, 394, 414, 415 in general, 393–5 infants, 408 newborns, 397 phases of, 393 preschool children, 412 school-aged children, 414 Growth charts, 394–5, 395 Growth hormone (GH), 38 deficiency, 415 excess, 21, 39 failure, 40, 41 Grunting, 400 Guarding, 198 Gummas, 72, 262 Gut bacteria, 201 Guttate psoriasis, 59, 69, 69 Gynaecomastia, male, 232, 233, 258, 258 H Haematemesis, 7, 100, 116, 196 Haematuria, 203 Haemochromatosis, 46, 61 skin colour, 61 Haemoglobin, 122, 157–8 Haemoptysis, 7, 100, 116–17, 133 Haemorrhage cerebral, 372 splinter, 79, 158, 158 subconjunctival, 23 Haemorrhagic pancreatitis, 207 Haemorrhoids, 201, 224 Haemosiderosis, 61 Hair dermatophytes, 74 disease, 60, 60–1 pubic see Pubic hair structure and function, 58 Hairline, low, 405 Hairy tongue, 102 Halitosis, 98 Hallpike (Dix-Hallpike) test, 92–3 Hallucinations, 318, 322 Hallux rigidus, 301 Hallux valgus, 301, 301 Hammer toe, 301, 301 Hamstrings, 291, 292, 298 Handedness, 9, 311 Hands, 286, 286–90 in heart disease, 158, 158 muscle wasting, 362, 362 Handshake, 21, 21 Haversian canals, 265 Hay fever, 98 Head and neck lymph nodes, 53–4, 54 428 Head circumference measurement, 393, 393, 397, 402, 402 Head lice, 75 Head position, 354 Head rotation, 356, 357 Headache, 8, 320–1 Hearing, 82–3 loss see Deafness Heart, 139–85 auscultation, 167, 167–73, 398, 399 autonomic effects on the, 145 blood supply, 148–51 chambers, 139, 140 disease, 117–18, 158, 158 electrical activity of the, 144, 144–5 enlargement, 142, 142 muscle, 141, 141–2 structure and function, 139, 139–44, 140 valves, 142, 142, 170, 170 Heart block, 146, 146 Heart failure, 175–6 acute, 175, 175 chronic, 175–6, 176 oedema, 174–5 Heart sounds, 142–4, 143–4, 168–70, 168–73 newborns, 398, 399 Heartburn, 7, 194 Heberden’s nodes, 287 Heel-knee-shin test, 373, 374 Heel-toe walking, 374, 374 Hegar’s sign, 249 Height measurement, 394, 394, 412, 414, 414–17 midparental, 412 norms in adults, 41, 41 Hemianopia, 325, 331, 333, 334 Hemiballismus, 369, 371 Hemidesmosomes, 57 Hemifacial spasm, 352, 352 Hemiplegia, 357, 363 acute, 364 gait, 305, 305 Henoch-Schönlein purpura (HSP), 410 Hepatic encephalopathy, 201, 212–13, 213 Hepatitis, 196, 201 Hepatocellular disease, 201, 212–13 Hepatocytes, 190–1, 191 damage, 201 Hepatomegaly, 211, 212 Herald patch, 70 Herniae divarication, 206, 206 femoral, 220, 221 hiatus, 194, 194 incisional, 206, 206 inguinal, 206, 206, 220–1, 260 linea alba, 206 paraumbilical, 206, 206 scrotal, 258, 258, 260 transtentorial, 386, 387 umbilical, 401, 401 uncal, 386, 387 Herpes simplex, 73, 73–4, 244, 245 Herpes zoster, 62, 74, 74, 117 Hertel exophthalmometer, 31 Heschl’s gyrus, 353 Hesitancy, urinary, 203 Hiatus hernia, 194, 194 Hilar lymph nodes, 52 Hindgut pain, 198, 198 Hip joint, 290–5, 292, 293, 294, 295 in infants, 411 in newborns, 401, 401–2 Hirsutism, 60–1, 242 History-taking, 1, 3–7 adolescents, 418 background information, 5–6 biomedical perspective, children, 390–2 elderly people, 18 exploration of patient’s problems, 3–4 infants, 408–9 newborns, 398 past medical history, 6–7 preschool children, 413 psychosocial perspective, 4–5 recording, 11, 12–13 school-aged children, 414–15 skin, 59 see also specific system Hoarseness, 100–1 Hobbies and respiratory disease, 119 Hodgkin’s disease, 50 Holmes-Adie syndrome, 341 Holocrine secretion, 58 Holosystolic murmur, 171 Holter monitoring, 145 Homan’s sign, 49, 180 Home circumstances, history, Hordeolum, 72 Horizontal saccades, 334–5, 336 Hormones gastrointestinal, 189 in puberty, 226, 252–3, 253 Horner’s syndrome, 124, 291, 340, 340 Hospital wards, consultation in, Hospitalised patients, posture, 21 Hostile patients, 10 House dust mites, 114 Human chorionic gonadotrophin (HCG), 228 Humerus, 282 fracture, 280 Hung up reflexes, 373 Huntington’s disease, 341–2, 371 Hyaline bodies, 329, 329 Hyaline cartilage, 266 Hyaline laminae, 274 Hyaluronic acid, 57 Hydatid of Morgagni, 255 Hydration, clinical assessment of, 44, 44 Hydrocele, 260–1, 262, 401 Hydrochloric acid, 187 Hydronephrosis, 217 Hydrosalpinx, 250 Hydrostatic pressure, 47, 47 Hydrothorax, 47 Hydroxyapatite, 265 Hyperacusis, 351 Hyperadrenalism see Cushing’s syndrome Hyperbilirubinaemia, 61 Hypercalcaemia, 34 Hypercapnia, 388 Hypercholesterolaemia, familial, 23, 26, 26, 27 Hyperextension, 271 Hyperinflation, 136, 211 Index Hyperlipidaemia, 177 skin manifestations of, 80 Hypermetria, 342, 373 Hyperparathyroidism, 34, 34 Hyperpigmentation, 46 of the areola, 37, 37 in dermatitis herpetiformis, 76 Hyperprolactinaemia, 39, 40 Hypertelorism, 403 Hypertension, 163 heart sounds, 169 pulmonary, 181 retinopathy, 330, 330 Hyperthyroidism, 30, 31, 32 onycholysis in, 79 skin manifestations of, 80 Hypertrophic cardiomyopathy, 160, 160, 182, 182 Hypertrophic obstructive cardiomyopathy (HOCM), 144, 154, 182 Hypertrophic pulmonary osteoarthropathy, 121, 122 Hypertrophy heart, 142 muscle, 273 Hyperventilation, 112, 126 central neurogenic, 385, 386, 386, 387 dizziness with, in shock, 45 in the unconscious patient, 385, 386 Hyperventilation syndrome, 115 Hyphaema, 23 Hypoadrenalism, 37 Hypoalbuminaemia, 42, 47 leukonychia in, 79 Hypodermis, 58, 58 Hypoglossal (twelfth) nerve, 357–9, 358, 411 Hypogonadism, 258 Hypomania, 320 Hypometria, 342, 373 Hyponychium, 59 Hypoparathyroidism, 34 Hypopharynx, 100 Hypopituitarism, 40, 41 skin colour, 61 Hypopyon, 23 Hyposmia, 94, 322 Hypospadias, 258, 259, 406 Hypotelorism, 403 Hypotension, 163–4 in acute heart failure, 175 postural see Postural hypotension Hypothalamic-anterior pituitary endocrine axis, 38, 38 Hypothalamic-pituitary-gonadal axis, 227, 254 Hypothalamus, 28, 38, 38, 252 position of, 27 tumours, 21 Hypothenar eminence, 286 Hypothermia, 50 Hypothyroidism, 32–3 juvenile, 414 Hypotonia, 363, 373, 373 Hypoventilation, 112 Hypovolaemic shock, 45 Hypoxia, 113, 115 Hysteria, 320 Hysterical gait, 306 Hysterical personality, 320 I Ichthyosis, 50, 80 Idiopathic guttate hypomelanosis, 62 Idiopathic thrombocytopenic purpura (ITP), 410 Ileocaecal valve, 190 Ileum, 187, 189 Iliac crest, 205, 205 Iliacus, 291, 292 Illicit drugs, history taking, Illusions, 318 Immunisation, 407–8 Immunity, 407 Immunoglobulin A, 105–6 Immunoglobulins, 407, 408 Imperforate anus, 405 Impetigo, 71–2, 72 Impotence, 39, 257 Incisional hernia, 206, 206 Incisions, surgical, 158, 158 Incontinence faecal, 8, 222 urinary, 8, 203 Incus, 82, 353 Indigestion, 195 Infants, 407–12 development, 408 examination, 409–12 growth, 393, 393, 394, 394, 408 history-taking, 408–9 rashes, 410, 410 Infections ear, 87 skin, 71–8 see also Bacterial infections; Fungal infections; Viral infections Infectious keratitis, 23 Infectious mononucleosis, 102 Infective endocarditis, 158, 181–2 Inferior vena caval obstruction, 207 Infertility, male, 257 Infestations, skin, 75, 75 Inflammation ear, 87 oedema, 47 skin lesions, 63 Inflammatory joint disease, 268, 300 Infraclavicular lymph nodes, 52, 53 Infraspinatus, 279, 280, 281 Inguinal canal examination, 