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Part 2 book “Atlas of adult physical diagnosis” has contents: Neurologic examination, knee examination, shoulder examination, hand, wrist, and thumb examination, elbow examination, hip, back, and trunk examination, foot and ankle examination, skin examination, eye examination.
4886.LWW.Berg.ch07pp161-200 07/18/05 10:41 AM Page 161 ■ Neurologic Examination PRACTICE AND TEACHING OVERALL EXAMINATION Overall neurologic examination includes the thorough assessment of power, tone, reflexes, cranial nerves, and function of the sensory structures Power Assessment The neurologic examination includes the assessment of the power, also known as strength of various muscle groups Two muscle groups from the proximal upper and lower extremities should be examined Shoulder elevation or shrugging against resistance is assessed for proximal muscle strength, trapezius muscle function, and cranial nerve (CN) XI function (Fig 7.1) For this assessment, the patient actively elevates the shoulders, i.e., shrugs, while the examiner applies resistance; feel the trapezius muscle Arm extension is assessed for triceps function, radial nerve, and root C7 (Fig 7.2) For this, the patient’s arm is passively abducted to horizontal (90 degrees), forearm dangling down at the elbow; the patient then actively extends the forearm at the Figure 7.1 Technique for power assessment of proximal upper extremities: elevation of shoulders TIPS Figure 7.2 ■ Active shoulder elevation or Technique for power assessment of triceps and proximal arm: extension of elbows shrugging: apply resistance to tops of the scapula ■ Trapezius contraction ■ Proximal muscle problems: bilateral weakness TIPS ■ With patient’s arm abducted to 90 degrees, forearm dangling at the side, actively extended at elbow: apply resistance to the distal forearm ■ Triceps muscle contraction ■ Radial nerve or root of C7 problem: unilateral paresis, fasciculations, and even atrophy of the triceps muscle ■ Proximal muscle weakness: bilateral paresis 161 4886.LWW.Berg.ch07pp161-200 07/18/05 10:41 AM Page 162 162 Chapter Figure 7.3 Technique for power assessment of proximal hip A Forward flexion of hip with patient standing B Patient supine TIPS ■ Patient standing (A), or supine (B), or sitting (see Hip Examination chapter) ■ Start from about 10 to 20 degrees, leg supported by the examiner at this baseline; apply resistance on the distal anterior thigh ■ Iliopsoas muscle damage or nerve roots L2 and 3: unilateral paresis ■ Proximal muscle problem: bilateral paresis A B elbow against resistance applied by the examiner; feel the triceps muscle Hip forward flexion is assessed for proximal muscle strength, upper lumbar roots (L1, 2, 3), and iliopsoas muscle function (Fig 7.3) Assessment is either from a baseline position of standing, supine, or sitting The standing position (Fig 7.3A) or with the patient supine with leg suppported by examiner at 10 degrees of forward flexion (Fig 7.3B) or, sitting with knees flexed are all acceptable The patient then actively forward flexes the leg while the examiner applies resistance to the distal anterior thigh From the seated position, the patient is instructed to raise the knee straight upward Hip backward flexion is assessed for proximal muscle strength, gluteal muscle function, and lower lumbar and upper sacral root function (L4, and S1, 2) (Fig 7.4) Assessment is with the patient either standing and leaning onto a wall supported by hands placed on wall (Fig 7.4A) or in the prone position with the leg assessed slightly off the side of the table (Fig 7.4B) The patient actively backward flexes the leg against resistance applied to the posterior distal thigh Extension at knee is assessed for proximal muscle weakness, midlumbar root function (L3, 4), femoral nerve and quadriceps muscle function (Fig 7.5) Assessment is one in which the patient is either supine or sitting with knees flexed and supported in 40 degrees of flexion The patient actively extends the leg at the knee while the examiner applies resistance at the middistal anterior leg The grading of power uses the classic to numerical system In this system, is normal, is completely absent; is able to perform against gravity alone (Table 7.1) The pattern of weakness (paresis) or paralysis (plegia) is of greatest diagnostic use See Table 7.2 for specific details The various patterns Figure 7.4 Technique for power assessment of proximal hip A Backward flexion of hip, patient standing B Patient prone TIPS ■ Note patient standing, stabilized by examiner or wall (A) or supine (B); active backward flexion of hip: apply resistance on the distal posterior thigh ■ Gluteus maximus muscle damage: unilateral paresis ■ L5 or S1 or S2 roots or gluteal nerve damage: unilateral paresis ■ Proximal muscle weakness: bilateral paresis A B 4886.LWW.Berg.ch07pp161-200 07/18/05 10:41 AM Page 163 163 Neurologic Examination: Practice and Teaching Table 7.1 Grading of Power Proximal muscle groups Absent Twitch Move, but not to gravity Gravity Gravity with two fingers of resistance Gravity with full hand of resistance Distal muscle groups Absent Weakness Normal Plegia Paresis Paresis Paresis Paresis Normal Paralysis Weakness Weakness Weakness Weakness Plegia Paresis Often excellent to repeat this set of tests for follow-up because incremental improvement or decremental deterioration of strength indicates specific diagnoses include paraparesis, paraplegia, tetraparesis, tetraplegia, hemiparesis, hemiplegia, and proximal muscle weakness (see Table 7.1) Although useful, the grading system of power itself has several problems inherent to it First, there is a significant amount of interobserver variation: (normal) that may be markedly different for different examiners Second, the grading system is best used on proximal muscle groups like the pectoralis and pelvic, and is not easily used on distal muscle groups The distal muscle groups are best graded as normal, weak, or absent Finally, the effectiveness of the examination is diminished when concurrent joint swelling or pain is present Table 7.2 Definitions of Weakness and Paralysis Type Pattern Company it Keeps Paraparesis Bilateral Usually lower extremity weakness Trauma to thoracic or lumbar spine Decreased anal wink Sacral sparing if a thoracic lesion Incomplete transection Paraplegia Bilateral Usually lower extremity paralysis Trauma to thoracic or lumbar spine Absent anal wink Complete transection Tetraparesis All four extremities Weakness Also called quadriparesis Trauma to cervical spine Incomplete transection Tetraplegia All four extremities paralyzed Also called quadriplegia Trauma to cervical spine Complete transection High risk of respiratory defect Hemiparesis Unilateral, upper and lower weakness Contralateral CVA Spastic hemiparetic gait Positive Hoffman or Tromner maneuver Positive Babinski sign Clonus Hemiplegia Unilateral, upper and lower paralysis Contralateral CVA Usually unable to ambulate Positive Hoffman maneuver Positive Babinski sign Clonus CVA = cerebrovascular accident Figure 7.5 Technique for power assessment of the proximal lower extremity, quadriceps muscle Extension at the knee, patient supine TIPS ■ Patient sitting or supine ■ Note knee held in 30 to 40 degrees flexion; patient told to actively straighten the leg ■ Apply resistance on the middistal leg ■ Quadriceps muscle or femoral nerve (L4) problem: unilateral paresis ■ Proximal muscle problem: bilateral paresis 4886.LWW.Berg.ch07pp161-200 07/18/05 10:41 AM Page 164 164 Chapter Tone Figure 7.6 Technique to perform tone assessment at elbow (A), wrist (B), and ankle (C) TIPS ■ Place one hand on proximal to joint, the other distal ■ Passively fully, and with a gliding ■ ■ ■ ■ ■ ■ ■ ■ A smoothness, flex and extend at elbow (A) Passive circumduction at the wrist (B) Passive circumduction at the ankle (C) Perform three to five cycles, then repeat in opposite direction Instruct patient to tap hand on thigh, which distracts the patient Normal: smooth gliding action Rigidity: cogwheel sensation Spasticity: clasp-knife phenomenon Contracture: no movement because of primary joint problem Assessment of tone is an often overlooked, underutilized, and misunderstood component of the neurologic examination Tone is, however, central to the neurologic examination and should be assessed and taught Tone is the summation of the contributions that the muscles provide within a joint to maintain baseline position Many neurologic problems manifest with an increase or decrease in joint tone The technique to most effectively assess tone is one in which the examiner places one hand proximal to the joint, the other distal to the joint to be assessed (Fig 7.6) Passively and with a gliding smoothness, fully flex and extend the patient’s elbow, fully circumduct the wrist, or circumduction* of the ankle Perform this in three to five cycles, then repeat in the opposite direction In our opinion, the best overall site and procedure is circumduction of the wrist To optimize the sensitivity of the examination, the joint being examined must be as passive as possible An excellent method to optimize the passive aspect is to instruct a patient to repetitively tap contralateral hand on their thigh, in order to distract them Upper motor neuron (UMN) damage manifests with increased tone on the side contralateral to damage The increased tone is spastic, i.e., agonists and antagonists are equally involved The classic clasp-knife phenomenon, in which there is severe resistance initially that dramatically decreases with passive motion, of spastic paralysis may be present Examples of diseases with spasticity include cerebrovascular accident (CVA) and head trauma Basal ganglia damage manifests with increased tone on the side ipsilateral to damage This increased tone is rigid, i.e., involves an imbalance between agonists and antagonists, and manifests with cogwheel rigidity In severe cases, it is profoundly akin to resistance provided in trying to bend a lead pipe, hence the term “lead-pipe” rigidity The best sites for tone assessment include flexion and extension of the elbow; circumduction of the wrist; and circumduction of the ankle Examples of diseases with rigidity include Parkinson’s disease and the effects of neuroleptic agent use Myotonic dystrophy manifests with increased tone in which there is the inability to relax a muscle contraction (Fig 7.7) An excellent method to assess for this is to instruct the patient to squeeze your hand for 10 seconds, then to rapidly release and spread out the fingers A patient with myotonia is unable to perform this rapidly The company myotonic dystrophy keeps includes the classic male pattern baldness and an acquired atrophy of the sternocleidomastoid and facial muscles with bilateral ptosis Also noted are profound proximal muscle weakness and abnormal flexion of the thumb on the thenar eminence percussion test (Fig 7.8) For this test, place the patient’s hand neutral and B C *Passive dorsiflexion and plantarflexion may be used at ankle instead of circumduction 4886.LWW.Berg.ch07pp161-200 07/18/05 10:41 AM Page 165 165 Neurologic Examination: Practice and Teaching Figure 7.7 Facies of myotonic dystrophy Sad appearing, bilateral ptosis, and male pattern alopecia TIPS ■ Inspect hair distribution and muscles of the face, head, and neck ■ Myotonic dystrophy: muscle atrophy of the facial muscles (masseter or temporalis) and the sternocleidomastoids ■ Myotonic dystrophy: male pattern balding, which is important in that if no balding, myotonic dystrophy is highly unlikely forearm supinated, tap on the thenar muscle (Fig 7.9) A finding that is of historical importance only is the tongue percussion test in which the percussion of the midline corsal tongue feels stiff, i.e., the test is positive Finally, the patient will have systolic heart failure Cerebellar problems manifest with a marked decrease in tone, ipsilateral to the damage The tone about the joints is inappropriately loose or floppy