220–1, 221 Inguinal hernia, 206, 206, 220–1, 260 Inguinal ligament, 220 Inguinal lymph nodes, 52, 53, 55, 55 enlarged, 263 Inherited disorders, Injuries see Traumatic lesions Inner ear, 353, 353 examination, 90–3 structure of the, 82–3 Innocent murmurs, 172 Inspiration, 126 Insulin, 189 Intelligence, 311, 312 Intermenstrual bleeding, 239, 240 Intermittent claudication, 157, 178 Internuclear ophthalmoplegia, 343, 343 Interosseus, dorsal, 286, 289, 289 Interphalangeal joints, 287, 287, 288 Interstitial fluid, 47 Intervertebral discs, 274 prolapsed, 276–7 Interview see Consultation Intestinal obstruction, 200 abdominal pain, 197 Intracardiac shunting, 149, 149–51 Intracranial pressure, raised, 328 Intrahepatic cholestasis, 201 Intravascular fluid, 47 Intrinsic factor, 187, 187 Introitus, 236 Involuntary movement, 368 Iodine, 28, 28 Iridocyclitis, 124 Iritis, 23 Iron deficiency, 42 anaemia, 201 nails in, 79, 80 Iron overload see Haemochromatosis; Haemosiderosis Ishihara test plates, 324, 325 Islets of Langerhans, 192 Isthmus, 82 Itching see Pruritus J J receptors, 114 Jamais vu, 318 Janeway lesions, 181 Jaundice, 46, 46, 201, 202 in liver disease, 211 newborns, 400 skin colour, 61 Jaw jerk, 346, 348, 348 Jaw opening and closing, 345 Jejunum, 187, 189 Jendrassik manoeuvre, 365 Jerky carotid pulse, 160, 160 Jobson Horne probe, 88, 88 Joint position sense, 378–9, 379 Joints crepitus, 268 disease symptoms, 267–8 examination, 269, 269–72 locking, 268 movement, 271, 271–2, 272 pain, 267–8, 268 palpation, 270 structure and function, 266, 266–7 swelling, 268, 269, 270 temperature, 270, 271 tenderness, 270 see also specific joint Jugular foramen tumours, 357 Jugular venous pressure, 183, 184 Jugular venous pulse, 123, 164, 164–6, 165 Junctional naevus, 76, 76, 77 Juvenile hypothyroidism, 414 K Kaposi’s sarcoma, 78, 78, 101 Keratitis, infectious, 23 Keratosis, senile, 81 429 Index Kernig’s sign, 384, 384 Kidneys, 192–3, 193 disease, 202–3 examination, 215–17 pain, 203 palpation, 216, 216–17 polycystic disease, 174, 217 stones, 34 surface markings, 216 see also entries beginning with Renal Knee, 295–9, 296, 298, 299 clonus, 366, 367 deformities, 269, 269 pain, 294, 298 reflexes, 366, 366 Knock-knees see Genu valgum Koebner phenomenon, 69, 71, 71 Koilonychia, 42, 79, 80 Korotkoff sounds, 162, 162 Kremer, 368 Kupffer cells, 190 Kussmaul breathing, 126 Kyphoscoliosis, 126, 126 Kyphosis, 20, 126, 274, 274 L L-dopa, 369 Labia majora, 235–6, 243, 243 Labia minora, 236, 243–4 Labyrinth, ear, 82, 353 dysfunction, 86, 92 Lacrimation, loss of, 351 Lactation, 230, 231, 239 Lactiferous duct, 229, 230 Langerhans cells, 57 Language function, 308 see also Speech Lanugo hair, 58 Laryngeal nerves, 27 palsy, 115 Laryngitis, 103, 115 Laryngopharynx, 100 Laryngoscopy, 101, 101, 102 Laryngotracheobronchitis, 103 Larynx, 99–100, 100 examination, 103 tumours of the, 103 Lasegue’s test, 276, 277 Lateral epicondyle, 282, 283 Lateral geniculate body lesions, 331 Latissimus dorsi, 279, 281 Learning ability, new, 310–11 Left bundle branch block, 144 Left to right shunt, 150, 150 Left ventricle, 139, 140, 140, 141 hypertrophy, 167, 169 impairment, 169 Left ventricular failure, 114–15 dyspnoea, 153 oedema, 47 posture, 21 Legs GALS, 272–3 lymph nodes, 55 see also Lower limb Leucocytes in sputum, 116 Leukonychia, 42, 79, 79 Leukoplakia, 77, 77, 102, 244 430 Leydig cells, 252, 254 Lhermitte’s phenomenon, 371, 381 Libido, 8, 241 loss of, 238 (see also Impotence) Lice, 75 Lichen planus, 70–1, 71, 102 Lid lag, 31, 31, 32 Light reflex, 82, 89, 89 Light touch, 378, 378 Limbs in cerebellar disorders, 373, 373 clumsiness, 372 cranial nerve symptoms, length measurement, 292, 294 lower see Lower limb spastic, 363 thin in hyperadrenalism, 36, 37 upper see Upper limb weakness, 364 (see also Muscle(s), weakness) Linea alba hernia, 206 Lipase, 189 Lipid storage diseases, 51 Lipids, 189 Lips, central cyanosis, 122 Liver, 190, 190–1, 191 abnormal shape, 210–11, 211 auscultation, 220 disease, 201, 201–2 general signs of, 211–13, 213 malnutrition in, 42, 42 oedema, 47, 48 downward displacement of, 210, 211 enlargement, 211, 212 examination, 204, 204, 209, 209–13, 210 palpation, 209–11, 210 percussion, 210, 211 small, 211, 212 Liver cell damage, 201, 202 Lobes, lung, 105, 106, 107 collapsed, 135–6, 136 pneumonia, 133 Long bones, 265 Long saphenous vein, 179 Loop of Henle, 193 Lordosis, 274, 274 Low birth weight, 402 Lower limb, deep tendon reflexes, 366, 366–7 Lower motor neuron, 359, 360–2 facial weakness, 351 lesions, 358, 370, 370 Lower oesophageal sphincter, 187 Lumbar meningomyelocele, 405 Lumbar nerve roots, 299, 299, 303, 303 Lumbar spine, 275, 275, 276, 278, 279 Lumbosacral plexus, 375 Lumbrical muscles, 286 Lumps breast, 231, 232, 234 neck, 100 Lung cancer, 105 chest pain, 117 risk factors, 119 weight loss in, 118 Lungs abscess, 116, 131 collapsed, 128, 130, 133, 135–6, 136 breath sounds, 131 defence and histology, 105–8 effect of disease on other structures, 117–18 fibrosis see Fibrosis, lung function, 108–9 lobes see Lobes, lung volume, 109, 109–10, 110 in disease, 111 Lunule, 59 Lupus pernio, 80, 124 Luteinising hormone (LH), 38, 226, 227, 252, 253, 254 failure, 40, 41 Lymph, 47 Lymph nodes, 51, 51, 52, 52 enlargement see Lymphadenopathy examination of, 53–5 inguinal, 220 malignant, 53 thyroid carcinoma, 29 tuberculous, 124 Lymphadenitis, 53 Lymphadenopathy, 51, 52 in infants, 411 in respiratory disease, 123–4 Lymphangitis, 53 Lymphatic ducts, 51, 51 Lymphatic oedema, 49 Lymphatic system, 50–5 drainage, 51, 52, 53 breasts, 229–30 examination, 50–1 lymph nodes see Lymph nodes male genitalia, 255, 263 organs, 51 structure and function of, 51–2 Lymphoedema, 49 Lymphogranuloma venereum, 263, 263 Lymphoid tissue, 99 Lymphoma of the tonsil, 102 M Mackenrodt’s ligaments, 238 Macrophage, alveolar, 106 Macules, 62, 65, 65 Malar erythema, 80 Malassezia furfur, 74 Maldigestion, 192 Male genitalia and genital tract, 252–64, 253 disease symptoms, 255–7 examination, 56, 257–63, 258 in infants, 411 newborns, 400–1, 401 structure and function, 252, 252–5 Malignant lymph nodes, 53 Malignant melanoma, 77–8, 78 Malignant vasovagal syncope, 156 Mallet deformity, 269–70, 270 Malleus, 82, 89, 353 Mallory-Weiss tear, 196 Malnutrition, 21, 40, 42, 42 Mania, 320 Manometers, 161, 162 Marfan’s syndrome, 23, 24, 24 arm span, 42 Masseter, 346, 347, 348 Mastitis, 234, 235 Mastoid air cells, 82 Mastoiditis, 89 Index Maxillary sinusitis, 98 McMurray’s test, 297, 298 Mechanical joint disease, 268 Mechanoreceptors, 374–5 Medial epicondyle, 282, 283 Medial lemniscus, 375, 376, 377 Medial longitudinal fasciculus, 334 Median nerve, 289, 289 Mediastinum crunch, 126 displacement, 128, 128 palpation, 127–8 Medical audit, problem-orientated medical records, 16–17 Medical records see Recording Medical Research Council classification of muscle power, 363, 364 Medical students, 10 Melaena, 8, 201 Melanin, 57, 61 Melanocytes, 57, 61 Melanoma, malignant, 77–8, 78 Melasma, 61 Melena, 196 Memory, 9, 309, 310–11, 311 acquisition, 308 see also Amnesia Menarche, 226, 238–9 Ménière’s disease, 86, 92 Meningeal irritation, 384, 384 Meningitis, 89 Meningococcal septicaemia, 410 Meningomyelocele, lumbar, 405 Meniscal tears, 298 Menopause, 228–9, 229 Menorrhagia, 8, 239 Menstruation, 227–8, 228 history-taking, 238–41 pattern, 239 systems review, Mental state, 310–14, 319–20 Meralgia paraesthetica, 299 Mercury manometers, 161 Mesangium, 192 Mesencephalic nucleus of the trigeminal nerve, 345–6 Mesenteric angina, 199 Metabolic acidosis, 45, 112 Metabolic alkalosis, 112 Metabolic coma, 385, 386 Metacarpophalangeal joints, 286, 287 Metatarsophalangeal joints, 301 Micelles, 189 Michelin man, 126 Micrognathia, 406 Microtia, 84 Micturition frequency, 8, 202–3 hesitancy, 203 pain, syncope, 156 urgency, 202–3 Mid-diastolic murmurs, 172, 172 Mid-systolic click, 170, 170 Midarm muscle circumference, 42–3, 43 Middle ear, 353, 353 examination, 89, 89–90 pain, 84 structure of the, 82 Midgut pain, 198, 198 Midparental height, 412 Midtarsal joints, 299, 301 Migraine, Miliary tuberculosis, 124 Milk line, 229, 230 Mineralocorticoids, 35–6 Mini mental-state examination, 313, 314 Miosis, 124 Mitral facies, 158 Mitral valve, 142 incompetence, 168 prolapse, 171 regurgitation, 142, 170 stenosis, 167, 168–9, 172, 172, 173, 173 Mittelschmertz, 241 Mixed heart failure, 176, 176 Molluscum contagiosum, 73 Mondor’s disease, 231 Mongolian blue spots, 405 Monitoring tests, problem-orientated medical records, 14 Mono-iodotyrosine (MIT), 28, 28 Monoaminergic pathways, 360 Monoplegia, 363 Mons pubis, 235–6 Mood, 309, 317–18 Moon-shaped face, 36, 37 Moro reflex, 402 Motilin, 189 Motility disorders, 194 Motion sickness, 195 Motor neurons, 267 disease, 292 see also Lower motor neuron; Upper motor neuron Motor responses in the unconscious patient, 385 Motor system, 359, 359–71 Motor units, 267, 360–1 Mouth see Oral cavity Movement disorders, 371 see also specific disorder Mucociliary escalator, 106 Multisystem atrophy, 371 Murmurs, heart, 170, 170–3, 171, 172, 173 in endocarditis, 181 infants, 409 newborns, 400 in rheumatic fever, 183 Murphy’s sign, 213 Muscle pump mechanism, 179 Muscle(s) atrophy, 42, 362 cramps, 269 disease symptoms, 268–9 eye, 338–40, 339 fasciculation, 269 fibres, 267, 361 GALS, 273–4 hypertrophy, 362 increased bulk of, 273 pain and stiffness, 268–9 palpation, 273 power, 363–4 testing, 273–4, 289, 289, 364 spontaneous contractions, 273 structure and function, 267 tone, 362–3 abnormal, 361 wasting, 42, 42, 269, 270, 273, 281, 281 general examination, 42 hands, 289, 291, 292, 362, 362 weakness, 20, 269, 362 patterns of in disease, 303–6 Muscular dystrophies, 303, 304 Musculoskeletal system chest pain, 155 examination, 56 review, 10 Myasthenia gravis, 345, 370, 370 muscle power, 273 Mydriatics, 326 Myelinated nerve fibres, 329, 329 Myelocele, thoracic, 405 Myocardial infarction, 154–5, 167, 177–8 heart sounds, 169 Myocardial ischaemia, 154–5, 194 symptoms, Myocarditis, 182 Myocardium see Heart, muscle Myoclonus, 368, 371 Myofibrils, 266 Myokymia, 352, 369, 369, 371 Myomalacia, 178 Myopathies, 304 Myosin, 266, 267 Myotomes, 377 Myotonia, 303, 364, 365 Myotonia dystrophica, 21, 305 Myringitis bullosa, 88 Myxoedema, 31, 32, 33 N Nabothian cysts, 247 Naevi, 76, 76, 77 Nails dermatophytes, 74 disease, 61 disorders, 79–80, 79–80 in psoriasis, 70 structure and function, 58–9, 59 Naming defect, 313 Nasal cavity, 93–4, 96 Nasal deformity, 95, 96 Nasal obstruction, 95 Nasendoscope, 96, 97, 102 Nasolacrimal duct, 93–4 Nasopharyngeal carcinoma, 355 Nasopharynx, 100 Nausea, 195–6, 196 Near reaction, 332–3, 337 Neck lump in the, 100 stiffness, 384, 384 see also entries starting with Cervical; Head and neck lymph nodes Necrobiosis lipoidica, 80 Nelson’s syndrome pigmentation in, 46 skin colour, 61 Neocerebellum, 372 Neonates see Babies; Newborns Nephrogenic diabetes insipidus, 40 Nephrons, 192, 193 Nephrotic syndrome, 47, 48, 135, 263 431 Index Nerve disorders, 380, 380 Nerve palsies, 281 Nerve root disorders, 370, 380 pain in, 377 Nerve stretch tests, 275–6, 277 Nervous system, 8–9, 307–89 Neural tube defects, 405 Neuralgia glossopharyngeal, 355 trigeminal, 321 Neuralgic amyotrophy, 281, 282 Neurofibromas, 76 Neurofibromatosis, 23 Neurohypophysis, 38 Neurological examination, 56 infants, 411–12 newborns, 402 preschool children, 413–14 New York Heart Association (NYHA) classification of heart failure, 153, 154 Newborns, 397–407 baby check, 399 congenital abnormalities, 404, 404–6 development, 397 growth, 393, 397, 397 low birth weight, 402 rashes, 407 routine neonatal examination, 403–7, 404 Niacin, 43 Nikolsky’s sign, 75 Nipple, 229 abnormal, 234–5 discharge, 231 palpation, 234, 234 Nits, 75 Nociceptors, 375 Nocturia, 203 Nocturnal asthma, 114 Nodules, 62, 65, 65 Non-refractive visual disturbances, 23 Non-ST segment elevation myocardial infarction (NSTEMI), 177–8 Non-steroidal anti-inflammatory drugs (NSAIDs), Nonaccidental injury, 410 Nonorganic sensory loss, 382, 382 Nose, 93–8 disease symptoms, 94–6 elderly people, 103 examination, 56, 96–7, 96–8 structure of the, 93, 93–4 Nose bleed, 94–5, 98 Nucleus ambiguus, 354 Nucleus interpositus, 372 Nucleus pulposus, 274 Nucleus Z, 375 Numbness, 377 Nummular eczema, 67 Nutcracker oesophagus, 195 Nutritional status assessment, 40–3, 55 Nystagmus, 92, 336, 339–40, 340 in infants, 411 types of, 345 in the unconscious patient, 385 O Obesity, 21, 36, 37, 40 Obsessions, 318, 320 432 Obstetric history, 242 Obturator nerve palsy, 299 Occipital cortex lesions, 331–2 Occipital infarction, bilateral, 332 Occipital lobe, 331 Occipital lymph nodes, 52, 52, 53, 54 Occult rectal bleeding, 200–1 Occupational history, 5–6 cardiovascular disease, 157 lung disease, 119–20 psychiatric assessment, 319 Ocular sympathetic fibres, 333–4, 335 Oculocephalic reflex, 338, 338, 385 Oculocutaneous albinism, 25 Oculomotor nuclei, 384 Oculomotor (third) nerve, 332–45, 411 compression, 344 palsy, 343–4, 344 Odours, 321–2 Odynophagia, 195 Oedema, 46–9, 47, 48 cellulitis-associated, 72 chronic venous insufficiency, 179 peripheral vascular disease, 174, 174–5 signs of, 48–9, 49 symptoms of, 47 see also specific site; specific type Oesophagus, 186, 186–7 cancer, 194 nutcracker, 195 stricture, 194 varices, 196, 201 Oestrogen, 226 Olecranon, 282, 283 Olfaction, 321–2 Olfactory (first) nerve, 321–2, 411 Olfactory hallucinations, 322 Oligomenorrhoea, 39, 239, 240 Oliguria, 45, 203 Oncotic pressure, 47, 47 One-and-a-half syndrome, 343, 343 Onycholysis, 70, 79, 79 in Graves’ disease, 31 Open-ended questions, 3, Opening snap, 170, 170 Ophthalmoplegia, 31 Ophthalmoscope, 20 Opponens digiti minimi, 286 Opponens pollicis, 286, 289, 289 Opposition, thumb, 286, 287 Optic atrophy, 327, 327 Optic disc, 326 Optic radiation, 331–2 Optic (second) nerve, 322, 322–32, 323, 411 clinical application, 327–32 disease, 330–1, 331 