and upon performing reflexes, there is pendulum swinging, i.e., the arm or leg swings to and fro several times with patellar and triceps reflexes The baseline stance of the patient is with hand slightly flexed and bilateral pes planus is noted Figure 7.8 Technique for the thenar eminence percussion test Excellent confirmatory test for myotonia TIPS ■ Hand neutral, forearm supinated ■ Use a plexor to tap over thenar muscle ■ Normal: thumb mildly bounces upward ■ Myotonia: thumb moves upward, i.e., it flexes slightly Reflexes Although the term deep tendon reflexes (DTR) is best known as an integral part of the medical vernacular, they are best referred to as muscle stretch reflexes (MSR) because they impact on the spindle cells in the muscle, not the tendons Because DTR is universally recognized, we will use that term and its acronym These reflexes are a set of techniques that the lay public expects a physician to perform These tests are especially useful with a patient who has increased or decreased tone and has concurrent paresis Two fundamental components to the assessment and measurement of DTR include: first, a complete relaxation of the joint and, second, the use of a reflex hammer Several different reflex hammers are demonstrated in Fig 7.10 Although the finger is the most portable and convenient to use, our favorite is the Queens Square hammer (Fig 7.10) Obtain DTRs from two to three sites in both upper and lower extremities; compares side-to-side Sites for DTR measurement include the biceps (C5), pectoralis major (C7), triceps (C7), quadriceps (L4), Achilles (S1), and the plantar (S1) The technique for biceps reflex: with the patient sitting, elbow in 90 degrees of flexion and the forearm neutral between supination and pronation, grasp the elbow, with the thumb on the olecranon and the index finger to press on, and stretch the biceps tendon (Fig 7.11) Tap a hammer on the finger overlying the tendon of the biceps where it inserts on the proximal forearm (mediate percussion) The technique for triceps reflex: with the patient standing or sitting, support the arm so that it is parallel to floor, then flex the forearm (dangled) to 90 degrees; use the hammer to tap over the proximal triceps aponeurosis (Fig 7.12) The technique for pectoralis major reflex: with the patient supine, arm at the side, approximately 20 degrees of humeral abduction, place your hand over the top of acromion, fingers toward the back, thumb Figure 7.9 Stance of hypotonia TIPS ■ Instruct patient to stand with arms at 90 degrees of forward flexion, forearms pronated ■ Hypotonia: able to perform, but the pronated hands are flexed almost to 90 degrees ■ Concurrent bilateral pes planus and even mild out toeing 4886.LWW.Berg.ch07pp161-200 07/18/05 10:41 AM Page 166 166 Chapter Figure 7.10 Some tools for a neurologic examination A Tuning fork, 128 Hz B Tuning fork, 256 Hz C Tuning fork, 512 Hz D Babinski plexor E Taylor plexor F Queen’s square plexor with plastic handle (recommended by us) G Bucks or modified Dejerine plexor H Camel hair brush I Cotton-tipped swab J Set of monofilaments K Tongue blades L Opthalmoscope head M Pocket Snellen chart N Pocket watch O Penlight TIPS L J I H C B A N O M K F E D G ■ Queen’s square hammer: circular structure on a flexible stick; this is highly satisfactory in all endeavors ■ Taylor hammer: tomahawk-shaped, may use either the flat or the pointed side, adequate ■ Bucks hammer: two-headed, structures ■ Fingertip: the most portable of hammers over the tendon of the pectoralis major; then tap on the thumb that is transmitted to the tendon (Fig 7.13) The technique for the quadriceps reflex: with the patient sitting, legs hanging over the table at 90 degrees of flexion (Fig 7.14A) or supine with the knees flexed to 20 degrees (Fig 7.14B), tap over the infrapatellar ligament (Fig 7.14) The technique for the Achilles reflex: with the patient kneeling on a chair or supine (Fig 7.15), gently stretch the gastrocnemius tendon by passively dorsiflexing the foot and striking the distal Achilles tendon with the reflex hammer (Fig 7.15) The technique for the plantar reflex: with the patient kneeling on a chair, gently stretch the gastrocnemius tendon by passively dorsiflexing the foot and striking the plantar foot Figure 7.11 Technique for biceps reflex Use mediate percussion to perform Here, a Queen’s square hammer is used TIPS ■ Assessment of cervical root ■ Patient is sitting, the elbow is in 90 degrees flexion, the forearm neutral between supination and pronation ■ Grasp the elbow, thumb on the olecranon, second digit on the biceps tendon ■ Tap hammer over the finger overlying the tendon of the biceps where it inserts on the proximal forearm (mediate percussion) ■ Note biceps brachii contraction and flexion of the forearm Figure 7.12 Figure 7.13 Technique for triceps reflex Use direct percussion to perform Here, a Queen’s square hammer is used Technique for pectoralis major reflex Use mediate percussion to perform Here, a Queen’s square hammer is used TIPS ■ Assessment of cervical root ■ Patient standing or sitting, the arm is supported by examiner so that it is parallel to floor ■ Note that the forearm is then flexed to (dangled at) 90 degrees ■ Use hammer to tap over the triceps aponeurosis ■ Note triceps contraction or extension at the elbow TIPS ■ Assessment of C7 ■ Patient is supine, arm at side, ap- proximately 20 degrees of abduction ■ Place hand over top of acromion, fin- gers toward the back, thumb over the tendon of the pectoralis major ■ Tap on thumb, to transmit the tap to the tendon ■ Note contraction of the pectoralis major or adduction of the humerus 4886.LWW.Berg.ch07pp161-200 07/18/05 10:42 AM Page 167 167 Neurologic Examination: Practice and Teaching Figure 7.15 A B Figure 7.14 Technique for quadriceps reflex A Patient sitting B Patient supine Use direct percussion to perform Here, a Queen’s square is used TIPS Technique for Achilles reflex, patient kneeling Mild passive dorsiflexion of the foot at ankle; here, a Queen’s square hammer is used TIPS ■ Assessment of S1 ■ Patient is kneeling on a chair; may also be sitting or supine ■ Gently stretch the tendon by pas- sively dorsiflexing the foot ■ Assessment of L4 (lesser extent roots L2 and L3) ■ Patient sitting, legs hanging over the table side: 90 degrees of flexion (A) or supine ■ Strike the distal Achilles tendon with with knee flexed to 20 degrees (B) ■ Tap the hammer over the infrapatellar ligament ■ Note quadriceps contraction and extension of knee ■ Note gastrocnemius contraction and with the reflex hammer (Fig 7.16) We find the plantar reflex to be the superior maneuver, for S1 Grading for DTR is on a to scale (Table 7.3), in which is absent, 1+ is barely present, 2+ normal, 3+ is brisk but without clonus, and 4+ is brisk with clonus An excellent rule to interpret reflexes is that reflexes that are graded or 4+ are abnormal until proved otherwise, whereas, reflexes that are graded 1+, 2+, or 3+ are normal until proved otherwise To confirm that reflex is absent, the reflex procedure should be performed while the patient is performing Jendrassik’s maneuver (Fig 7.17) The technique for Jendrassik’s maneuver is one in which the patient holds hands before in front and mightily squeezes them together; then repeat the reflex assessment during this Upper motor neuron damage manifests with hyperreflexia (3+ or 4+); lower motor neuron damage and primary muscle problems manifest with hyporeflexia (1+ or 0) Clonus, the rhythmic involuntary alternation of joint movement can also be assessed and demonstrated by passively stretching a joint These include passive wrist dorsiflexion or passive ankle dorsiflexion Recall, clonus means that the reflex is Table 7.3 Deep Tendon Reflex (DTR) or Muscle Stretch (MSR) Grading Grade Interpretation 0* 1+ 2+ 3+ 4+ No reflex present Minimal contraction of muscle; no joint movement Contraction of muscle with mild movement of joint Significant muscle contraction with brisk joint movement Significant muscle contraction with brisk joint and clonus or crossover to contralateral side the hammer plantarflexion of foot Figure 7.16 Technique for plantar reflex Direct percussion Queen’s square hammer is used here TIPS ■ Assessment of S1 ■ Patient kneeling on a chair; may also be sitting or supine ■ Stretch the tendon by passively dor- siflexing the foot ■ Strike the plantar foot with the ham- mer ■ Note any contraction of the gastroc- *If 0, repeat after doing the Jendrassik maneuver; if now present, the reflex is truly 1+ nemius and plantarflexion of foot 4886.LWW.Berg.ch07pp161-200 07/18/05 10:42 AM Page 168 168 Chapter T E A C H I N G P O I N T S OVERALL POWER, TONE, AND REFLEXES Power = strength Power is graded from to 5: = no movement; = normal; system is satisfactory for proximal muscle grading, but not for distal muscles Use two muscle groups from the upper and two muscle groups from the lower; compare upper versus lower and side-to-side Tone is the baseline summation of all muscle activity within a joint when passive Hypotonicity: usually cerebellar dysfunction Hypertonicity: usually cogwheel rigidity or spasticity Hypertonicity does not equal hyperreflexia Reflexes are graded to 4: and are almost always abnormal; 1, 2, are often normal Use two reflexes from the upper extremity and two reflexes from the lower extremity; compare upper versus lower and side-to-side indeed 4+ In addition to the grading of reflexes, the contraction and the relaxation phases of the reflex movement need to be assessed Hypothyroidism manifests with reflexes that have a delayed relaxation phase Hypotonia manifests with pendulum swinging with the triceps and the patellar reflexes, i.e., the contraction and relaxation phases continue over and over Of final note, in lower spinal cord transection injury (L2, L3, or L4), the quadriceps reflex paradoxically flexes the knee This grossly unusual and pathologic reflex is called Boyle’s sign Figure 7.17 Technique for Jendrassik’s maneuver to increase sensitivity of deep tendon reflexes (DTR), also known as the muscle stretch reflexes (MSR) TIPS ■ The patient is holding hands before her and is instructed to squeeze mightily ■ Repeat the lower extremity reflexes ■ Perform on patient with a reflex; may become present, i.e., 1+, with this maneuver Anal Wink and Cremasteric Reflexes Two unique peripheral reflexes that are extremely important in the evaluation of spinal cord injuries and low back pain are the anal wink and the cremasteric reflex After an acute spinal cord injury, presence of the reflexes indicates a favorable prognosis; in the setting of low back pain, their absence suggests cauda equina syndrome or central spinal cord compression (See Chapter 12 for further details.) CRANIAL NERVE EXAMINATION Smell is the function of cranial nerve I, a purely sensory nerve Smell deficits are usually nonspecific; however, viral rhinitis manifests with overall decrease in smell sense The company it keeps includes cough, serous rhinitis, and sore throat Unilateral frontal lobe tumor manifests with unilateral, ipsilateral loss of smell; the company it keeps includes a change in behavior and olfactory hallucinations Determining smell requires two vials, one for each nostril, of different odiferous materials, e.g., one of ground coffee and a second of vanilla A useful tool for assessing smell sensation is the University of Pennsylvania Smell Identification Unit (UPSIT), which is commercially available Overall, this set of tests is rarely performed 4886.LWW.Berg.ch07pp161-200 07/18/05 10:42 AM Page 169 169 Neurologic Examination: Practice and Teaching Vision is the function of cranial nerve II, another purely sensory nerve, which is extensively discussed in the chapter on eye examination Recall, a magnificent method to detect visual function is that of the rotating black and white drum in which blindness results in no nystagmus; however, feigned blindness or normal vision manifests with involuntary, optokinetic horizontal nystagmus