examination, 323–7 structure and function, 322 symptoms, 322 Optic tract lesions, 331, 333 Opticokinetic nystagmus, 340, 340 Oral cavity, 98, 99, 186–7 blood in, 100 carcinoma, 101 Oral temperature, 49–50 Orbicularis oculi, 350 Orbicularis oris, 350 Orchitis, 262, 262 Organ failure, major, 27 Organ of Corti, 353 Organic mental state, 319–20 Orientation, 310 see also Geographical orientation/ disorientation; Right-left orientation/ disorientation Orofacial dyskinesia, 353 Oropharynx, 100 dysphagia, examination, 102 Orthopnoea, 21, 114–15, 153, 154 Ortolani manoeuvre, 401 Osler’s nodes, 181 Osseous spiral lamina, 353 Ossicles, auditory, 82, 83, 353 Osteoarthritis, 287–8, 288 ankle and foot, 301 hip, 293, 294 knee, 298, 298 pain, 267–8 Osteoblasts, 265 Osteoclasts, 265 Osteocytes, 265 Osteoporosis first impressions, 20 height in, 41 Otalgia, 84 Otitis externa, 68, 87, 88 Otitis media, 89–90 Oto-acoustic emissions test, 92 Otoliths, 354 Otorrhoea, 84–5 Otoscope, 20 Ovaries, 237, 238 abnormalities, 250 cyst, 242, 242, 250 follicles, 228, 228 ligaments, 237 palpation, 249–50, 250 position of, 27 tumours, 250 Overflow incontinence, 203 Ovulation, 227–8, 241 Oxygen, 108, 109 Oxygen dissociation curve, 111–12, 112 Oxytocin, 38, 39, 230, 231 P P wave, 145, 145 Pacemaker, cardiac, 144 Pacinian corpuscles, 375 Paget’s disease of the breast, 232, 233, 234 Pain abdomen see Abdomen, pain anal, 199–200 assessment, back, 276 bone, 267 breasts, female, 230–1 chest see Chest pain ear, 84 facial, 95 in general, 376–7, 377 gynaecological disorders, 241 joint, 267–8, 268 knee, 294, 298 micturition, muscle, 268–9 Index nasal, 95 referred, 377 on swallowing, 195 testicular, 257 testing, 379, 380 thalamic, 377 urinary tract, 203 visceral, 376–7 see also specific location Painful arc syndrome, 279–80 Palaeocerebellum, 372 Pallor, 45, 45 Palmar crease, single, 406 Palmar grip, 408, 408 Palmar interosseus, 286 Palmomental reflex, 314, 317 Palpebral fissure, 403 Palpitations, 7, 155–6 Pampiniform plexus, 255 Pancarditis, 183 Pancreas, 191–2, 192 disease, 202 enzymes, 192 position of, 27 Pancreatic ducts, 191, 192 Pancreatic glucagon, 189 Pancreatic juice, 189 Pancreatic polypeptide, 189 Pancreatitis, 202 abdominal pain, 197, 197 hemorrhagic, 207 posture, 21 weight loss, 195 Pansystolic murmur, 170, 171 Papillary muscles, 142, 142 Papilloedema, 124–5, 321, 327–9, 328, 359 Papules, 62, 64, 64 Paradoxical splitting of the second heart sound, 144 Paralysis, 363 Paralytic ileus, 219 Paranasal sinuses, 93, 94, 94 examination, 98 pain, 95 Paraphasias, 312 Paraphimosis, 258 Paraplegia, 363 Parasites, travel-related, Parathyroid glands, 27, 33–4 Parathyroid hormone (PTH), 33–4, 34 Paraumbilical hernia, 206, 206 Parents, 390 Paresis, 363 Paresthesia, 377 Parietal abdominal pain, 198 Parietal cells, 187, 187 Parietal lobe, 307, 308, 331 Parinaud’s syndrome, 341 Parkinsonism, 305, 306, 371 Parkinson’s disease, 20, 342, 368, 371 Paronychia, 79, 79 Paronychium, 59 Parotid duct, 98 Parotid glands, 98, 186 Paroxysmal nocturnal dyspnoea, 114–15, 153, 154 Paroxysmal tachycardia, 156 Pars flaccida, 89 Pars tensa, 89 Passive immunity, 407 Patella, 295, 298 Patellar tap, 297 Patent ductus arteriosus, 398 Pathophysiological abnormalities, consultation, 1–2 Patients perspective, Pause neurons, 335 Pavement epithelium, 89 Peak expiratory flow rate (PEFR), 110, 110, 111 in children, 415, 416 Peau d’orange skin, 232 Pectoralis major, 229 Pectus carinatum, 125 Pectus excavatum, 125, 125 Pedal oedema, 42, 48, 49 Pediculosis, 75 Pedigrees, 391, 391 Peer review, 16–17 Pel-Ebstein fever, 50 Pellagra, 42, 42 Pelvic fascia and ligaments, 238, 238 Pelvic floor, 236, 236, 238, 238 Pelvic tumour, 242, 242 Pemphigus, 75, 76 Penicillin, skin reactions to, 64 Penis, 252, 252, 254–5 abnormalities of, 258–9, 259 anatomy, 254 examination, 258–9 normal, 258 ulcers, 259, 259 Penlight inspection of red eye, 23 Pepsin, 187, 187, 189 Pepsinogen, 187, 187 Peptic stricture, 194 Peptic ulcer, perforated, 197 Perceptions, abnormal, 318 Percussion abdomen, 217–18, 219, 242, 242 bladder, 218, 219 chest, 129, 129–30 clavicles, 129, 129 liver, 210, 211 spleen, 215, 215 Percussion myotonia, 364, 365 Perforating veins, 179 Perfusion, 111, 111 Perianal warts, 245 Pericarditis, 155 acute, 183 constrictive, 123, 165, 184, 184–5 jugular venous pulse, 165 posture, 21 Pericardium disease, 183–5 (see also specific disease) effusion, 123, 183–4, 184 rub, 183, 185 Perilymph, 353 Perinephric abscess, 21 Periostitis clubbing, 80 in Graves’ disease, 31 Peripartum cardiomyopathy, 182 Peripheral cyanosis, 46, 46, 122, 157–8 Peripheral nerve injury, 377 Peripheral neuropathy, 370 Peripheral oedema, 174–5 Peripheral vascular system, 174–8 disease, 178, 178–85 Peripheral vertigo, 86 Peristalsis, visible, 206 Peritoneum, 221 Peritonitis, 126 abdominal palpitation, 208 in infants, 411 posture, 21 Peritonsillar abscess, 102, 104 Permanent teeth, 99 Peronei, 300, 300, 303 Persistent ductus arteriosus, 150, 150 Personal history, Personal hygiene, doctors, 2–3 Personality profile, 319 Pes cavus, 301, 301 Pes planus, 300–1, 301 Petechiae, 62, 62 Pets and respiratory disease, 119 Peutz-Jeghers syndrome, 23, 25, 25 Peyer’s patches, 51, 51 Phalen’s sign, 290 Pharyngeal pouch, 115 Pharyngitis, 102 Pharynx, 99–100 Phenothiazines, 353 Philtrum, 403 Phimosis, 258 Phlegm, 115–16 Phobias, 320 Phobic anxiety, 318 Phonocardiography, 168, 169 Photophobia, 23 Photoreceptors, 322 Photosensitive drug rashes, 66–7 Physical stature, 21 Pigeon chest, 125 Pigmentation, 46, 46, 57, 61–2 in chronic cholestasis, 46, 46 malignant melanoma, 77–8 see also Hyperpigmentation Pill rolling, 20 Pilonidal sinuses, 222, 224 Pincer grip, 408, 408 Pinhole test, 23 Pink puffers, 127, 127 Pinna, 82, 83, 84, 87–8, 403 Pitting oedema, 63, 175 Pituitary gland, 38, 38–40 hormone overproduction syndromes, 39, 39–40, 40 hypofunction syndromes, 40 position of, 27 structure and function, 38–9 tumours, 39 Pityriasis rosea, 70, 70, 71 Pityriasis versicolor, 62, 74 Placental circulation, 397, 397 Plantar flexion, 299, 302 Plantar response, 367–8, 368 Plantaris, 300 Plaque, 62, 69 Plateau pulse, 160 Platysma, 350 Plegia, 363 Plethora, 45 Pleural effusion, 47, 133, 134, 135 breath sounds, 131 433 Index Pleural rub, 117, 132–3 Pleurisy, 115, 128 Pleuritic chest pain, 4, 117 Plummer’s nails, 79 Pneumoconiosis, 120 Pneumonia atypical, 133 bronchial breathing, 131 causes of, 133 crackles, 132 lobar, 133 pleuritic chest pain, 117 sputum in, 116 Pneumothorax, 126, 128, 135, 135 chest percussion, 130 pleuritic chest pain, 117 Podocytes, 192–3 Polycystic kidney disease, 174, 217 Polycythaemia, 45, 122 Polycythaemia rubra vera, 45 Polydipsia, 8, 10 Polymenorrhagia, 239 Polymenorrhoea, 239 Polyuria, 8, 193, 203 cranial diabetes insipidus, 40 diabetes mellitus, 10 Pompholyx, 68, 69 Popliteal lymph nodes, 52, 55 Popliteal palsy, 303 Popliteal pulse, 161, 161 Porphyria of drugs, 60 Portal hypertension, 201 fluid retention, 47 in hepatic encephalopathy, 213 venous collaterals in, 201 venous return in, 207 Portal venous system, 190, 190 Portosystemic shunting, 201 Positional dyspnoea, 153 Posseting, 400 Post pill amenorrhoea, 239 Post-term babies, 403 Postauricular lymph nodes, 53 Postcapillary pulmonary hypertension, 181 Postcoital bleeding, 239, 240 Posterior columns, 375 Posterior pituitary, 38 Postmenopausal bleeding, 240 Postnasal mirror, 101 Postoperative endocarditis, 182 Postural hypotension, 9, 157, 163 in dehydrated patients, 44 in hypoadrenalism, 37 in shock, 44–5 Posture abnormal, 20 compensatory, 293 hospitalised patients, 21 Potassium in hypoadrenalism, 37 loss, 36 Pott’s fracture, 301 Pouch of Douglas, 221, 236 Pout, 314 PR interval, 145 Praxis, 313 Pre-pro-PTH, 33–4, 34 Preauricular lymph nodes, 52, 52, 53 Preauricular sinus, 87, 87 434 Preauricular tags, 405 Precapillary pulmonary hypertension, 181 Precordial catch syndrome, 155 Precordium palpation, 166, 166–7 Pregnancy abdomen in, 243, 243 cervix during, 247 height of fundus in, 243, 243 and nausea, 196 secondary amenorrhoea, 239 skin colour during, 61 Prepuce, 254, 258 Presbyacusis, 85 Preschool children, 412–14 Preshock, 44 Pressure load, heart, 142, 143 Pressure sores, 81 Presystolic accentuation, 172 Preterm babies, 403 Pretibial myxoedema, 80 in Graves’ disease, 31 Priapism, 259 Primary chancre, 72, 72, 73 Primitive reflexes, 313–14, 314, 317, 402, 402 Primordial follicle, 228 Prinzmetal’s angina, 154 Problem-orientated medical record (POMR), 12, 13 advantages of, 16–17 confidentiality, 17 flow charts, 15–16, 17, 18 initial problem-related plans, 14–15, 16 problem list, 13–14, 14, 15 progress notes, 15, 17 Progesterone, 228 Progress notes, 15, 17 Progressive supranuclear palsy, 342, 343 Prolactin, 38, 39, 230, 231 overproduction, 39, 40 Pronator, 284 Proprioception, 375, 378–9, 379 Prostate gland, 252, 255 anatomy, 222 examination, 223, 224, 225 Prosthetic heart valve sounds, 170, 170 Protein digestion, 189, 189 Proteolysis, 189 Protozoan diseases, travel-related, Proverb interpretation, 311 Pruritus, 59, 60, 202 Pseudo-Cushing’s syndrome, 36 Pseudoathetosis, 379, 379 Pseudobulbar palsy, 315 Pseudohypertrophic muscles, 273, 304, 304, 362, 363 Pseudomonas ear infection, 84 Psoas major, 291, 292 Psoriasis, 57, 68–70, 69, 287, 288 ear signs, 87 guttate, 59, 69, 69 nail symptoms, 79, 79 Psoriatic arthropathy, 70, 70 Psychiatric assessment, 317–20 clinical application, 319–20 examination, 319 history, 319 history of present condition, 317 specific symptoms, 317–18 Psychosexual history, 241 Psychosocial concerns of patients, 1–2, 4–5 Pterygoids, 347 Ptosis, 124, 336, 337 Puberty, 393, 393, 417, 417–18 delay in, 417–18 female, 226–9, 227 male, 252–4, 253 Pubic hair failure to develop, 60 growth, 227, 227, 253, 253 lice, 75 Pubic tubercle, 204 Pubocervical fascia, 238 Pulmonary embolism, 113, 114 acute massive, 180–1 breathing pattern, 126 deep vein thrombosis, 180 haemoptysis, 117 heart sounds, 169 pleuritic chest pain, 117 Pulmonary hypertension, 181 Pulmonary infarction, acute, 180 Pulmonary oedema, 115 in acute heart failure, 175, 175 breathing patterns, 127 crackles, 132 in heart disease, 117 sputum in, 116 wheezing, 132 Pulmonary thromboembolic disease, chronic, 181 Pulmonary valve, 142, 143 incompetence, 172 stenosis, 144, 171 Pulses, 151–2, 152 character, 159 palpation, 159–61, 159–61 rate assessment, 44 Pulsus paradoxus, 123, 183, 184, 184 Punch tenderness, kidneys, 217, 217 Pupillomotor fibres, 332 Pupils, 340–1 inspection, 337 light response pathway, 332, 334, 337 responses, 384, 384–5, 388 syndromes, 339 Purpura, 62 Pustular psoriasis, 69, 70 Pustules, 64, 64 Pyelonephritis, 21, 203, 217 Pyloric obstruction, 219, 219 Pyoderma gangrenosum, 80 Pyosalpinx, 250 Pyramidal tract, 359–60, 360, 364, 364 Pyrexia see Fever Pyridoxine deficiency, 43 Q QRS complex, 145, 145 Quadriceps femoris, 295, 298 Questioning patients, 3, see also Consultation; History-taking Quinsy, 102 R Radial nerve palsy, 286, 286 Radial pulse, 159, 159, 274 Index Radiography of respiratory system, 105, 106, 118 Radius, 282 Raised intracranial pressure, 328 Ramsay Hunt syndrome, 74, 352, 352 Rapport, establishing a, Rashes, 59–60 babies, 407 infants, 410, 410 nutritional deficiency, 42, 42 skin examination, 10 Raynaud’s phenomenon, 122 Re-entry phenomenon, 145–6, 147, 147, 148 Reading, 313 Rebound tenderness, 198 Recall memory, 310 Recent memory, 310–11 Recording examination, 13 history, 11, 12–13 medical interview, 10–19 see also Problem-orientated medical record (POMR) Rectocoele, 238, 244–5 Rectum, 188 anatomy, 222 bleeding, 199, 200, 200–1 examination, 221–3, 223, 224 prolapsing, 238, 238 rectocoele, 238, 244–5 temperature, 50 Rectus muscles, 208 Recurrent laryngeal nerve, 27 palsy, 115, 355, 356 Red eye, 22–3 Red nucleus, 373 Red reflex, 402, 402 Referred pain, 377 Reflex(es) and abnormal muscle tone, 361 ankle, 32, 33, 366–7, 367 anus, 368 biceps brachii, 365, 365 brainstem, 387, 388 cornea, 347, 347, 349, 388 cough, 106 cremasteric, 367 deep tendon, 365–7, 365–7 fingers, 366, 366 gag, 354, 355, 355, 388 grasp, 314, 314, 317 up, 373 knee, 366, 366 light, 82, 89, 89 Moro, 402 newborn, 402, 402 oculocephalic, 338, 338, 385 palmomental, 314, 317 primitive, 313–14, 314, 317, 402, 402 red, 402, 402 sclera, 347 startle, 402 stretch, 361, 361 suckling, 314, 317 supinator, 365–6, 366 triceps, 366, 366 vestibulo-ocular, 388 Reflux, 194 Refractive visual disturbances, 23 Reiter’s syndrome, 256, 256, 259 Relationship, doctor-patient, Relative afferent pupillary defect, 341 Remote memory, 311 Renal artery bruit, 174 Renal colic, 197, 203 Renal failure acute, 215–16 chronic, 34, 217 Renal hypoperfusion, 47 Renin, 192 Renin-angiotensin system, 35–6, 36, 47, 176 Repetition, 313 Residual volume (RV), 110 Respiration, 108, 385, 386 Respiratory acidosis, 45, 112 Respiratory alkalosis, 112 Respiratory rate, 126 adolescents, 418 in Cheyne–Stokes respiration, 385 newborns, 400 older babies and toddlers, 409 preschool children, 413 school-age children, 415 Respiratory system, 105–38 chest examination, 125–33 common patterns of abnormality, 133–7 disease, 133, 400 symptoms, 112–20 examination, 56, 120–5 failure, bedside assessment, 137 infants, 409–11 preschool children, 413 review, structure and function, 105–12, 106, 107, 108, 109–11 in the unconscious patient, 383 see also Lungs Restrictive cardiomyopathy, 182 Reticuloendothelial cells, 192 Reticulospinal tracts, 360, 361 Retinal artery occlusion, 329, 329 Retinal nerve fibres, 322, 322, 323 Retinal vascular disease, 329, 329–30, 330 Retinal vein occlusion, 329, 329 Rheumatic fever, acute, 182–3 Rheumatoid arthritis, 277, 278 foot, 302, 302 interphalangeal joints, 287, 287 pain, 268 swelling, 270 Rheumatoid nodules, 282, 300 Rhinitis, 115 Rhinitis medicamentosa, 98 Rhinophyma, 96 Rhinorrhoea, 95 Rhinoscopy, 101 Riboflavin deficiency, 43 Riedel’s lobe, 210–11, 211 Right