Cranial nerves III, IV, and VI, all purely motor nerves, are assessed together Deficits of these purely motor nerves manifest as a strabismus, the patient complaining of “double vision.” To assess these nerves, start from the baseline of a patient with a natural gaze at a point of light at least meters before the patient in the horizontal plane This is called a Hirschberg test for strabismus Place one finger in horizontal gaze plane, 20 to 25 cm anterior to the midline of the patient’s face Also place the thumb of the other hand on the chin to prevent head movement (Fig 15.2) The patient follows the finger in two diagonal and horizontal axes Cranial nerve III, oculomotor nerve, supplies the superior rectus, inferior rectus, inferior oblique, and medial rectus muscles Cranial nerve III deficit manifests with multiple extraocular motor defects and a baseline gaze of a walleye (exotropia) or exophoria (Fig 15.3) A walleye or an exophoria is caused by the fact that the lateral rectus remains intact and, therefore, will dominate the eye Also, a ptosis will be present on the affected side Cranial nerve IV, trochlear nerve, is the smallest of all of the cranial nerves and innervates the superior oblique muscle Cranial nerve IV deficit manifests with a paralysis (tropia) or weakness (phoria) to nasal and inferior (down and in) eye movements A not uncommon reason for this is a step-off fracture of the infraorbital rim (Fig 1.24) and basilar skull fracture with trochlear nerve damage In addition, Brown’s syndrome of superior oblique tenosynovitis results in a deficit without CN IV problem Cranial nerve VI, abducens nerve, innervates the lateral rectus muscle Cranial nerve VI deficit manifests with a cross-eye paralysis (Fig 15.4) (esotropia) or weakness (phoria) of lateral movement Furthermore, when performing active extraocular movements, use the axes of motion described in Fig 15.2 Box 7.1 contains a method to remember these Perform the range of motion (ROM) of the eyes with eyes closed if the patient has photophobia Cranial nerve V, trigeminal nerve, is a mixed motor and sensory nerve Motor is to the temporalis, pterygoid and masseter muscles To assess the motor function, place a sterile tongue depressor between the molar teeth of the maxilla and mandible (Fig 7.18) The patient gently bites on the blade as the examiner gently pulls blade outward Palpate the masseter and temporalis muscles To assess sensory function, touch the skin lightly with a cotton-tipped swab over the skin of V1, V2, and V3 (Fig 7.19) Cranial nerve V deficits manifest with weakness to bite and even atrophy of the temporalis and the masseter muscles and decreased sensation in V1, V2, and V3 sites The company it keeps includes weakness to movement of the jaw from side-to-side, which indicates pterygoid muscle problem and confirms a CN V deficit Tic douloureux manifests with hyperesthesia and pain on touching the affected branch, usually the V2 or V3 areas This is due to inflammation, trauma, or infiltration of the trigeminal ganglion, e.g., multiple sclerosis or Lyme disease Cranial nerve VII, the facial nerve, is also a mixed nerve—motor to the facial muscles, including the orbicularis oris and oculus, the frontalis muscle; and sensory to the lobe of the ear and to the lateral and anterior taste buds To assess motor function, have the patient actively smile; to assess the function of the orbicularis oris muscle, have the patient growl or puff out cheeks (Fig 7.20) The growl and the “puff out” of cheeks tests are the best two, because both false-positive and false-negative findings occur with a smile The second component required to assess the function of cranial nerve VII is for the patient to actively and against resistance close the eyes This is to assess the orbicularis oculus muscle Testing the function of orbicularis oris and orbicularis oculus muscles is required to satisfactorily assess the function of cranial nerve VII (Fig 7.21) In addition, it is important to note the function of the frontalis Box 7.1 Rules of Extraocular Movements All recti muscles move the eyeball out, except one—the medial All obliques muscles move eyeball nasal, opposite to superior or inferior Superior oblique muscle (SO) = 4; lateral rectus (LR) = 6; all the rest are Figure 7.18 Technique to assess masseter strength as a method to assess motor function of cranial nerve V TIPS ■ Place sterile tongue depressor ■ ■ ■ ■ ■ ■ between the molars of the maxilla and mandible on one side Patient gently bites the blade; examiner attempts to pull it outward Palpate masseter and temporalis muscle Repeat on other side Cranial nerve V deficit: weakness, ipsilateral, extremely rare Myasthenia gravis: weakness, bilateral Landry-Guillain-Barré polyneuritis: no weakness 4886.LWW.Berg.ch07pp161-200 07/18/05 10:42 AM Page 170 170 Chapter A B C Figure 7.19 Technique to assess sensory component of cranial nerve V A V1 B V2 C V3 TIPS ■ Touch lightly with cotton-tipped swab in middle of V1, V2, and V3 areas ■ Tic douloureux: severe pain on touching in V1, V2, or V3 distribution, usually V2 or V3 ■ V1 or V2 or V3 problem: decreased sensation muscle (Fig 7.22) To assess this, instruct the patient to look upward with both eyes in order to furrow the forehead (brow) The sensory examination of cranial nerve VII is far less important and will not be discussed other than to state that taste is partially served by cranial nerve VII Ramsay-Hunt syndrome manifests with clusters of vesicles in dermatome of CN VII This is due to herpes zoster of the geniculate ganglion Central cranial nerve VII deficit manifests with droop when smiling and when showing teeth (growl) on the side contralateral to the UMN* lesion Peripheral cranial nerve VII deficit manifests with a droop when smiling, when showing teeth (growl), and weakness to closure of the eye and a marked decrease in brow wrinkling with eyebrow elevation, all unilateral and ipsilateral to the damage Long-standing peripheral cranial nerve VII palsy may have a Bell’s phenomenon—a synkinesia in which the eye on the affected side rolls upward Obviously, the overall examination is difficult to perform if the patient has received botulinum toxin injections in the past Cranial nerve VIII is the purely sensory auditory nerve To assess this nerve, use the Weber and the Rinne tests With the Weber test, apply a vibrating tuning fork (512 Hz is best, but 256 Hz is acceptable) to the base of the mastoid process (Fig 7.23) When the patient can no longer hear the sound of Figure 7.20 Active smile (A) or puff out cheeks (B) tests These effectively use the orbicularis oris muscle A deficit is either ipsilateral peripheral or contralateral central cranial nerve VII damage A Patient has right weakness TIPS ■ Actively smile (A) or “puff-out” (B) using the orbicularis oris muscle ■ Peripheral cranial nerve VII deficit (LMN): ipsilateral inability to smile ■ Central cranial nerve VII deficit (UMN): contralateral inability to smile ■ Growl or cheek puff out is the supe- rior maneuver A *UMN = upper motor neuron B 4886.LWW.Berg.IDXpp411-426 07/29/05 2:01 PM Page 412 412 Aortic stenosis (continued) pulse in, 81t, 82, 85, 85f Aortic valve, 75, 75f bicuspid, 91 Aphthous stomatitis, 20 Apical tissue, of lung, 106, 106f Apley distraction test, 211t, 213, 214f Apley grind test, 211t, 213, 214f, 218t Apnea, 113, 113t sleep, 113, 113t Appendicitis, 137, 148f, 149, 149f, 149t, 150f Apprehension sign in humeral laxity, 245–246, 246f in patellar instability, 208 Arcus senilis, 395, 395f Argyll-Robertson pupil, 386, 387f Arm extension, 161–162, 161f Arm forward flexion and elevation, 77 Arrhythmias, 79 Arsenic poisoning, common peroneal nerve injury in, 191, 192t Arterial occlusion, transient, 90 in aortic insufficiency, 92, 92t in mitral regurgitation, 88 Arterial ulcers, 366–367, 367f Arteriosclerosis, aortic artery, 136t, 137 Arteritis, temporal, in polymyalgia rheumatica, 179f Arthritis degenerative of elbow, 285, 285f of fingers, 270 of hip, 299t, 304–305, 305f rheumatoid digital clubbing in, 119, 120t digital deformities in, 270, 270f of elbow, 283t, 284, 284f of fingers, 270, 270f, 271, 271f Ascites, 142–143, 143t, 153–154, 153t, 154f, 155f Asterixis, 196–197, 196f, 196t in end-stage liver disease, 143, 143t Asthma, 126t, 127 auscultatory findings in, 117t, 118–119 cough in, 121 intercostal movements in, 108t, 111–112 Asynergia, 182t, 183, 185f in ataxia, 182t, 183, 185f Ataxia cerebellar, 180–183, 182t sensory (proprioceptive), 182t, 183–187 truncal, 182t, 183 vestibular, 182t, 187–188 Ataxic gaits in cerebellar ataxia, 180–183, 182t, 193t in sensory ataxia, 182t, 183–187, 193t in vestibular ataxia, 182t, 187–188, 193t Atelectasis, tracheal deviation in, 112, 112t Atherosclerosis, aortic artery, 136t, 137 Athetosis, 196, 196t Atopic conjunctivitis, 392 Atopic dermatitis, 353, 353f, 370 Atrial fibrillation, 79 Atrial flutter, 79 Atrial myxoma, 93t, 95 Atrial septal defect, 91 digital clubbing and, 119, 120t Atrioventricular dissociation, 79 Atrophic glossitis, 24–25, 25f Atrophic vaginitis, 61t, 62 Auditory nerve, 170–172, 171f, 172f Auenbrugger’s percussion sign, 250, 250f Auricle anatomy of, 1–2, 1f disorders of, 2–5, 2f–4f, 4t Index Auricular lymph nodes anterior, 1, 1f posterior, 1, 1f in mastoiditis, Auscultation abdominal, 136–137, 136t of breath sounds, 97–98, 115t, 116–122, 121t, 126t of heart sounds, 82–96, 82t See also Heart sounds tracheal, 121f, 122 Auspitz sign, 369 Axilla, 228, 228f Axillary hair, in females, 52, 53t Axillary lymph nodes, 228, 228f, 229f Axillary nerve, 230t, 231 Babinski’s maneuver, 179, 181f Back See also Hip, back, and trunk examination Back pain, 299–304, 299f–302f, 299t, 302t, 303t Bacterial vaginosis, 61–62, 61t Baker’s cyst, 209 Balanitis, 40, 40f Balanoposthitis, 40, 40f Ballance sign, 150 Ballottement, patellar, 205, 206f Band keratopathy, 388t Banner test, 382 Barrel chest, 107t, 108 Barre’s pyramidal sign, 179, 182f Bartholin cysts, 55, 55f Bartholin glands, 51, 52f abscess of, 55, 55f Basal cell carcinoma, 360–361, 360f, 368, 370 Basilar skull fractures, 9t, 11, 11f Battle’s sign, 11 Beaus lines, 341342, 341f Behỗets syndrome, 56t, 57 Bells palsy, 13, 14t, 170, 171f Benediction sign, 264, 264f, 282 Benign positional vertigo, vestibular ataxia in, 187–188, 188f Benign prostatic hypertrophy, 48, 49t Biceps brachii muscle, 225–226, 225f, 231, 231f, 278, 278f tears of, 241, 241f Biceps femoris muscle, 203, 203f, 204, 291 strain of, 214, 214f, 215t Biceps reflex, 165, 166f Biceps tendon, tears of, 239–241, 241f Bicipital groove, 225, 225f Bicipital tendinitis, 239, 240f, 245 Bicornuate uterus, 68 Bifid pulse, 81t, 82 Bifid uvula, 27, 27f Bilic-Pecina test, 263 Bilirubin, in end-stage liver disease, 143, 143t Bimalleolar fractures, 330 Bimanual palpation of fetus, 156 in pelvic examination, 66, 67f Biot’s breathing, 113, 113t Black tongue, 26, 26f Bladder distention, 132f, 142, 156 in prostate disease, 48–49 scratch test for, 48, 48f Bleeding See also Hematomas; Hemorrhage ocular, 394, 394f retroperitoneal, 133t, 134 Grey Turner’s sign in, 146, 150, 151, 348, 349f Kehr’s sign in, 146, 147, 150 in pancreatitis, 146 in ruptured ectopic pregnancy, 151 in splenic rupture, 149–150 Blepharitis, 391, 391f Blood in stool, 138–139, 147, 148f in urine, in pyelonephritis, 147 Blood pressure measurement in arm, 92f in thigh, 92f, 93 in transient arterial occlusion maneuver, 92 Blot hemorrhages, retinal, 398–399 Blue finger, 272, 272f, 348, 348t Blue nose, Blue sclera, 395–396, 396f Blue toe, 332, 348, 348t Boas’ sign, 147 Bohler’s sign, 211 Bonaparte position, 233, 250 Borborygmi, 136 Botox injections, 13 Bouchard’s nodes, 271, 271f Bounding pulse, 80–81, 81t, 93 Boutonnière’s fracture, 270, 270f Bowel obstruction, 44–45, 153, 153t Bowel sounds, 44–45, 136–137, 136t, 137 Boxer’s fracture, 270 Boyle’s sign, 168 Brachial artery, 278 Brachial plexus, 226, 242 Brachioradial delay maneuver, 85, 85f Brachioradialis muscle, 231, 278, 278f Bradykinesia, 188 Brain herniation, pupils in, 385t, 386 Brain tumors, 168 Branchial cleft cyst, 16–17 Breast anatomy of, 69–70 cancer of, skin abnormalities in, 370 development of, 70, 70t development of, Tanner staging system for, 52, 53t disorders of, 72, 72f enlarged male, in end-stage liver disease, 143 examination of, 69–72, 70f, 71f quadrants of, 69–70 Breathing See Respiration Breath sounds, 97–98, 115t, 116–122, 121t, 126t adventitious, 115t, 116–119, 117t–118t, 121–122, 121t auscultation of, 97–98, 115t, 116–122 vesicular, 116 Bronchial obstruction, tracheal deviation in, 112, 112t Bronchiectasis, 126t auscultatory findings in, 117t, 119 Bronchitis acute, 126t cough in, 122 chronic, 126t auscultatory findings in, 117t, 119, 123 breath sounds in, 97 cough in, 122, 123 Brown’s syndrome, 384t Bruises, 339t, 340, 346 abdominal, 133t, 134, 347 Bruits, abdominal, 136–137, 136t Brushfield spots, 397, 397f Budd-Chiari syndrome, scrotal edema in, 45 Buerger’s disease, 348, 348t, 349f 4886.LWW.Berg.IDXpp411-426 07/29/05 2:01 PM Page 413 413 Index Bulbar palsy, 173 Bulge sign, 205 Bullae, 339, 339t, 372–374 Bullous impetigo, 353, 374, 374f Bullous myringitis, 6t, Bullous pemphigoid, 373, 373f, 374 Bull’s eye maculopathy, 398 Bunions, 331t, 332 Burners, 242 Burns, 368, 373, 373f Bursae of elbow, 277f, 278 of foot and ankle, 202, 315, 315f, 318 of hip, 290f, 291 of knee, 201, 201f, 202 of shoulder, 228 Bursitis of elbow, 283–284, 283f, 283t, 284f of foot, 210, 210t, 325, 333, 334f of hip, 299t, 303, 303t, 306, 307, 307f, 310 of knee, 206, 214 Café au lait spots, 361, 361f Calcaneus, 315, 315f, 318, 318t fractures of, 325 Calculi renal, 147 salivary, 15, 16f Calluses, 332, 362, 369–370, 369f crack pipe, 368, 368f Canal of Hunter, 289f, 290 Cancer, 183 See also specific types brain, 168 breast, 72, 72f skin abnormalities in, 370 cervical, 63–64 chest wall, 111 choroidal melanoma, 398 endometrial, 68 hepatic, 138 bowel sounds in, 136t, 137 bruit in, 136t leukemia, sternal involvement in, 97, 124t, 125 lip, 22, 22f oral, 20 ovarian, 69 penile, 41 periampullary, 142 prostate, 48, 49t skin See Skin cancer squamous cell See Squamous cell carcinoma tongue, 26–27, 26f uveal melanoma, 397 vulvar, 56t, 57 Candidiasis oral, 20, 23, 24f penile, 40, 40f vaginal, 61t, 62 Capillary refill time, 367 Caput medusae, 134 Carbuncles, 374, 375f urethral, 55 Cardiac arrhythmias, 79 Cardiac examination See also Heart auscultation in, 82–96, 82t See also Heart sounds; Murmurs neck vein inspection in, 76–79, 77f, 78t positioning for, 76, 76f, 82–83 precordial inspection in, 76–77, 76f precordial palpation in, 79–80 surface anatomy in, 75–76 Cardiology constant, 77 Cardiomegaly, 126t Cardiomyopathy, hypertrophic obstructive, 81t, 82, 84t, 86–87, 86f, 87f Cardiovascular examination, 75–98 auscultation in, 82–96, 82t See also Heart sounds; Murmurs cardiac examination in, 75–76, 84–96 See also Cardiac examination chest pain in, 97–98 orthopnea and paroxysmal nocturnal dyspnea examination in, 96–97 precordium and neck inspection in, 76–80 pulse palpation in, 80–82 surface anatomy in, 75–76 Caries, 21 Carnett’s sign, 142, 150, 150f Carotid artery pulse, 80–82, 81t Carpal tunnel, 256 Carpal tunnel syndrome, 262–264, 262f, 263f, 263t, 264f Casanova heel, 325 Castell’s point, 131f, 144, 144f, 146 Cataracts, 387, 388f, 388t Cauda equina syndrome, 294 Cauliflower ear, 4, 4t Cellulitis, 352–353, 352f orbital, 403, 403f preseptal, 403 scrotal, 43t, 45, 46f Central retinal vein occlusion, 399, 399f Central venous pressure, 78t Cerebellar ataxia, 180–183, 182t Cerebellar tremor, 196t, 197 Cerebrospinal fluid rhinorrhea, 11 Cerumen impaction, 5, 5f, 6t Cervical hood, 63 Cervical lymph nodes enlargement of, 15–16 in Hodgkin’s disease, 238, 240f palpation of, 16f Cervical masses, 15–17, 15f–17f Cervical spine anatomy of, 248 examination of See Hip, back, and trunk examination fractures of, 249 Cervicitis, 63 Cervix disorders of, 63–64, 63f examination of, 58–60, 58f–61f, 59f See also Gynecologic examination in pregnancy, 64, 68–69, 68t, 156 prolapse of, 65, 65f Chaddock’s maneuver, 179 Chadwick’s sign, 64, 68–69, 68t, 156 Chalazion, 391f, 392, 403 Chancre, 368 syphilitic penile, 40, 40f vulvar, 56t, 57 Chancroid, 41–42, 368 vulvar, 56–57, 56t Charcot joint, 325 Charcot-Marie-Tooth disease, 191, 192t Charley horse, 306 Cheek puff maneuver, 169–170, 170f, 171f Cheilitis, 22 Cheilosis, 22–23, 23f Cheiomosis, 394, 394f Cherry hemangioma, 346, 347f Cherry red macula, 399, 399f Chest, 76, 109, 109f barrel, 107t, 108 funnel, 76, 107, 107t, 108f incisional scars on, 76, 109, 109f pigeon, 107–108, 107t, 108f surface anatomy of, 105–106, 105f, 106f Chest and lung examination, 105–127 auscultation in, 115t, 116–122, 121t, 126t for chest pain, 97–98, 124–125, 124t chest wall examination in, 109–114 clubbing in, 119, 120t cough in, 121–122 impending respiratory failure in, 125–127 incisional scars in, 76, 109, 109f inspection in, 76, 107–112, 108f–110f, 112f neck muscle inspection in, 112 orthopnea in, 122–123 palpation in, 79–80, 112 paroxysmal nocturnal dyspnea in, 122–123 percussion in, 113t, 114–115, 114f, 126t pleuritic chest pain in, 124–125, 124t pulmonary examination in, 107–120 respiratory patterns in, 112–113, 113t sputum examination in, 121, 121f, 121t surface anatomy in, 105–106, 106f, 150f tactile fremitus in, 114t, 115–116, 115f, 126t Chest expansion, 109–110, 110f Chest pain, 97–98 pleuritic, 124–125, 124t Chest wall abnormalities of, 107–109, 107t, 108f–110f, 112f pain in, 124–125, 124t auscultation of, of breath sounds, 97–98, 115t, 116–122, 121t, 126t inspection of, 76, 107–112, 108f–110f, 112f metastases to, 111 palpation of, 79–80, 112 percussion of, 113t, 114–115, 114f, 126t respiratory movements of, 108t splinting of, 111 tactile fremitus of, 114t, 115–116, 115f, 126t Chest wall expansion maneuver, 300 Cheyne-Stokes’ breathing, 113, 113t Chickenpox, 371, 371f Child-Pugh-Turcotte classification, 143, 143t Chlamydial infections in females, 56t, 57, 63 in males, 47 Chlamydial urethritis, 41, 47 Cholecystitis, 146–147, 146f, 147f, 151t Cholesteatoma, epidermoid, 6t, Chondritis, costal, 80, 112, 124t, 125 Chorea, 196, 196t Chorioretinitis, 398, 399f Choroidal melanoma, 398 Choroid plexus, 381 Chronic obstructive pulmonary disease, 126t auscultatory findings in, 97, 117t, 119, 123 cough in, 122, 123 digital clubbing in, 119, 120t intercostal movements in, 108t, 111–112 neck muscle hypertrophy in, 112 Chvostek’s sign, 12–13, 13f Cicatricial pemphigoid, 373 Ciliary body, 381 Clasp-knife phenomenon, 164 Clavicle, 106, 225f, 226 fracture of, 238 Clavicular percussion test, 238 4886.LWW.Berg.IDXpp411-426 07/29/05 2:01 PM Page 414 414 Claw toe, 332 Cleft palate, 27, 27f Clitoris, 51, 52f Clonus, 167–168 Clubbing, 119, 120t, 341, 341f Coarctation of aorta, 82 digital clubbing in, 119, 120t Coccydynia, 310 Coccyx, contusion of, 310 Cock-up toe, 332 Codman’s maneuver, 243, 243f Cogwheel rigidity, 164, 188 Cold sores, 22, 22f, 371 Collar-button abscess, 272 Collateral ligaments, 203–204, 203f injuries of, 210–211, 210t, 213, 214f Collateral veins from inferior vena cava obstruction, 134 from portal hypertension, 134 Colle’s fracture, 266–267, 267f Color vision tests, 382 Colposcopic examination, 63–64 Combination gallop, 95 Common peroneal nerve anatomy of, 203f, 204 damage to, 190–191, 191t, 192t injuries of, 327, 327f Compression fractures, vertebral, 298–299, 299t, 303, 303t, 310 Conductive hearing loss, 172 Condylomata acuminata, 360, 360f in females, 55, 55f, 63 in males, 41 Condylomata lata, 56, 360 Confrontation testing, 382 Congenital lues, 21 Congestive heart failure, 96–97, 122–123, 123f, 127 dyspnea/orthopnea in, 122–123 nails in, 97, 342, 342f scrotal edema in, 45, 46f, 46t Conjunctiva, 381 examination of, 390, 390f Conjunctivitis, 392, 392f Consolidation, pulmonary, 114t, 115, 117t, 118, 121, 126t Constrictive pericarditis, 78 intercostal movements in, 108t, 111–112 Contact dermatitis, 353, 353f, 372 vulvar, 54 Contracture Boutonnière’s, 270, 270f Dupuytren’s, 265, 265f typewriter, 270, 270f Contusion of coccyx, 310 of extensor digitorum brevis, 331 of quadriceps muscle, 306 of sacrum, 310 Cope’s pinch, 147, 147f Cope’s sign, 149 Copper deposits, ocular, 396 Coracoid process, of humerus, 225f, 226 Cornea, 381, 387 abrasion of, 390, 393, 393f perforation of, 388t Corneal opacities, 387, 388f, 388t Corns, 328, 332, 362, 369–370, 369f Corpus luteal cyst, 69 Corrigan’s (waterhammer) pulse, in aortic regurgitation, 93 Costal chondritis, 80, 112, 124t, 125 Cotton-wool spots, 397–398, 398f Cough, 121–122, 121f, 121t Courvoisier’s sign, 142 Index Coxsackie labialis/stomatitis, 22, 22f Cozen’s maneuver, 285, 285f Crackles, 115t, 116 Crack pipe ulcers, 368, 368f Cracks, 339t, 340 Cranial nerves, 10 See also specific nerves examination of, 168–174 Crank tests, 233–235, 234f, 235f, 243, 245 active, 235, 235f Liu’s, 245–246, 247f passive, 233–235, 234f Cremasteric muscle, 39 Cremasteric reflex, 168 Cricoid cartilage, 29, 29f Crossed straight leg raise test, 301, 302t Crosseye, 384, 385f Cross-legged maneuver, 211, 212f Cross-over test, 238, 238f Crowe’s sign, 361, 361f, 366 Cruciate ligaments, 204 examination of, 216–219 injuries of, 216–219 Crusts, 339t, 340 Cryptorchidism, 43, 43t Cubital tunnel, 277, 278–279, 279f Cubital tunnel syndrome, 282–283, 282f, 283f Cullen’s sign, 146 Cushing’s syndrome, facies in, 14t Cuska-McCarty test, 176 Cutaneous larva migrans, 355, 355f Cuticle, 341 Cyst(s) Baker’s, 209 Bartholin’s, 55, 55f branchial cleft, 16–17 corpus luteal, 69 epidermal inclusion, 62 ganglion of ankle, 328 of wrist, 271–272, 271f Gardner’s duct, 62 Nabothian, 63, 63f ovarian, 69 sebaceous, auricular, 4t, thyroglossal duct, 15, 15f vulvar, 55 Cystic hygroma, 17, 17f Cystocele, 64, 65f Cytobrush, for Pap specimen, 60, 61f Cytolytic vaginosis, 62 Cytomegalovirus infection, ocular complications of, 398 Dacryocystitis, 403 Dahl’s sign, 97, 123, 123f, 365, 365f Dalrympal’s sign, 31, 31f Dancer’s foot, 325, 325f, 332 Daniel’s test, 218 Dartos muscle, 39 Darwin’s tubercle, 2, 2f, 4t Dead arm position, 233, 233f, 242, 250 Deafness, 172 Decubital position, 48 for anorectal examination, 139f Decubital ulcers, 368, 368f Deep peroneal nerve, 316f, 320, 320t Deep tendon reflexes, 165–168, 166f–168f in abnormal gaits, 193t elicitation of, 165–167, 166f–168f grading of, 167, 167t Deep venous thrombosis, 209, 334, 335f Degenerative joint disease See Arthritis, degenerative Delayed puberty, 52, 53t Delirium, 193–194 Deltoid ligament, 316, 317f sprains of, 326, 326f Deltoid muscle, 225f, 227, 227f, 231, 231f atrophy of, 245 Dementia, 193–194 DeMusset’s maneuver, 93, 93t, 94 Dental mirror, 21, 21f Dental problems, 18, 19f, 21, 21f De Quervain’s tenosynovitis, 267f, 268 Dermatitis See also under Skin Dermatitis herpetiformis, 374 Dermatomyositis Grotton’s papules in, 178f rash in, 178f, 349–350, 350f waddling gait in, 177t Dextroscoliosis, 298, 298f Diabetes mellitus, pretibial skin changes in, 364, 365f, 370 Diabetic retinopathy, 401–402, 401f, 402f Diaphragm, 106 Diastolic heart sounds, 84–96 See also Heart sounds Dicrotic pulse, 80–81 Digital rectal examination, 138, 139b Digits See Finger(s); Toe(s) Dinkler’s sign, 173, 173f Dinner fork deformity, 266, 267f Discharge, vaginal, 60–62, 61t Disc herniation, 301–302, 302t Discoid lupus alopecia in, 344, 345t hypopigmentation in, 363, 363f malar rash in, 359 Dislocation finger, 270–271, 271f glenohumeral, 250–251 humeral, 233, 250 patellar, 207, 207t, 209 scapholunate, 266, 267f Diverticulitis, 150–151, 151t Dix-Hallpike-Nylen maneuver, 182t, 187–188, 188f Doormat sign of Pecina, 309, 309f Dorsal interosseus muscle, 259 Dorsalis pedis artery, 316 Dorsalis pedis pulse, 80–82, 81t, 316f Dorsal lithotomy position, 48, 53 Dorsal vein thrombosis, 41 Dowager’s hump, 107t, 108, 299 Drawer test anterior for ankle instability, 329, 329f for knee instability, 217, 217f, 218t posterior in glenohumeral laxity, 245–246, 246f in posterior cruciate ligament tears, 218, 218f Drop sign, 244, 244f