bundle branch block, 144 Right-left orientation/disorientation, 313, 316–17 Right to left shunt, 150–1, 151 Right ventricle, 139, 139, 140 failure, 173–4 hypertrophy, 123, 165, 167 Rigidity, 362, 363 Rigors, 50 Ringworm, 74, 74 Rinne test, 90–1, 91, 92 Risk-taking behaviour, 416 Rodent ulcer, 77, 77 Romberg’s test, 306, 379 Root syndromes cervical, 278, 284 lumbar, 278, 298, 299, 303 sacral, 303, 303 Rosacea, 64, 64 Rotation, 271–2 Rotator cuff, 279–80, 280 Roth spots, 181 Runny nose, 95 S Saccadic eye movements, 334–5 Sacral oedema, 175 Sacroiliac joints, 275, 276 Salivary fluid, 186 Salivary glands, 98 Salpingitis, 241, 250 Saphenofemoral junction, 179 Sarcoidosis, 124 skin manifestations of, 80 Sarcomere, 267 Sarcoptes scabei, 75 Scabies, 75, 75 Scaphoid fractures, 288 Scapula, winging of the, 281, 282 Scapulothoracic joint, 279 Scarlet fever, 59 Scarring, 64, 64 Schizophrenia, 320 School-aged children, 414–16 Sciatic nerve, 275–6 palsy, 294, 295, 295 Sclera jaundice, 46, 61, 211 reflex, 347 Scleroderma, skin manifestations of, 80 Sclerosants, 179 Sclerotomes, 267, 377 Scoliosis, 126, 274, 274 Scotomas, 325, 326, 331, 331 Scrotum, 252, 253, 255, 255 abnormalities, 260, 261 examination, 260–3 hernia, 258, 258, 260 oedema, 263 swellings, 260–2, 261 Sebaceous cysts, 244, 260 Sebaceous glands, 58 Seborrheic dermatitis, 68, 68, 96 Sebum, 58 Second heart sound, 168–9 Secretin, 189, 192 Secretory otitis media, 89–90, 90 Self-harm, deliberate, 416 Semicircular canals, 82–3, 353 Semilunar cartilages, 295, 297–8 Semilunar valves, 142, 143 Semimembranosus, 292 Seminal vesicles, 252, 255, 255 Seminiferous tubules, 252, 254, 254, 255 Semitendinosus, 292 Senile keratosis, 81 435 Index Sensorimotor neuropathy, hereditary, 292 Sensorineural deafness, 85 Sensory system, 374–82 clinical application, 380–2 disturbances, 376, 377 examination, 377–80, 378 Septic arthritis, 268 Septum, nasal, 93 perforation, 96–8 Serratus anterior, 229 Sertoli cells, 252, 254 Setting for examination, 22 Sex hormone-binding globulin (SHBG), 252–3 Sexual activity, Sexual arousal, 254–5 Shape recognition, 380 Sharpey’s fibres, 266 Sheehan’s syndrome, 40 Shingles, 62, 74 Shivering, 50 Shock, 164 clinical assessment of, 44–5 Short stature, 21 Shotty lymph nodes, 53 Shoulder, 266, 279–81 dislocation, 279, 279, 280–1 inspection and palpation, 279 movement, 279–81, 280 muscle function, 281, 281 structure and function, 279 Shunting, intracardiac, 149, 149–51 Sigmoid colon, 188 abdominal palpitation, 208 Silent chest, 130 Silver poisoning, 46 Sinoatrial node, 144, 144 Sinuses, paranasal see Paranasal sinuses Sinusitis, 98 Sinusoids, hepatic, 190, 190, 191 Size recognition, 380 Skeletal system in the unconscious patient, 383 Skin abdominal examination, 206, 206–7 appendages, 58 assessment for dehydration, 44, 44, 63 changes ear, 87–8 in elderly people, 81 colour, 45, 45–6, 57, 61–2 in peripheral vascular disease, 174 disease, 59–60 examination, 56, 61–71, 63 infections, 71–8 joint examination, 270 manifestations of systemic disease, 78, 80 pigmentation see Pigmentation in respiratory disease, 124, 124 review, 10 staphylococcal infection, 407, 407 structure and function, 57–8, 58 temperature in peripheral vascular disease, 174 Skinfold thickness, triceps, 43, 43 Skull compression, 274–5, 275 Sleep apnoea syndrome, 118 Slow twitch fibres, 267 Small intestine, 187–9, 188, 189 436 Smell, 321–2 loss of, 94 Smith’s fracture, 285 Smoking see Tobacco smoking Snail-track ulcers, 72 Snellen chart, 323, 324 Snoring, 118 Snout reflex, 317, 389 Social history, children, 391 respiratory disease, 118–20 Sodium retention, 36, 47 Soleus, 299, 300 Somatostatin, 38, 189 Sore throat, 100 Sound waves, 353 Space of Disse, 190, 191 Spasmodic torticollis, 357, 358 Spastic gait, 305, 305 Spastic limbs, 363 Spasticity, 361–2 Speculum examination, vaginal, 245–6, 246, 247 Speech, 309, 310, 311–13, 315, 372 development, 408 impediment, see also Dysarthria Spermatic cord, 220, 255 Spermatogenesis, 254 Spermatozoa, 254 Sphenopalatine ganglion, 349 Sphygmomanometer, 161, 162 Spider naevi, 62, 63, 211–12 Spinal cord, 360–2 disorders, 380–1, 381 Spinal roots, 375, 375, 376 see also Nerve root disorders; Root syndromes Spinal trigeminal tract, 345–6, 346 Spine cervical, 274–5, 275 conditions, 277–9, 278 deformities, 274, 274 disease, 117 examination, 274 GALS, 272 lumbar, 275, 275, 276 nerve stretch tests, 275–6, 277 pain, 267 prolapsed intervertebral disc, 276–7 sacroiliac joints, 275, 276 structure and function, 274 thoracic, 275, 276 traumatic lesions, 279 tumours, 277 Spinocervical tract, 375–6, 377 Spinothalamic tract, 375, 377 Spirometry, 105, 109 Spleen, 51, 51, 192 auscultation, 220 enlarged, 174, 215, 215 examination, 204, 204 palpation, 214, 214–15, 215 percussion, 215, 215 Splenomegaly, 174, 215, 215 Splinter haemorrhages, 79, 158, 158 Spondylosis, 303 Spurious diarrhoea, 200 Sputum, 115–16 Squamous cell carcinoma ears, 87 skin, 77, 77 Square hand, 288, 288 Squint, 338, 412 ST segment elevation myocardial infarction (STEMI), 177 Stapedius, 351 Stapes, 82, 353 Staphylococcal skin infection, 407, 407 Staphylococcus aureus, 181 furuncle, 72 impetigo, 72 Starling forces, 47, 47 Startle reflex, 402 Stasis oedema, 175 Static lung volumes, 109–10 Static perimetry, 324 Stature, 21 Steatorrhoea, 8, 43, 192, 200 Steele-Richardson-Olsczewski syndrome, 371 Sternoclavicular joint, 279 Sternomastoid, 356 Steroid hormones, 35–6 Stethoscope, 20, 130, 130, 167–8 Stevens-Johnson syndrome, 66, 66 Stoke-Adams attack, 156 Stomach, 187, 187 Stomatitis, angular, 42 Stones kidney, 34 ureteric, 197 Stool output, 190 Strabismus, 338 Straight leg raising, 275–6 Strawberry naevus, 405 Streptococcal infection, 59 beta-haemolytic, 182 Streptococcus pneumoniae, 181 Streptococcus pyogenes, 72 Streptococcus viridans, 181 Stress incontinence, 203 Stretch marks, 206, 206 Stretch reflex, 361, 361 Stretch tests, 275–6, 277 Striae gravidum, 206, 206 Stridor, 100, 117, 127, 132, 133 Structural coma, 385, 386–7, 387 Students, medical, 10 Stye, 72 Subclavian vein, 51, 51 Subconjunctival haemorrhage, 23 Subcostal plane, 205, 205 Subluxation, 269 Submandibular glands, 98 Submandibular lymph nodes, 52, 52, 53, 54 Submaxillary lymph nodes, 52, 52 Submental lymph nodes, 52, 52 Substantia gelatinosa, 376, 377 Subtalar joint, 299, 300, 301 Succussion splash, 219, 219 Suckling, 230, 231 Suckling reflex, 314, 317 Sulphonamides, skin reactions to, 64, 65 Sunburn, 46, 60 Superior laryngeal nerve, 27 Superior mesenteric vessels, 187 Superior vena cava obstruction, 123, 123, 133, 166 Index Supinator, 284 reflexes, 365–6, 366 Suppurative otitis media, 89 Supraclavicular lymph nodes, 54, 54, 123, 124 Supraglottitis, 103 Supranuclear palsy, 371 Supraspinatus, 279, 281 Supratentorial masses, 386–7 Surface markings bone, 265 kidneys, 216 lungs, 105, 107 Surgical emphysema, 126 Surgical incisions, 158, 158 Surgical scars, 207, 207 Swallowing, 187 difficulty see