Drusen, 397 Dry eye, in Sjögren’s disease, 395 Dry-eye keratitis, 390 Dry gangrene, 366 Duchenne muscular dystrophy, waddling gait in, 177t Duodenal ulcers, 147, 151t Dupuytren’s contracture, 265, 265f Durozier’s maneuver, 92t, 94 Dyck’s femoral traction test, 305, 305f Dysarthria, 173–174, 179–180 Dysdiadochokinesis, 181, 182t, 184f Dyskinesis, 196, 196t Dysmetria, 181–182, 185f Dysphonia, 180 Dysplastic nevus, 363–364, 364f 4886.LWW.Berg.IDXpp411-426 07/29/05 2:01 PM Page 415 415 Index Dyspnea, 122–123, 123f Dysrhythmias, 79 Ear, 1–7 anatomy of, 1–2, 1f, 2f cauliflower, 4, 4t disorders of of external ear, 2–5, 2f–4f, 4t of middle ear, 6–7, 6f, 6t otoscopic examination of, 5, 5f Earlobe See also Auricle keloids of, 3, 3f, 4t Ecchymoses, 339t, 340, 346 abdominal, 133t, 134, 347 Ecthyma gangrenosum, 368, 368f Ectocervix See also Cervix examination of, 58 Ectopic pregnancy, 69 ruptured, 151, 152t Ectropion cervix, 63, 63f Eczema, 353, 353f, 370 nummular, 354, 354f, 370 Edema ascitic, 154, 155f peripheral, in end-stage liver disease, 142, 155f pulmonary, 126t auscultatory findings in, 118t, 119 noncardiogenic, 146 scrotal, 43t, 45, 46f, 46t tiger-striping, 154f Egophony, 121, 121t, 122t Ehlers-Danlos syndrome, 387, 388t Elbow examination of, 277–287, 278f disorders in, 280–287 of lateral elbow, 284–287 of medial elbow, 280–283 of olecranon process, 283–284 of posterior elbow, 283–284 elbow-knee comparison in, 277t range of motion in, 279–280, 279t, 280f, 281 surface anatomy in, 277–279, 277f–279f Little Leaguer’s, 281, 281f tennis, 285, 285f Embolism air, 96 pulmonary, 97, 124 Emphysema, 126t See also Chronic obstructive pulmonary disease auscultatory findings in, 117t, 119 digital clubbing in, 119, 120t mediastinal, 91 Empyema necessitans, 107t, 111 Encephalopathy, hepatic, 143, 143t Endocervix See also Cervix examination of, 58, 58f–61f Endometrial cancer, 68 Endometriosis, 62 End-stage liver disease, 142–143, 143t Enterobiasis, 139t, 141 Enterocele, 64 Entropion cervix, 63, 63f Ephelis, 365 Epicondyle lateral, 277f, 278, 278f medial, 277f, 278, 278f Epicondylitis lateral, 285, 285f medial, 280, 280f Epidermal inclusion cyst, 62 Epidermoid cholesteatoma, 6t, Epididymis, 39 Epididymitis, 47 Epigastric area, 132, 132f, 132t Epigastric bruits, 136–137, 136t Episcleritis, 396 Epitrochlear node, 277f, 278, 278f enlargement of, 280–282 Eponychia, 342, 343f Epulis, 18 Erosion(s), 339, 339t, 366 See also Ulcers dental, 21 vulvar, 56–57, 56t Erysipelas, 352f, 353 Erythema ab igne, 356, 356f, 356t, 365 Erythema chronicum migrans, 355–356, 355f, 356t Erythema infectiosum, 357t, 358, 358f, 359f Erythema marginatum, 356, 356f, 356t Erythema multiforme, 356, 356f, 356t Erythema multiforme major, 374 Erythema nodosum, 349, 349f, 356 Erythrasma, 351, 352f Esotropia, 384, 385f Essential tremor, 190, 190t, 196t, 197 Ewart’s sign, 115 Exanthems, 356–359, 357t, 358f Exanthem subitum, 357t, 359, 359f Excoriations, 339t, 340 Exophthalmus, 385 in Graves’ disease, 33, 33f Exotropia, 384, 384f Extensor carpi radialis brevis muscle, 257f, 258, 259 Extensor carpi radialis longus muscle, 257–258, 257f, 259 Extensor carpi ulnaris muscle, 257f, 258, 258t Extensor compartments, of wrist, 257–258, 257f, 258t tenosynovitis of, 268, 268f Extensor digitorum brevis muscle, contusion of, 331 Extensor digitorum brevis tendon, 316, 316f Extensor digitorum communis muscle, 257f, 258, 258t Extensor digitorum longus muscle, 318–319, 318t Extensor digitorum longus sprains, 327, 327f Extensor digitorum longus tendon, 316, 316f Extensor digitorum minimus muscle, 257f, 258, 258t Extensor hallucis longus muscle, 318t, 319 strains of, 327, 327f Extensor hallucis longus tendon, 316 Extensor pollicis brevis muscle, 257, 257f, 258t Extensor pollicis longus muscle, 257f, 258, 258t, 259 Extensor retinaculum muscle, 259 Extensor tendon, tears of, 268, 268f External ear canal anatomy of, 1, 1f disorders of, 5, 5f, 6t External oblique muscle, 289, 298 strains/tears of, 307–308 Extracoular movements, 169, 169b Extraocular movements, 169, 169b, 383–385, 383f, 384t Eye foreign bodies in, 390, 390f in hyperthyroidism, 31–32, 31f, 33f movements of, 169, 169b, 383–385, 383f, 384t Eye closing, in facial nerve examination, 170, 172f Eye examination, 381–403 accommodation in, 386, 387t anterior chamber findings in, 387, 388t fluorescein staining in, 390, 390t, 393 fundoscopic, 389, 389f, 398f–402f iris in, 396–397 ophthalmoscopic, 387 periorbital, 402–403 pupil assessment in, 385, 385t red eye in, 390–395 retina in, 397–402 slit lamp, 387 surface anatomy in, 381–383, 382f vision testing in, 382–383, 382f Eyelid, eversion of, 390, 390f Eyelid lag, 403 in hypothyroidism, 31–32, 31f FABER maneuver, 109, 299, 299f, 300, 310 Facial muscles, 10 Facial nerve, 169–170, 170f, 171f Facies, in systemic disease, 11–13, 14t Fallopian tubes, 66 Fascia, plantar, 315, 315f Fascial hernia, of thigh, 306 Favus, 344, 369 Felon, 272 Femoral artery, 289f, 290 aneurysm of, 306 Femoral artery pulse, 80–82, 81t Femoral hernias, 43t, 44, 45t, 305, 306f Femoral intertrochanteric fractures, 311, 311f Femoral neck fractures, 311, 311f Femoral nerve, lumbosacral roots of, 293, 293t Femoral shaft fractures, 311 Femoral traction test, 305, 305f Femoral triangle, 289–290, 289f Femoral vein, 289f, 290 Femur greater trochanter of, 289f, 290, 291f See also Greater trochanter lesser trochanter of, 292 Festination, 188 Fever, in exanthems, 357t Fibrocystic breast disease, 72 Fibroid tumors, 68 Fibular fractures common peroneal nerve injury in, 191, 192t distal, 330 of head, 329f, 330 of neck, 214, 215t, 329f, 330 Fibula-tibial squeeze sign, 330, 330f Fifth disease, 357t, 358, 358f, 359f Finger(s) arthritis of, 270, 270f, 271, 271f blue, 272, 272f, 348, 348t clubbing of, 119, 120t, 341, 341f congenital absence of, 273 contractures of, 270, 270f dislocation of, 270–271, 271f disorders of, 270–273 examination of See Hand, wrist, and thumb examination fractures of, 270, 270f inflammatory arthritis of, 270, 270f Jersey, 272–273 locking, 265 mallet, 271, 271f osteoarthritis of, 271, 271f trigger, 265 4886.LWW.Berg.IDXpp411-426 07/29/05 2:01 PM Page 416 416 Finger march, 181, 184f Finger tap technique, for pyelonephritis, 148f Finkelstein maneuver, 267–268, 267f Fissures, anal, 139t, 140 Fist percussion test, 143 Fistula-in-ano, 139t, 140 Fistulas, chest wall, in actinomycosis, 107t, 111 Flame hemorrhages, retinal, 398–399 Flank hyperesthesia, in cholecystitis, 147 Flexor carpi radialis muscle, 231, 255f, 256, 278 Flexor carpi ulnaris muscle, 255, 255f Flexor digitorum brevis muscle, 315, 315f Flexor digitorum brevis sprain, 325 Flexor digitorum brevis tendon, 315f, 316 Flexor digitorum longus muscle, 316, 317f, 318, 318t Flexor digitorum longus tendon, 315, 315f Flexor digitorum profundum tendon, 255f, 256 Flexor digitorum superficial tendon, 255f, 256, 278 Flexor hallucis brevis tendon, 316 Flexor hallucis longus muscle, 317, 317f, 318, 318t strain of, 323, 324f Flexor hallucis longus tendon, 315–316, 315f Flexor pollicus longus muscle, 278, 278f Flexor retinaculum, 316, 317f Flexor tendons, sprains/tears of, 265 Flint murmur, 92 Floating ribs, 106 Flow murmurs, 85b, 86 Fluid wave maneuver, 154, 155f Fluorescein staining, in eye examination, 390, 390t, 393 Follicular cysts, vulvar, 55 Folliculitis, 375 Foot dancer’s, 325, 325f, 332 midaxis of, 316 runner’s, 324, 324f Foot and ankle examination, 315–335 dorsal foot and ankle disorders in, 327–328 lateral foot and ankle disorders in, 328–331 medial foot and ankle disorders in, 326 neurologic examination in, 320, 320t plantar foot disorders in, 323–325 posterior ankle and leg disorders in, 333–335 range of motion in, 320–322, 321t, 323t surface anatomy in, 315–319, 315f–317f, 318t, 319t toe disorders in, 331–333 Foot dorsiflexion variant, of straight leg raise test, 301, 301f Fordyce disease, 55 Forearm pronators, 278 Forearm squeeze test, 266, 266f, 268f, 287 Foreign bodies, ocular, 390, 390f Foreskin, 39 retraction of, 39, 41f Fornices, vaginal, 58 plus grid, in abdominal examination, 131–133, 132f, 132t Fourchette, 51, 52f Fournier’s gangrene, 43t, 45, 46f, 140–141 Fowler’s position, 123, 123f Fractures bimalleolar, 330 boxer’s, 270 Index calcaneal, 325 cervical spine, 249 clavicle, 238 Colle’s, 266–267, 267f facial, 9, 11f, 14t, 384t femoral shaft, 311 fibular common peroneal nerve injury in, 191, 192t distal, 330 of head, 329f, 330 of neck, 214, 215t, 329f, 330 hip, 311, 311f humerus, 233, 251 Jones, 331 Lisfranc’s, 326 metatarsal, 328 stress, 328, 331t, 332–333 nasal, 9, 9f, 9t orbital rim, 384t patellar, 206–207, 207t radial head, 268, 286f, 287 rib, 80, 97, 107t, 111, 112, 124–125, 124t scaphoid, 266, 266f skull, 9t, 11, 11f stress, metatarsal head, 328, 331t, 332–333 tuft, 333 vertebral compression, 298–299, 299t, 303, 303t, 310 zygomatic, 9, 11f, 14t Freckles, 365 Froment’s sign, 265, 265f Frontalis muscle, assessment of, 170, 171f Frontal lobe tumors, 168 Frontal release signs, 193–194, 194t Frontal sinuses, 10, 10f Frontal sinusitis, 10, 10b Frostbite, 348–349, 348t, 373, 373f Fundal height, measurement of, 68 Fundoscopic examination, 389, 389f, 398f–402f Funnel chest, 76, 107, 107t, 108f Furuncles, 374, 375f of ear canal, 5, 5f Gait, 174–193 abnormal, 175–193 causes of, 175 antalgic, 175, 304 ataxic, 180–188, 182t, 193t narrow-based, 175, 175f, 176 normal, 174–175, 175f poker, 108–109, 191–193, 192t, 193t scissors, 180 shuffling, 188–190, 193t spastic hemiparetic, 176–180, 178t, 193t steppage, 190–191, 193t waddling, 175–177, 176f, 177t, 193t wide-based, 175, 175f, 176 Gallbladder disease, 146–147, 146f, 147f, 151t Gallops, 82t, 83 combination, 95 quadruple, 95 S3, 95 S4, 95 summation, 95 Gamekeeper’s thumb, 266, 267f Ganglion cyst of ankle, 328 of wrist, 271–272, 271f Gangrene dry, 366 Fournier’s, 43t, 45, 46f, 140–141 Gardner’s duct cyst, 62 Gastric ulcers, 147, 151t Gastrocnemius muscle, 318, 318t Gastroesophageal reflux disease, cough in, 121 Gaze assessment of, 383–384, 384f in hyperthyroidism, 31, 31f Gemelli muscles, 291 Genital herpes in females, 56, 371 in males, 40, 40f, 371 Genital warts, 360, 360f in females, 55, 55f, 63 in males, 41 Genitourinary disorders female male, 40–49, 43t, 45t, 46t, 49t Genitourinary examination female external anatomy in, 51, 52f hair in, 52, 53f, 54t male, 39–49 surface anatomy in, 39, 39f Geographic tongue, 25, 25f Gerdy’s tubercle, 203f, 204 Gingiva disorders of, 17–20, 19f inspection of, 17, 18f Gingival hypertrophy, 17–18, 19f Gingivitis, 18, 19f Glans penis, 39, 39f Glaucoma, 383, 385t, 386, 390–391 Glenohumeral dislocation, 250–251, 250f Glenohumeral laxity, 245–246, 246f, 247f Glenoid labrum tears, 245, 246, 247f Glossitis, atrophic, 24–25, 25f Glossopharyngeal nerve, 172–173, 172t Gluteal compartment syndrome, 303, 303t Gluteal nerves, lumbosacral roots of, 293, 293t Gluteus muscles, 290f, 291 strains of, 308, 310 Godfrey’s test, 218, 219f Goiter, 15, 29–31, 30f in Graves’ disease, 29–31, 30f retrosternal, 29–31, 30f, 111 superior vena cava syndrome and, 107t, 111 toxic multinodular, 33 Golfer’s wrist, 265 Gonococcal urethritis, 41 Gonorrhea in females, 55 in males, 41 Goodell’s sign, 68, 68t Gottron’s papules, 359 Gout auricular tophi in, 2–3, 2f, 4t digital tophi in in fingers, 272 in great toe, 331, 331f olecranon tophi in, 283t, 284, 284f podagra in, 331, 331f Gower’s sign, 176 Gracilis muscle, 292 Granuloma annulare, 359 Granuloma inguinale, 56t, 57 Graphesthesia, 195 Grasp reflex, 194, 194t Graves’ disease, 31–33, 32f, 33f Graves’ speculum, 58–60 Greater trochanter, 289f, 290, 291f Greater trochanteric bursa, 291 4886.LWW.Berg.IDXpp411-426 07/29/05 2:01 PM Page 417 417 Index Greater trochanteric bursitis, 299t, 307, 307f Grey Turner’s sign, 146, 149, 348, 349f Griffith sign, 31 Groin pull, 304, 304f Grotton’s papules, 178f Growl test, 169–170, 170f, 171f Guaiac test, 139, 140t, 147, 148f Guarding, abdominal, 137, 146 Guy-Mallet sign, 146, 146f Gynecologic examination, 53–72 bimanual palpation in, 66, 67f breasts in, 69–72 