Dysphagia pain on see Odynophagia thyroid examination, 29 Swan neck deformity, 269–70, 270 Sweat glands, 58 Sweating, 50, 58, 124 dehydration, 44 Swinging light test, 341 Sydenham’s chorea, 371 Sympathetic tone, 145 Symphysis pubis, 235–6 Symptoms, establishing, Synarthroses, 266–7 Syncope, 8, 156–7 Syndactyly, 406 Syndrome X, 154 Syndromes, 22–7 Synovial fluid, 266 Synovial joint, 266, 266 Synovial membrane, 266 Syphilis, 72, 72, 73, 244, 245, 259, 259 oral ulceration, 101 Syringing, ear, 88 Systemic disease, skin manifestations of, 78, 80 Systemic lupus erythematosus, 60, 80 Systemic veins, 152 Systems review, 7–10 see also specific system Systolic murmurs, 170, 171–2 T T lymphocytes, 51, 106–8 T wave, 145 Tachycardia, 145, 146–8, 148, 156 in acute heart failure, 175 heart sounds, 169 sustained, 147–8 Tachypnoea, 115 Tail of Spence, 229, 229, 233, 233 Tall stature, 21 Tamponade, cardiac, 183–4, 184 Tanner’s pubertal milestones, 226, 227, 253, 253 Taste, 350, 351 Teeth, 98, 99 Telangiectasia, 62, 62, 80 Telarche, 226 Telogen hair growth, 58 Temperature body, 49–50, 50 joint, 270, 271 response to, 380 skin, 174 Temporal lobe, 307, 308, 331 Temporalis, 346, 347, 348 Temporomandibular joints, 274 Tendocalcaneus, 300 Tendon reflexes, deep, 365–7, 365–7 Tendonitis, bicipital, 280 Tenesmus, 199 Tennis elbow, 282 Tenosynovitis, 280 De Quervain’s, 270, 271, 284 Tension headaches, 321 Tension pneumothorax, 135 Terminal dribbling, Terminal hair, 58 Terminal ileum, 189 Testes, 252, 254, 255, 255 examination, 260, 260 histology of the, 254 in infants, 411 pain in, 257 palpation, 260, 260 position of, 27 swollen, 262 torsion of the, 263, 263 tumour, 262 Testosterone, 252–3, 253 Tetraplegia, 126, 363 Texture, appreciation of, 380 Thalamic pain, 377 Thalamus, 376 disorders, 381 Thenar eminence muscles, 286, 289, 289 Thermocouple, 50 Thermometers, 49, 50 Thermoreceptors, 374–5 Thiamine, 43 Third heart sound, 169 Thomas’ test, 292, 293 Thoracic duct, 51, 51 Thoracic myelocele, 405 Thoracic outlet syndrome, 290 Thoracic spine, 275, 276, 279 Thoracoplasty, 125, 125 Thoughts, abnormal, 318 Thrills, 167 Throat, 98–103 disease symptoms, 100–1 elderly people, 103 examination, 56, 101–2, 101–3 sore, 100 structure of the, 98–100 Thromboembolic disease, chronic pulmonary, 181 Thrombophilia, 180 Thrombophlebitis, 49, 179 Thudicum speculum, 96, 97 Thumb movements, 287 Thymus gland, 51, 51 Thyroglobulin, 28, 28 Thyroglossal cyst, 27 Thyroid binding globulin (TBG), 28, 28 Thyroid gland, 27–33 anatomy and surrounding structures, 28 auscultation, 29, 30 cancer, 27, 29 clinical assessment of function, 29 clinical examination and function, 28–9 overactive, 10 palpation, 29, 30 position of, 27 structure and function, 27 thyroxine synthesis and secretion, 27–8 underactive, 10 see also Graves’ disease; Hyperthyroidism; Hypothyroidism Thyroid releasing hormone (TRH), 28 Thyroid stimulating hormone (TSH), 27–8, 28, 38 failure, 40, 41 Thyroid storm, 31–2 Thyrotoxicosis, 30, 31 Thyroxine (T4), 27–8, 28, 29 Tibialis anterior, 299, 300 Tibialis posterior, 299, 303 Tibialis posterior pulse, 161, 161 Tics, 353, 369 Tidal percussion, 130 Tietze’s syndrome, 117, 128, 155 Time management, consultation, 2, 10 Tinea, 74, 74 Tinea versicolor, 62, 74 Tinel’s sign, 290 Tinnitus, 9, 86 Tissue pressure, 47 Tobacco smoking, 119 history taking, respiratory disease, 118 Toddlers, 407–12 see also Infants Tongue, 99 assessment for dehydration, 44 examination, 102, 357–8, 358 paralysis, 357 percussion myotonia, 364, 365 Tonic pupil syndrome, 340–1, 341 Tonsillar lymph nodes, 52, 52, 53 Tonsillitis, 102 Tonsils, 51, 51, 99 examination, 102 unilateral enlargement of, 102 Topical steroids, 60 Torticollis, spasmodic, 357, 358 Total lung capacity (TLC), 109–10 Toxic adenoma, 30 Toxic erythema, 65, 65 Trachea palpation, 127, 127–8 Tracheitis, 115 chest pain, 117 Transcortical motor aphasia, 315–16 Transcortical sensory aphasia, 316 Transfer factor (TF), 110–11 Transient ischaemic attack (TIA), 86 Transpyloric plane, 205, 205 Transtentorial herniation, 386, 387 Trapezius, 356, 357 Traub’s space, 215 Traumatic lesions ankle, 301–2 elbow, 283 forearm and wrist, 285–6 hands, 288 hip, 294–5 knee, 298 shoulder, 280–1 spine, 279 Travel-related risks, 437 Index Treatment, problem-orientated medical records, 14 Tremor, 122–3, 371, 373 flapping, 213, 213 thyrotoxicosis, 30, 31 Trendelenburg’s sign, 292, 293, 304 Tri-iodothyronine (T3), 28, 29 Triceps, 284 reflexes, 366, 366 skinfold thickness, 43, 43 Trichomonas vaginalis, 241, 241 Tricuspid valve, 142 incompetence, 174 regurgitation, 165, 166 Trigeminal (fifth) nerve, 345–8, 345–9, 411 neuralgia, 321 Trigger finger, 288, 288 Triglyceride, 51, 189 Trisomy 21, 23, 24, 24 Trochlear (fourth) nerve, 332–45, 411 palsy, 343, 344 Trousseau’s sign, 34, 35 Trypsin, 189 Tuberculosis, 105, 124, 278–9 family history, 120 haemoptysis, 117 lung collapse, 136 oral ulceration, 101 radiographic deformity, 118 Tuberculous epididymitis, 262, 263 Tuberculous lymph nodes, 124 Tuberculous lymphadenitis, 53 Tuberculous pericarditis, 184 Tuberous sclerosis, 23, 24, 25, 25 Tumours acidophil, 39 hypothalamic, 21 jugular foramen, 357 laryngeal, 103 ovarian, 250 pelvic, 242, 242 skin, 62, 77–8, 77–8 spinal, 277 testicular, 262 Tunica albuginea, 255 Tuning forks tests, 90–1, 91 Turbinates, 93 Turner’s syndrome, 23, 24, 24, 238, 405 Two-point discrimination, 378, 378 Tylosis, 80 Tympanic membrane, 82, 83, 88, 89, 89, 353 perforation, 90, 90 Tympanometry, 89, 90 Tympanosclerosis, 89 Typhoid fever, 50 U Ulcerative colitis, skin manifestations of, 80 Ulcers aphthous, 101 buccal mucosa, 101–2 decubitus, 81 genital, 256, 259 oral, 101 penis, 259, 259 peptic, 197 438 rodent, 77, 77 snail-track, 72 varicose, 174, 179, 180 vulva, 244 Ulna, 282 Ulnar nerve, 289, 289 lesions, 290, 290 Ultrasound abdominal, 174 Doppler, 179 Umbilical hernia, 401, 401 Umbo, 82, 89 Uncal herniation, 386, 387 Unconscious patient, 382, 382–9 coma grading, 383, 383 Unilateral deafness, 85 Unstable angina, 154–5, 177–8 Upper limb deep tendon reflexes, 365–6, 365–6 Upper motor neuron, 359 facial weakness, 351, 352 lesions, 358, 370 syndrome, 349 Upper pharyngeal sphincter, 187 Ureteric pain, 198 Ureteric stones, 197, 203 Urethra, male, 254, 254 discharge, 256, 256, 258–9 Urethral meatus, external, 258 Urethritis, 256, 259 Urgency of micturition, 202–3 Urinary incontinence, Urination see Micturition Urine appearance, assessment for dehydration, 44 Urticaria, 65, 65 Uterosacral ligaments, 236, 238 Uterus, 236, 237 abnormal bleeding, 240 abnormalities, 249 examination, 248–50 palpation, 218, 249, 249 prolapse, 245, 246 V Vagal tone, 145 Vagina, 236, 237 discharge, 240–1 examination, 244–6, 246, 247, 248 swabs, 248 Vaginismus, 241 Vaginitis, 241 Vagus (tenth) nerve, 186, 187, 187, 355–6, 411 damage, 194 palsy, 355, 356 Valsalva manoeuvre, 156 Valves, heart, 142, 142 Varicella-zoster virus, 74 Varicoceles, 258, 261–2, 262 Varicose eczema, 68, 179 Varicose ulcers, 174, 179, 180 Varicose veins, 174, 179 Vas deferens, 255, 255 Vasculitis erythema nodosum, 65 splinter haemorrhages in, 79 Vasoactive intestinal polypeptide (VIP), 189 Vasodilatation, 49 Vasomotor rhinitis, 98 Vasovagal syncope, 156 Veins, 152, 153 chronic insufficiency, 179 diseases of peripheral, 179–81, 180 varicose, 174, 179 visible abdominal wall, 207, 207 Vellus hair, 58 Ventilation, 109, 111, 111 Ventricles, 139, 139–40, 140, 141, 144 hypertrophy, 142 see also Left ventricle; Right ventricle Ventricular fibrillation, 148, 178 Ventricular septal defect, 150, 150, 170 Verdoperoxidase, 116 Vermis, 371 Vernix caseosa, 58 Vertebrae see Intervertebral discs; Spine Vertebral arteries, 308, 309 Vertebral body fractures, 279 Vertebrobasilar insufficiency, 157 Vertebrobasilar ischaemia, 86 Vertical saccades, 334–5, 336 Vertigo, 9, 86, 354 Vesicocele, 238 Vesicular breath sounds, 130, 131 Vestibule, 353 see also Inner ear Vestibulitis, 98 Vestibulo-ocular reflex, 388 Vestibulospinal tract, 360 Vibration sense, 379, 379 Villous atrophy, 76 Vincent’s angina, 101 Viral infections skin, 72–4 travel-related, Viral pericarditis, 184 Virchow’s node, 54 Visceral pain, 197–8, 198, 376–7 Vision cranial nerve symptoms, double see Diplopia in elderly people, 18 red eye, 23 Visual acuity, 323–4, 324 test, 23 Visual agnosia, 317 Visual cortex, 322 Visual fields, 324–6, 325, 326 Visual hallucinations, 318 Visual memory, 310–11, 311 Visuospatial ability, 308 Vital capacity (VC), 110 Vitamin deficiencies, 43 Vitamin status, 43–4 Vitiligo, 62, 62 in Addison’s disease, 37 Vocal cords, 100, 100 paralysis, 315 Vocal fremitus, 128 Vocal resonance, 131–2 Voice hoarse, 100–1 in hypothyroidism, 32 tone of, 20 Volume load, heart, 142, 142 Index Vomiting, 196, 196 dehydration, 44 in infants, 411 newborns, 400 systems review, Von Recklinghausen’s disease, 76 Vulva, 235–6 abnormalities, 244 examination, 243, 243–4, 244 ulceration, 244 Vulvitis, 244 W Waardenburg’s syndrome, 23, 26, 26 Waddling gait, 306 Warts, 72–3, 73 Wasting, muscle see Muscle(s), wasting Water drinking, compulsive, 40 Water retention, 47 Water-soluble vitamin deficiency, 43 Waterbrash, 7, 194 Wax, ear, 82, 84, 88, 88 Weakness, muscle see Muscle(s), weakness Weber test, 90–1, 91 Weed, Lawrence, 12 Weight appreciation, 380 change, at gestation, 403 loss diabetes mellitus, 10 gastrointestinal disease, 195 general examination, 42 lung cancer, 118 norms in adults, 41, 41 Wernicke’s aphasia, 316 Wernicke’s area, 308, 310 Wernicke’s encephalopathy, 386 Wheals, 62, 65, 65 Wheezing, 117, 127, 132, 133 systems review, Whispering pectoriloquy, 131–2 White coat hypertension, 163 White lesions, buccal mucosa, 102 Wickham’s striae, 70–1 Wind, 199 Wolff-Parkinson-White syndrome, 147 Wood’s lamp, 61 Wrist, 283–6, 285, 286 Wrist drop, 286, 286 Writing, 313 X Xanthelasmata, 80 Xanthomas, 26, 27 Xiphisternum, 204–5 439 [...]... aesthetic and complete examination General examination The general examination permits you to obtain an overview of the general state of health and provides an opportunity to examine systems that do not fall neatly into a regional examination For the patient, the general examination is also a gentle introduction to the more intense systems examination to follow FIRST IMPRESSIONS The examination commences... physical examination, although remain sensitive to some cultural norms where same-sex examinations might be preferable This acceptance usually extends to medical students who can be reassured that most patients welcome students and recognise their need to learn the examination technique Explain the necessity of undertaking a full physical examination The examination adds information to the clinical. .. growth retardation • Marasmus • Kwashiorkor 21 Chapter 2 The general examination The examination requires full exposure: men and women should be asked to remove superficial clothing and vests or undershirts For a chest examination, women should be asked to remove their bra Ensure a clean and presentable examination gown is available in the examination room for the patient to don before you enter the room... examination Start the examination with the patient supine and the head and shoulders raised to approximately 45° above the horizontal Most modern examination couches and hospital beds are designed to allow easy adjustment of the upper body Most of the examination takes place with the patient comfortably resting in this position (Fig 2.2) Three further adjustments will be made in the course of the examination. ..User guide to icon boxes Differential diagnosis summarise the common cause of clinical abnormalities Emergency outline the implications for history and examination of certain clinical emergencies Examination of elderly people guide the reader through the particular difficulties encountered when examining the elderly Questions to ask list... resonance imaging and fibreoptics greatly broaden our powers of observation The physical examination begins with a general examination and is followed by examination of the skin, head and neck, heart and lungs, abdominal organs, musculoskeletal and neurological systems With practice it is possible to perform the ‘routine’ examination in 20 10–15 min, although if you discover an abnormality, considerably... history Systems review • cardiovascular • respiratory • gastrointestinal • genitourinary • nervous • endocrine • musculoskeletal • skin and hair 19 2 The general examination The dividing line between the history and examination is artificial The examination really begins from the moment you set eyes on the patient During the course of the history you will examine the patient’s intellect, personality, family... serious pathology; they are also useful in guiding a directed history/ examination if time is short Review summarise the most important points to remember about the examination of each body system Risk factors give the basic information on the risk factors associated with a particular disease Symptoms and signs provide the core clinical features of the diseases and disorders x 1 Consultation, medical... general illumination You should be fully equipped to undertake the examination without disruption Ensure you have a working penlight torch and stethoscope Close at hand there must be a sphygmomanometer, ophthalmoscope, otoscope, tongue depressors and disposable gloves (for genital and rectal examination) Basic equipment for the neurological examination should be available This includes a patellar hammer,... Recording the medical interview 1 The structure of problem-orientated medical record History Examination Database Problem list Progress notes Problem-related plans Flow chart Fig 1.7 Structure of the problem-orientated medical record (POMR) events or illnesses that may otherwise have been overlooked THE EXAMINATION The examination may confirm or refute a diagnosis suspected from the history and by adding this