cervix in, 58–60 rectovaginal examination in, 66 uterus and adnexa in, 65–69 vagina in, 58–62 vulva in, 53–57 Gynecomastia, in end-stage liver disease, 143, 143t Hair axillary, female, 52, 53t disorders of, 52, 344–346 pubic, female, 52, 53f, 54t Hairy leukoplakia, 23, 24f Hallux valgus, 331t, 332 Hamman’s crunch, 91 Hammertoe, 332, 332f Hamstring, 202 strains of, 210t, 308–309, 309f Hamstring squeeze test, 209–210, 210f, 308 Hand, wrist, and thumb examination, 255–273 disorders in, 262–273 of anatomic snuffbox, 266–268 of dorsal hand and fingers, 266–268 of fingers, 270–273 of palmar hand and fingers, 262–266 of ulnar hand and fingers, 269 neurologic examination in, 258t range of motion in, 259–262, 260t, 261t surface anatomy in, 255–259, 255f, 257f Hand-foot-mouth disease, 22, 372 Handgrip maneuver, 84t, 87, 87f, 231 Handwriting in ataxia, 183 in Parkinson’s disease, 188–189 Hard exudates, retinal, 397, 398f Harrison’s sulcus, 107t, 108 Hasselbach’s triangle, 39f, 43, 44f Hawkins impingement sign, 243–244, 244f, 246, 247f Head, ears, nose, and throat (HENT) examination, 1–33 ear in, 1–7 facial structures in, 10–13, 14t gingiva and oral mucosa in, 17–21 goiters in, 29–33 lips in, 22–23 neck masses in, 15–17 nose in, 7–9 palate and posterior pharynx in, 27–28 sinuses in, 10 teeth in, 21 thyroid in, 29–33 tongue in, 23–27 Hearing tests, 170–172, 171f, 172f Heart See also under Cardiac; Cardiovascular apex of, 75, 75f examination of, 72–98 See also Cardiac examination surface anatomy of, 75–76 Heart failure congestive, 96–97, 122–123, 123f, 127 nails in, 97, 342, 342f systolic, pulse in, 81t Heart sounds, 82–96, 82t See also Murmurs in aortic insufficiency, 91f, 92–94, 92t, 93t in aortic sclerosis, 86, 86f in aortic stenosis, 84–85, 84b in atrial septal defect, 91 auscultation of, 84 maneuvers for, 84t in bicuspid aortic valve, 91 diastolic, 84–96 extra, 93t, 95–96 gallops, 82t, 83, 95 at heart base, 84b from hemodialysis fistula, 96 in hyperthyroidism, 91 in hypertrophic obstructive cardiomyopathy, 81t, 82, 84t location of, 75–76, 75f, 83 in mitral regurgitation, 87f, 88, 88f in mitral stenosis, 93t, 94–95, 94f in mitral valve prolapse, 88–89, 88f murmurs, 80, 82t, 83, 84–95 See also Murmurs normal, 82t, 83 in patent ductus arteriosus, 95–96, 95f from prosthetic valves, 96 in pulmonary embolism, 97 in pulmonic insufficiency, 95 in pulmonic stenosis, 91–92 rubs, 82t, 83 S1, 82t, 83 S2, 82t, 83 splitting of, 86t, 91 S3, 93t S4, 93t systolic, 84–92 extra, 95–96 in triscuspid regurgitation, 89–90, 89f, 90t in ventricular septal defect, 90 Heavy metal poisoning, common peroneal nerve injury in, 191, 192t Heberden’s nodes, 271, 271f Heel, 315, 315f Casanova, 325 Hegar’s sign, 68 Heliotrope rash, in dermatomyositis, 178f, 349–350, 350f Helomas (corns), 328, 332, 362, 369–370, 369f Hemangiomas, cherry, 346, 347f Hematochezia, 147, 148f Hematomas, 339t, 340 rectus sheath, 133t, 134 septal, 9, 9f, 9t subungual, 344, 344f of finger, 273 of toe, 333 Hematuria, in pyelonephritis, 147 Hemiballism, 196, 196t Hemiparesis, 163t Hemiplegia, 163t Hemodialysis, fistula in, heart sounds in, 96 Hemorrhage ocular, 394, 394f, 402 retinal, 398–401 retroperitoneal, 133t, 134, 146, 147, 150 Grey Turner’s sign in, 146, 150, 151, 348, 349f Kehr’s sign in, 146, 147, 150 in pancreatitis, 146 in ruptured ectopic pregnancy, 151 in splenic rupture, 149–150 splinter, 342 subconjunctival, 394, 395f vitreous, 402 Hemorrhoids, 139t, 140, 140f HENT examination See Head, ears, nose, and throat (HENT) examination Heparin injection, abdominal ecchymosis and, 133t, 134, 347 Hepatic disease, 142–144 See also Liver end-stage, 142–143, 143t nail abnormalities in, 342, 342f nails in, 154, 155f, 342, 342f scrotal edema in, 43t, 45, 46t Hepatic encephalopathy, 143, 143t Hepatitis, 143, 151t Hepatocellular carcinoma, 138 bowel sounds in, 136t, 137 Hepatojugular reflux, 77 Hepatojugular reflux test, in mitral regurgitation, 90 Hepatomegaly, 142 definition of, 138 in end-stage liver disease, 143 scratch test for, 137–138, 138f Hereditary telangiectasia, tongue lesions in, 26, 26f Hernias fascial, of thigh, 306 femoral, 43t, 44, 305, 306f incarcerated, 44, 45t incisional, 135, 141, 141f inguinal, 43–44, 43t, 45t strangulated, 43t, 44, 45t umbilical, 141, 141f Herniated intervertebral disc, 301–302, 302t Herpangina, 22, 22f Herpes simplex infection of cervix, 63 of eye, 390, 392, 393 of lip, 22, 22f, 371 of oral cavity, 22, 22f of penis, 40, 40f, 371 of vulva, 56, 56t, 371 Herpes stomatitis, 22, 22f Herpes zoster, 371, 371f red eye in, 393, 393f sciatica in, 302, 303t Herpetic whitlow, 371–372, 371f Hesselbach’s triangle, 131, 131f, 289 Hidradenitis suppurativa, 375 Hill’s maneuver, 92t, 94 Hip osteoarthritis of, 299t, 304–305, 305f snapping, 309–310 Hip, back, and trunk examination, 289–311 for anterior/medial hip and thigh disorders, 304–307 for back and spine disorders, 298–304 for hip fractures, 311 for lateral hip and bony pelvis disorders, 307–308 neurologic examination in, 293–295, 293f, 294f, 295b for posterior hip, pelvis, and back disorders, 308–311 range of motion in, 295–298, 295t–297t surface anatomy in, 289–292, 290f, 291f Hip backward flexion, 162, 162f Hip forward flexion, 162, 162f Hip fractures, 311, 311f Hip pointer, 306, 308 Hirsutism, 52, 346 Hives, 355, 355f 4886.LWW.Berg.IDXpp411-426 07/29/05 2:01 PM Page 418 418 HIV infection parotid gland enlargement in, 15 white hairy tongue in, 23, 24f Hodgkin’s disease, bullneck in, 238, 240f Hoffman’s maneuver, 179, 179f Hollenhorst plaques, 401 Holt-Oram syndrome, 91 Homocystinuria, 387, 388t Hooking maneuver in abdominal examination, 137, 137f, 138, 145 in bimanual pelvic examination, 66, 67f for rib-tip syndrome, 97, 124t, 125 for spleen, 145, 146f Hordeolum, 391–392, 391f, 402–403 Horner’s syndrome, 173, 385t, 386, 386f, 402 Horse rider’s thigh, 304 Human immunodeficiency virus infection parotid gland enlargement in, 15 white hairy tongue in, 23, 24f Humerus coracoid process of, 225f, 226 dislocation of, 233, 250–251, 250f fractures of, 233, 251 greater tuberosity of, 227, 227f landmarks on, 226f laxity of, 245–246, 246f, 247f lesser tuberosity of, 225, 225f Hutson’s test, 238, 238f Hydrocele, 43t, 45, 45f Hymen, 51 Hyperabduction test, in iliotibial band syndrome, 214, 215f in thoracic outlet syndrome, 239, 240f Hyperdynamic state, 76 Hyperesthesia in appendicitis, 149t in cholecystitis, 147 Hyperpigmentation, in pregnancy, 156 Hyperreflexia, in upper motor neuron disease, 179–180 Hypertension cardiovascular, retinal complications in, 399–401, 400f, 401f intracranial, pupils in, 385t portal, 133t, 134 pulmonary, 79, 90–91 Hyperthyroidism, 31–33, 31f–33f hair in, 344 heart sounds in, 91 reflexes in, 168 waddling gait in, 177t Hypertrophic obstructive cardiomyopathy, 84t, 86–87 heart sounds in, 84t, 86–87, 86f, 87f maneuvers for, 84t, 87 pulse in, 81t, 82, 87 Hypertrophic pulmonary osteoarthropathy, 341 digital clubbing in, 119, 120t Hyphema, 394, 394f Hypoglossal nerve, 173–174, 173f Hypophonia, 189 Hypopigmentation, 362–363, 362f Hypospadias, 40–41, 41f Hypothenar atrophy, in ulnar tunnel syndrome, 264, 264f, 265f Hypothenar eminence, 255f, 256, 256t Hypothenar hammer syndrome, 269–270, 269f Hypothenar sign, 264, 264f Hypothyroidism, 29–31, 30f common peroneal nerve injury in, 191, 192t Index facies in, 13, 14t hair in, 344 reflexes in, 168 waddling gait in, 177t Hypotonia, 168 stance in, 165f Icterus, 143, 143t eye discoloration in, 395 Ileus, 136t Iliac crest, 290f, 291f Iliac spines, 290f Iliopsoas bursitis, 306 Iliopsoas muscle, 290, 292 Iliotibial band, 203–204, 203f, 291, 291f Iliotibial band syndrome, 214, 215f, 215t, 299t, 303t, 307, 308f Impetigo, 353 bullous, 353 Impingement, shoulder, 246, 247f Incarcerated hernias, 43t, 44, 45t Incisional hernias, 135, 141, 141f Incisional scars See Scars Inclusion cysts, vulvar, 55 Increased intracranial pressure, pupils in, 385t Inferior calcaneofibular ligament, 317, 317f Inferior gluteal nerve, lumbosacral roots of, 293, 293t Inferior oblique entrapment, 384t Inferior vena cava obstruction, 133t, 134 Inflammatory bowel disease, digital clubbing in, 119, 120t Infraorbital rim fracture, Infrapatellar bursae, 201, 201f Infrapatellar bursitis, 206, 207f, 207t Infrascapular nerve, 230t, 231 Infraspinatus muscle, 226, 227f, 228 disorders of, 245, 246f Infraspinatus tendonitis, 245, 246f Inguinal hernias, 43–44, 43t, 44f, 45t, 141, 141f Inguinal ligaments, 131, 289 Inguinal lymph nodes enlargement of, 306 examination of, in male, 41–42 Inguinal ring, 39f, 43, 44f Inguinal scars, 134t, 135, 135f Insulin injection, abdominal ecchymosis from, 133t, 134, 347 Intention tremor, 196t, 197 in ataxia, 182t, 183 Intercostal movements, 108t, 111–112 bulges, 108t, 112 retractions, 108t, 111–112 Internal oblique muscle, 289, 298 strains/tears of, 307–308 Internus aponeuroses, tears of, 307–308 Intersection syndrome, 267–268, 267f Interstitial lung disease, 126t auscultatory findings in, 117t, 119 Intervertebral disc herniation, 301–302, 302t Intracranial hypertension, pupils in, 385t Introitus, 51, 52f Involuntary movements, 190, 190t, 195–197 in Parkinson’s disease, 188, 190t, 196t Iridectomy, 396 Iridotomy, 396–397 Iris, 381, 387 disorders of, 396–397 Ischial tuberosity, 290f Ischiogluteal bursae, 290f, 291 Ischiogluteal bursitis, 299t, 303, 303t, 310 Ishihara chart, 382 Jacquemier’s sign, 64, 68–69, 68t Janeway lesions, 346, 347f Jaundice, 143, 143t eye discoloration in, 395 Jendrassik’s maneuver, 167, 168f Jersey finger, 272–273 Jobe’s test, 245, 245f Joffroy’s sign, 31 Jogger’s foot, 324, 324f Jones fracture, 331 Jugular venous pressure, 77–79, 78t in aortic stenosis, 85 Kaposi’s sarcoma, 347–348, 347f Kasselbach’s plexus, Kayser-Fleischer ring, 396 Kehr’s sign, 146, 147, 150 Keloids, 3, 3f, 4t, 362 Keratitis, herpetic, 390, 393 Keratoacanthoma, 361, 368 Keratopathy, 388t Keratosis actinic, 361, 361f seborrheic, 364, 365f, 370 Kerion, 344, 369, 369f, 375 Kidneys See also under Renal location of, 290 Kilo-Nevin syndrome, 282 Knee elbow and, 277t swelling of, 205–215 anterior, 206–209, 207t causes of, 206b massive, 205f posterior, 209 Knee examination, 201–219 disorders in, 205–219 anterior, 206–209 lateral, 214–216 ligamentous, 216 medial, 209–213 swelling in, 205–215 See also Knee, swelling of range of motion in, 204–205, 205t surface anatomy in, 201–204, 201f, 203f Knee extension, 162, 163f Knee-to-chest test, 300, 300f Koebner’s phenomenon, 136, 340, 348, 369 Koenig’s isthmus, 106, 106f KOH preparation, for vaginal secretions, 61 Koilonychia, 342–343, 343f Koplik’s spots, 20 Kraurosis vulvae, 54 Kussmaul’s respiration, 113, 113t Kussmaul’s sign, 78, 78t Kyphosis, 298–299, 298f dowager’s hump and, 107t, 108 Labia minora/majora, 51, 52f, 53–57, 53f, 55f, 56t Lachman maneuver, 211f, 217, 218f, 218t, 219f Lacrimal gland, 381 Laguerre’s maneuver, 300–301, 301f, 302t Larva migrans, 355, 355f Lateral collateral ligaments, 203–204, 203f injuries of, 210–211, 210t, 213, 214–215, 214f, 215t Lateral cutaneous nerve, of thigh, 290 Lateral cutaneous nerve entrapment, 305–306, 306f Lateral decubitus position, 58, 60f in cardiac examination, 76, 76f, 82–83 in pelvic examination, 58, 60f Lateral epicondyle, 277f, 278, 278f 4886.LWW.Berg.IDXpp411-426 07/29/05 2:01 PM Page 419 419 Index Lateral epicondylitis, 285, 285f Lateral fornice, 58 Lateral meniscus muscle, 203f, 204 tears of, 215, 215t Lateral pivot shift test, 281, 281f Lateral plantar nerve, 316 Lateral quadriceps muscle, 291 Lateral tibiotalar ankle sprains, 328–330, 328f, 329f Latissimus dorsi muscle, 227f, 290 strain of, 249, 308 Lead-pipe rigidity, 164, 188 Lead poisoning common peroneal nerve injury in, 191, 192t gingival pigmentation in, 18 Left lateral decubitus position, in cardiac examination, 76, 76f, 82–83 Left ventricular hypertrophy, 76, 80 Lens, 381, 387 subluxation of, 387 Lentigo, 365 Leopold maneuver, 156 Lepromas, auricular, 3, 4t Leprosy, facies in, 13, 14t Leser-Trélat syndrome, 364 Lesser trochanter, 292 Lesser tuberosity, of humerus, 225, 225f Leukemia, sternal involvement in, 97, 124t, 125 Leukoplakia, hairy, 23, 24f Levator scapulae muscle, 226, 227f Levoscoliosis, 298, 298f Lichen planus, 348, 348f, 370 in scars, 136, 348 Lichen sclerosus et atrophicus, 54 Lid lag, 403 in hypothyroidism, 31–32, 31f Light reflex, 2, 385, 385t Lindsey’s nails, 342, 342f Lingula, 105, 105f Lip disorders, 22–23, 22f, 23f, 371, 371f Lipomas, 142 auricular, 3, 4t Lisch nodules, 361, 396, 396f Lisfranc’s fracture, 326 Lisfranc’s joint, 316 Lister’s tubercle, 257f, 259 Litten’s spots, 397 Little Leaguer’s elbow, 281, 281f Liu’s crank test, 245–246, 247f Liver See also under Hepatic disorders of, 142–144, 144t examination of, 137–138, 138f, 139f, 142–144 palpation of, 138, 139f percussion of, 138, 138f, 143 scratch test for, 137–138, 138f Liver cancer, 138 bowel sounds in, 136t, 137 bruit in, 136t Liver disease end-stage, 142–144, 143t nail abnormalities in, 342, 342f nails in, 154, 155f, 342, 342f scrotal edema in, 43t, 45, 46t Lobectomy auscultatory findings after, 115t, 117t, 118 tactile fremitus after, 114t, 116 Locking finger, 265 Loge de Guyon, 255, 255f Lordosis, 298 Low back pain, 299–304, 299f–302f, 299t, 302t, 303t Lower motor neuron disease, 167 Lower spinal cord transection injury, 168 Ludwig’s angina, 28 Lues venereum alopecia in, 344–346, 345t Argyll-Robertson pupil in, 386 congenital, 21 penile, 40, 40f vulvar, 56t, 57 Lumbar lordosis, 298 Lumbar radiculopathy, 299t, 305, 305f Lumbosacral nerve roots, 293, 293t, 295b Lumbrical muscles, 256–257 Lung See also under Pulmonary; Respiratory abscess of, 122 apical tissue of, 106, 106f examination of, 107–120 See also Chest and lung examination surface anatomy of, 105–106, 105f, 106f Lunula, 341 red, 341, 342, 342f Lupus, discoid alopecia in, 344, 345t See also specific nerves hypopigmentation in, 363, 363f malar rash in, 359 Lupus pernio, 348t, 349 blue nose in, Lyme disease, erythema chronicum migrans in, 355–356, 355f, 356t Lymph nodes auricular, 1, 1f in mastoiditis, axillary, 228, 228f, 229f cervical enlargement of, 15–16 in Hodgkin’s disease, 238, 240f palpation of, 16f inguinal enlargement of, 306 in male, 41–42 posterior auricular, 1, 1f in mastoiditis, preauricular, 1, 1f supraclavicular, 226 enlargement of, 239, 240f Lymphogranuloma venereum, 56t, 57 Macroglossia, 23, 24f Macula, 381 cherry red, 399, 399f Macular degeneration, 382–383, 382t Macules, 339, 339t Malgaigne’s sign, 308 Malignant melanoma See Melanoma Malleolus, 316f fractures of, 330 Mallet finger, 271, 271f Manubrium, 106 Marche a petit pes, 188 Marcus-Gunn jaw-wink sign, 386, 386f Marfan’s syndrome, 387, 388t Masses See also Tumors abdominal, 137, 141–142, 141f neck, 15–17, 15f–17f Masseter muscle, assessment of, 169, 170f, 171f Mastoiditis, 4t, Maxillary sinuses, 10, 10f Maxillary sinusitis, 10, 10b McBurney’s line, 131, 131f McBurney’s point, 131, 131f, 148f, 149 McMurray’s maneuver, 211–213, 211t, 212f, 215 Measles, Koplik’s spots in, 20 Medial canthus, 381 Medial collateral ligament, 203, 203f sprains of, 210–211, 210t, 213, 214f Medial epicondyle, 277f, 278, 278f, 279, 279f Medial epicondylitis, 280, 280f Medial meniscus tears, 210t, 211–213, 211t Medial plantar nerve, 316 Median nerve, 230t, 231, 232, 255f, 256, 256b, 257f, 258t, 278, 278f, 279, 279f Mediastinal emphysema, 91 Melanoma choroidal, 398 cutaneous, 363–364, 364f, 365f nodular, 364, 365f subungual, 342, 342f uveal, 397 vulvar, 56 Melena, 147, 148f Meniscus in ascites, 153t, 154 of knee, 203 tears of, 210t, 211–213, 211t, 215, 215t Mental status examination, 193–194 in end-stage liver disease, 143, 143t Meralgia paresthetica, 305–306 Mesenteric angina, 136t, 137 Metatarsal exostosis, 328 Metatarsal fractures, 328, 332–333 Metatarsalgia, 325, 331t, 332 Metatarsal head, 316 stress fractures of, 328, 332–333 Metria, 181–182, 185f Microaneurysms, retinal artery, 398, 399f Midaxis of foot, 316 Midclavicular lines, 106, 106f, 131, 131f Middle ear See also Ear disorders of, 6–7, 6t Midsystolic click, in mitral valve prolapse, 88, 88f Miliaria, 354, 355f Mill’s maneuver, 285 Miosis, 385, 385t, 386f Mitral regurgitation, 87f, 88, 88f vs tricuspid regurgitation, 90t Mitral stenosis, 93t, 94–95, 94f Mitral valve, 75, 75f Mitral valve prolapse, 88–89, 88f Modified speculum stress maneuver, 64, 64f Molluscum contagiosum, 360, 360f Monofilaments, in sensory examination, 185–187, 187f, 194–195 Mons pubis, 51, 52f Morton’s neuroma, 325, 325f, 331t, 333 Motor neuron disease lower, 167 upper, 164–165, 167 motor deficits in, 175–180, 178t spastic hemiparetic gait in, 176–180 Mouth See Oral cavity Mucocele, 23 Müeller’s maneuver, 92t, 94 Muercke’s lines, 154, 155f, 342, 342f Mulder’s maneuver, 325, 325f Mumps, 15 Murmurs, 80, 82t, 83 See also Heart sounds in aortic insufficiency, 91f, 92–94, 92t, 93t in aortic sclerosis, 86, 86f in aortic stenosis, 84–85, 84b, 84f, 85b, 86t in atrial septal defect, 91 auscultatory features of, 84 in bicuspid aortic valve, 91 diastolic, 92–96 Flint, 92 4886.LWW.Berg.IDXpp411-426 07/29/05 2:01 PM Page 420 420 Murmurs (continued) flow, 85b, 86 grading of, 84t at heart base, 84b in hypertrophic obstructive cardiomyopathy, 81t, 82, 84t in mitral regurgitation, 87f, 88, 88f in mitral stenosis, 93t, 94–95, 94f in mitral valve prolapse, 88–89, 88f in patent ductus arteriosus, 95–96, 95f in pulmonic insufficiency, 95 in pulmonic stenosis, 91–92 systolic, 84–92, 95–96 in triscuspid regurgitation, 89–90, 89f, 90t in ventricular septal defect, 90 Murphy’s point, 131, 131f Murphy’s punch maneuver, 147, 148f Murphy’s sign, 146–147, 147f Muscles See also specific muscles abdominal, in respiration, 125, 125f facial, 10 neck, 112 Muscle strength in abnormal gaits, 193t assessment of, 161–164, 161f–163f, 163t Muscle stretch reflexes, 165–168, 166f–168f in abnormal gaits, 193t grading of, 167, 167t Muscle tone, 164–165, 164f, 165f in abnormal gaits, 193t Muscle weakness, 163t waddling gait and, 175–176, 177t Muscular dystrophy, waddling gait in, 177t Musculocutaneous nerve, 230t, 231 Myasthenia gravis, waddling gait in, 177t Mydriasis, 385, 385t Myerson’s sign, 188, 189f, 193 Myoclonus, 196, 196t Myositis Grotton’s papules in, 178f rash in, 178f waddling gait in, 177t Myositis ossificans, 306–307 Myotonic dystrophy, 164–165, 165f facies in, 13, 14t waddling gait in, 177t Myringitis, bullous, 6t, Myxedema, 29, 30f facies in, 13, 14t pretibial, 32–33, 33f, 370 Myxoma, atrial, 93t, 95 Nabothian cysts, 63, 63f Nail plate, 341 Nails anatomy of, 340–341 in ascites, 154, 155f biting of, 342, 343f clubbing of, 119, 120t, 341, 341f in congestive heart failure, 97 disorders of, 341–344 hematoma under, 273, 333, 344, 344f Lindsey’s, 342, 342f Muercke’s lines on, 14, 154, 155f, 342, 342f Plummer’s, 31, 32f, 344 Terry’s, 97, 341, 342, 342f Narrow-based gait, 175, 175f, 176 Nasal anatomy, 7, 7f Nasal disorders, 8–9 Nasal fractures, 9, 9f, 9t Nasal polyps, 9, 9f NAVEL (mnemonic), 290 Navicular, 317f accessory, 326 Index Navicular tubercle, prominent, 326 Neck See also under Cervical lymph nodes in enlargement of, 15–16 in Hodgkin’s disease, 238, 240f palpation of, 16f range of motion of, 248t surface anatomy of, 227f, 248 Neck masses, 15–17, 15f–17f Neck muscles, inspection of, 112 Neck veins, inspection of, 76–78, 77f Necrobiosis lipoidica diabeticorum, 364, 365f, 370 Neer and Walsh impingement sign, 246, 247f Nephrolithiasis, 147 Nerves See also specific nerves cranial, 10 examination of, 168–174 examination of See Neurologic examination Neural hearing loss, 172 Neuritis, optic, 383 Neurofibroma, 361, 361f Neurofibromatosis, Lisch nodules in, 361, 396, 396f Neurologic examination, 161–197 cranial nerve examination in, 168–174 equipment for, 166f of foot and ankle, 320, 320t gait in, 174–193 in hand, wrist, and thumb examination, 258t in hip, back, and trunk examination, 293–295, 293f, 294f, 295b involuntary movements in, 195–196 mental status examination in, 193–194 muscle strength in, 161–164, 161f–163f, 163t muscle tone in, 164–165, 164f, 165f power assessment in, 161–164, 161f–163f, 163t reflexes in, 165–168, 166f–168f sensory examination in, 194–195 Neuroma acoustic, 362 Morton’s, 325, 325f, 331t, 333 Neurotropic ulcers, 366, 367f Nevi, pigmented, 363–364, 364f Nevus flammeus, 346 Nicholson’s maneuver, 96 Nipple, Paget’s disease of, 370 Node of Cloquet, 289f, 290 Nodules, 339, 339t abdominal, 137 Lisch, 361 prostate, 48, 49t Sister Mary Joseph’s, 133t, 134 Norwegian scabies, 350f, 351 Nose See also under Nasal anatomy of, 7, 7f blue, disorders of, 8–9 Nummular eczema, 354, 354f, 370 Nutritional status, in end-stage liver disease, 143, 143t Nystagmus, 181, 382 in ataxia, 181, 182t Ober’s maneuver, 214, 307, 308f Obesity, abdominal examination in, 153t, 156 Obliquus muscles, 289, 298 strains/tears of, 307–308 Obturator externus muscle, 291 Obturator internus muscle, 291 Obturator maneuver, 149, 150f Obturator nerve, lumbosacral roots of, 293, 293t Oculocardiac reflex, 172 Oculomotor nerve, 381 abnormalities of, 384 OK sign, 232f in carpal tunnel syndrome, 264f Olecranon bursa, 277f, 278 Olecranon bursitis, 283–284, 283f, 283t, 284f Olecranon process, 277, 277f Olfactory assessment, 168 Olfactory nerve, 168 Onychia, 342 Onychocryptosis, 344 Onychogryphosis, 341, 341f Onychomycosis, 341, 341f Open-angle glaucoma, 383 Opening snap, 93t, 94 Ophthalmic artery, 381 Ophthalmoscopic examination, 387 See also Eye examination Oppenheim’s maneuver, 179, 181f Optic nerve, 169, 381 Optic neuritis, 383 Optokinetic drum test, 382 Optokinetic nystagmus, 382 Oral cavity See also specific oral structures bimanual palpation of, 17f disorders of, 17–20 inspection of, 17, 18f Orbicularis oris muscle, assessment of, 169–170, 170f Orbital cellulitis, 403, 403f Orbital rim fracture, 384t Orchitis, 47 Orthopnea, 122–123 Ortner’s syndrome, 172 Osgood-Schlatter disease, 208, 208f Osler’s nodes, 346, 347f Osler-Weber-Rendu syndrome, tongue telangiectasia in, 26, 26f Osteoarthritis of elbow, 285, 285f of fingers, 270 of hip, 299t, 304–305, 305f Otitis externa, 5, 5f, 6t Otitis externa maligna, 2f, 3, 4t Otitis media, 6–7, 6t purulent, 6–7, 6t serous, 6, 6t Otoscopy, 5, 5f Ovary disorders of, 69 examination of, 66–67, 67f See also Gynecologic examination Overuse injuries of elbow, 281, 281f of shoulder, 245 Owen’s maneuver, 148f, 149, 149t Pace test, 302–303, 302f Paget’s disease of bone, facies in, 13, 14t of breast, 370 of vulva, 56–57, 56t Pain abdominal, 146–152, 151t–152t guarding in, 137 chest, 97–98 pleuritic, 124–125, 124t low back, 299–304, 299f–302f, 299t, 302t, 303t 4886.LWW.Berg.IDXpp411-426 07/29/05 2:01 PM Page 421 421 Index Pain perception, assessment of, 195 Palate cleft, 27, 27f disorders of, 27, 27f, 28 high-arched, 28 inspection of, 27f Pallanesthesia, 187, 187f Palmar aponeurosis, 256 Palmar interosseous muscle, 255f, 257 Palmaris longus muscle, 255f, 256 Palmaris longus tendon, 255f, 256 Palpation See also specific organs hooking technique in, 137, 137f Palpebral conjunctiva, 381 Pancoast tumor, 110–111 Pancreatitis, 146, 151t Papal (benediction) sign, 264, 264f, 282 Papanicolaou smear, 58, 60, 61f Papilloma, of tongue, 23–24, 25f Papules, 339, 339t Gottron’s, 359 Paralysis, 163t Paranasal sinuses, 9–10, 9f, 10b Paraparesis, 163t Paraphimosis, 40, 41f Paraplegia, 163t Paraspinous muscle, 227, 227f, 248, 290 Paraspinous strain, 299t, 300 poker gait in, 191–193, 192t, 300 Paraurethral glands of Skene, 51, 52f Parkinson’s disease, 188–190, 189t facies in, 13, 14t vs essential tremor, 190, 190t Parkinson’s syndrome, 190 Paronychia, 342, 343f of toe, 333 Parotid gland, 10f, 101 enlarged, 15–16 Paroxysmal nocturnal dyspnea, 122–123, 123f Pars flaccida, 2, 2f Pars tensa, 2, 2f Passive inversion maneuver, 329–330, 329f Passive leg elevation maneuver in hypertrophic obstructive cardiomyopathy, 84t in splenic rupture, 150 in tricuspid regurgitation, 89, 90t Patches, 339, 339t Patella, 201, 201f ballottement of, 205, 206f dislocation of, 207, 207t, 209 fracture of, 206–207, 207t Patella baja, 208f Patellar ligament, 201, 201f tears of, 206, 207, 207t Patellofemoral syndrome, 201–202, 208–209, 208f Patient positioning See Positioning Peau d’orange skin, of breast, 70, 72 Pectoralis major muscle, 225f, 226 injuries of, 242 Pectoralis major reflex, 165–166, 166f Pectus carinatum, 107–108, 107t, 108f Pectus excavatum, 76, 107, 107t, 108f Pederson speculum, 58–60 Pelvic examination, 53–69 bimanual palpation in, 66, 67f cervix in, 58–60 rectovaginal examination in, 66 uterus and adnexa in, 65–69 vagina in, 58–62 vulva in, 53–57 Pelvic inflammatory disease, 69, 151, 151t Pelvic relaxation problems, 64, 64f Pelvis See Hip, back, and trunk examination Pemberton’s sign, 29–31, 30f, 111 Pemphigus vulgaris, 373, 373f Penis anatomy of, 39, 39f disorders of, 40–42, 40f, 41f examination of, 39 Peptic ulcer disease, 147, 151t Percussion See specific organ Periampullary cancer, 142 Periapical abscess, sinus tract of, 18, 19f Pericardial effusion, 78–79 tactile fremitus in, 115 Pericardial knocks, 93t in constrictive pericarditis, 96 Pericardial rubs, 82t, 83, 93t, 115t, 116–118 Pericarditis constrictive, 78 intercostal movements in, 108t, 111–112 heart sounds in, 96 rubs in, 82t, 83 See also Pericardial rubs Peripheral edema See also Edema ascitic, 154, 155f in end-stage liver disease, 142, 155f Peripheral neuropathy, 185–187, 187f, 194–195 Peripheral sensory ataxia, 180–188, 182t Perirectal abscess, 43t, 47, 47f, 139t, 140–141 Peritonsillar abscess, 28, 29f Periumbilical area, 132, 132f, 132t Periumbilical scars, 134t, 135, 135f Perlèche, 22–23, 22f Peroneal nerve deep, 316f, 320, 320t injuries of, 327, 327f superficial, 320, 320t Peroneal tendon sprain, 330–331, 331f Peroneus brevis muscle, 317–318, 317f, 319, 319t Peroneus brevis tendon, 317f, 318 Peroneus longus muscle, 317, 317f, 319, 319t Peroneus longus tendon, 315f, 316, 317f, 318 PERRLA, 385, 385t Pes anserine, 203, 203f Pes anserine bursa, 203 Pes anserine bursitis, 210, 210t Pes planus, 323, 323f in ataxia, 181, 182f Petechiae, 339–340, 339t, 346 Peutz-Jeghers syndrome, 365 oral lesions in, 27 Peyronie’s disease, 41 Pfannenstiel scar, 134, 134t, 135f Phalanges See Finger(s) Phalen’s procedure in carpal tunnel syndrome, 263, 263f in ulnar tunnel syndrome, 264 Pharyngitis, 28, 28f, 29b, 29f Pharynx disorders of, 27f–29f, 28 inspection of, 27f Pheochromocytoma, 362 Phimosis, 40, 41f Photocoagulation, retinal, 402, 402f Photodermatitis, 354, 354f PH test, for vaginal secretions, 61 Physiologic tremor, 196t, 197 Pigeon chest, 107–108, 107t, 108f Pigmentation absence of, 362–363, 362f gingival, in African Americans, 17, 18f in pregnancy, 156 Pigmented lesions, 363–366 Pill-rolling tremor, 188, 190t, 196t Pinguecula, 395 Pinworms, 139t, 141 Piriformis muscle, 291 common peroneal nerve injury in, 191, 192t Piriformis syndrome, 302–303 Piriformis test, 302–303, 302f Pityriasis rosea, 370 Pivot shift test, 217, 218f, 218t Plantar fascia, 315, 315f Plantar fasciitis, 323, 323f Plantar reflex, 166, 167f Plantar warts, 360, 360f Plaques, 369–370 Hollenhorst, 401 Pleural effusion, 97, 116, 126t, 127 auscultatory findings in, 114t, 117t, 118, 123 breath sounds in, 97, 116 intercostal movements in, 108t, 111–112 percussion in, 113t, 115, 116 tactile fremitus in, 114t, 115 tracheal deviation in, 112, 112t Pleuritic chest pain, 124–125, 124t Plumbism common peroneal nerve injury in, 191, 192t gingival pigmentation in, 18 Plummer’s nails, 31, 32f, 344 Pneumonectomy, 126t auscultatory findings after, 115t, 117t, 118 tactile fremitus after, 114t, 116 Pneumonia, 97, 124 breath sounds in, 122t chest pain in, 97, 124 cough in, 121 dyspnea in, 123 egophony in, 121, 121t, 122t fever in, 122t heart rate in, 122t percussion in, 122t supportive clinical findings in, 122t Pneumothorax, 80, 97, 107t, 111, 112, 124, 126t, 127 auscultatory findings in, 117t, 119 percussion in, 113t tension, 111, 127 intercostal movements in, 108t, 111–112 tracheal deviation in, 112, 112t Podagra, 331, 331f, 331t Point of maximal impulse, 76, 79–80 Poisoning heavy metal, common peroneal nerve injury in, 191, 192t lead common peroneal nerve injury in, 191, 192t gingival pigmentation in, 18 Poker gait, 108–109, 191–193, 192t, 193t Polymyalgia rheumatica, waddling gait in, 177t Polymyositis, waddling gait in, 177t Polyps cervical, 63 nasal, 9, 9f Popliteal artery aneurysm, 209 Popliteal fossa, 203 Porphyria cutanea tarda, 372 Portal hypertension, 133t, 134 4886.LWW.Berg.IDXpp411-426 07/29/05 2:01 PM Page 422 422 Port-wine stains, 346 Position Bonaparte, 233, 250 dead arm, 233, 233f, 242, 250 decubital, 48, 139f dorsal lithotomy, 48, 53 Fowler’s, 123, 123f lateral decubital, in pelvic examination, 58, 60f lateral decubitus, in cardiac examination, 76, 76f, 82–83 Positioning for anorectal examination, 139f for cardiac examination, 76, 76f, 82–83 for pelvic examination, 58, 60f for prostate examination, 48 Posterior auricular lymph nodes, 1, 1f in mastoiditis, Posterior compartment syndrome, 335 Posterior cruciate ligament, 204 examination of, 216–219 injuries of, 216–219 Posterior drawer test in glenohumeral laxity, 245–246, 246f in posterior cruciate ligament tears, 218, 218f Posterior fornice, 58 Posterior interosseous nerve, 257, 257f Posterior leg compartment, 318, 318t Posterior lift test, 241, 241f Posterior midclavicular line, 105f, 106 Posterior neck triangle, 15 Posterior sag, 218 Posterior superior iliac spines, 290f Posterior talofibular ligament, 317, 317f Posterior tibial artery, 316–317, 317f Posterior tibialis pulse, 80–82, 81t Power, in abnormal gaits, 193t Power assessment, 161–164, 161f–163f, 163t Preauricular lymph nodes, 1, 1f Precalcaneal bursa, 315, 315f Precalcaneal bursitis, 325 Precordium examination of, 79–80 inspection of, 76 palpation of, 79–80 Pregnancy cervix in, 64, 68–69, 68t, 156 ectopic, 69 ruptured, 151, 152t epigastric bruit in, 136t, 137 Leopold maneuver in, 156 signs of, 68–69, 68t, 153t, 156 uterine changes in, 68–69 Prehn’s sign, 46 Prepatellar bursae, 201, 201f Prepatellar bursitis, 206, 207f, 207t Preseptal cellulitis, 403 Pretibial myxedema, 32–33, 33f, 370 Priapism, 41 Prickly heat, 354, 355f Prolapse cervical, 65 rectal, 65, 66f, 139t, 140 urethral, 65 uterine, 65 Pronator drift, 179, 181f Pronator quadratus muscle, 278, 278f Pronator teres muscle, 278, 278f, 279 Pronator teres syndrome, 282 Proprioceptive ataxia, 182t, 183–187 Proptosis, 385 in Graves’ disease, 33, 33f Prostate anatomy of, 39 Index disorders of, 48–49, 49t bladder distention in, 132f, 142 examination of, 47–48, 48f Prostatitis, 48, 49t Prosthetic heart valves, heart sounds from, 96 Proximal interphalangeal dislocation, 270–271, 271f Pseudobulbar palsy, 173, 180 Psoas maneuver, 149, 149f, 149t Psoriasis, 369, 369f nails in, 341 in scars, 136 Pterygium, 395, 395f Ptosis, 402 Puberty breast development in, 70, 70t delayed, 52, 53t pubic hair in, 52, 53f, 54t Tanner stages of, 52, 53t, 70, 70t Pubic hair, female, 52, 53f, 54t Pulmonary abscess, 122 Pulmonary consolidation, 114t, 115, 117t, 118, 121, 126t Pulmonary disease auscultation in, 97 chest pain in, 97–98 restrictive, 126t intercostal movements in, 108t, 111–112 Pulmonary edema, 126t auscultatory findings in, 118t, 119 noncardiogenic, 146 Pulmonary embolism, 124 chest pain in, 97, 124 Pulmonary hypertension, 79, 90–91 Pulmonic insufficiency, 95 Pulmonic stenosis, 91–92 Pulmonic valve, 75, 75f Pulse(s) in aortic stenosis, 85, 85f palpation of, 80–82, 81t brachioradial delay maneuver in, 85, 85f waterhammer, in aortic regurgitation, 93 waterhammer (Corrigan’s), 81, 81t in aortic regurgitation, 93 Pulsus alternans, 82 Pulsus bisferiens, 81, 81t Pulsus paradoxus, 78–79, 78t Pulsus parvus et tardus, 81t, 82, 85, 85f Pupil Argyll-Robertson, 386, 387f assessment of, 385–387, 385t Pupillary light reflex, 2, 385, 385t Purpura, 339t, 340, 346 Purulent otitis media, 6–7, 6t Push-out forward test, 173, 173f Pustules, 339, 339t, 374–375 Pyelonephritis, 147, 148f, 151t Pyoderma gangrenosum, 366, 366f Q angle, 208, 208f Quadriceps active test, 218 Quadriceps (Q) angle, 208, 208f Quadriceps muscle, 290, 291 anatomy of, 201, 201f atrophy of, 201–202 patellofemoral syndrome and, 202, 208 contusion of, 306 strain of, 304 tears of, 206, 207t, 208f, 304, 305f Quadriceps reflex, 166, 167f in spinal cord injury, 168 Quadriceps tendon, 201, 201f tears of, 207, 207t Quadruple gallop, 95 Queen Anne’s sign, 29, 30f, 345t Queens Square hammer, 165, 166f Quincke’s maneuver, 92t, 93–94 Quinsy, 28, 29f Radial artery, 255f, 256 Radial artery pulse, 80–82, 81t Radial head fracture, 268, 286f, 287 Radial nerve, 230t, 231, 256b, 258t, 278, 278f entrapment of, 268, 285, 286f Radial tunnel syndrome, 285 Radius, styloid process of, 255f, 256 Rales, 115t, 116 Ramsay Hunt syndrome, auricular lesions in, 3, 3f, 4t, 170 Ranula, 20 Rash See under Skin Raynaud’s syndrome, 348t, 349 Reactive airways disease, 126t auscultatory findings in, 117t, 118–119 Rebound tenderness, abdominal, 146 Rectal abscess, 43t, 47, 47f, 139t, 140–141 Rectal examination, 138–141, 139b, 139f, 139t Rectal prolapse, 65, 66f, 139t, 140 Rectocele, 64 Rectovaginal examination, 66 Rectus abdominis muscles, 298 Rectus sheath hematoma, 133t, 134 Recurvatum test, 218, 219f Red eye, 390–395 Red reflex, 387 Reflex(es) anal wink, 168, 294 cremasteric, 168 deep tendon (muscle stretch), 165–168, 166f–168f in abnormal gaits, 193t grasp, 194, 194t light, 2, 385, 385t oculocardiac, 172 red, 387 snout, 193–194, 194t in spinal cord injury, 168 sucking, 193–194, 194t Reflux abdominojugular, 77 gastroesophageal, cough in, 121 Reisman’s sign, 31 Relapsing polychondritis, auricular, 3, 3f, 4t Renal artery stenosis, 136, 136t Renal calculi, 147 Renal disease abdominal pain in, 147, 148f hemodialysis fistula in, heart sounds in, 96 Renal stones, 147 Respiration abdominal muscles in, 125, 125f Biot’s, 113, 113t Cheyne-Stokes, 113, 113t intercostal movements with, 108t, 111 Kussmaul’s, 113, 113t Respiratory alternans, 125–126 Respiratory failure, impending, 125–127 Respiratory paradox, 125 Respiratory patterns, assessment of, 112–113, 113t Respiratory rate, measurement of, 112–113, 113t 4886.LWW.Berg.IDXpp411-426 07/29/05 2:01 PM Page 423 423 Index Restrictive lung disease, 126t intercostal movements in, 108t, 111–112 Retinal artery, microaneurysms of, 398, 399f Retinal detachment, 401, 401f Retinal examination, 397–402 Retinal exudates hard, 397, 398f soft, 397–398, 398f Retinal hemorrhages, 398–401 Retrocalcaneal bursa, 318 Retrocalcaneal bursitis, 333 Retroflexed uterus, 67 Retroperitoneal bleeding, 133t, 134, 146, 147, 150 Grey Turner’s sign in, 146, 150, 151, 348, 349f Kehr’s sign in, 146, 147, 150 in pancreatitis, 146 in ruptured ectopic pregnancy, 151 in splenic rupture, 149–150 Retrosternal goiter, 29–31, 30f superior vena cava syndrome and, 107t, 111 Retroverted uterus, 67 Reverse Cozen’s maneuver, 280, 280f Rheumatic fever, 356, 357t heart disease in See Murmurs Rheumatoid arthritis digital clubbing in, 119, 120t digital deformities in, 270, 270f of elbow, 283t, 284, 284f of fingers, 270, 270f, 271, 271f Rhinitis allergic, viral, 168 Rhinophyma, 8, 8f Rhinorrhea, cerebrospinal fluid, 11 Rhomboid muscles, 226–227, 227f strains of, 249 Rhonchi, 115t, 116 Rib(s) anatomy of, 105–106 fractures of, 80, 97, 107t, 111, 112, 124–125, 124t Rib-tip syndrome, 97, 124f, 125 Rickets, chest deformities in, 108 Right angle sign, 250, 250f Right ventricular failure, 77, 78 scrotal edema in, 43t, 45, 46f, 46t Rigidity, 164 cogwheel, 188 lead-pipe, 164, 188 in Parkinson’s disease, 188 Ring of Nodes, cervical, 15, 16f Ringworm, 351, 352f, 370 Rinne test, 170–172, 172f Rivero Carvallo maneuver, 89–90 Rodeo thigh, 304 Romberg test, 182t, 183–185, 186f Rosacea, 13, 14t, 353, 353f rhinophyma in, 8, 8f Roseola, 357t, 359 Rotator cuff component muscles of, 227t tears of, 243–245, 243f–245f, 243t Roth’s spots, 397 Rovsing’s maneuver, 148f, 149, 149t Rubella, 357t, 358, 358f, 359f Rubeola, 357t, 358, 358f Rubeosis iridis, 397 Rubs, 82t, 83, 93t, 115t, 116–118 Runner’s foot, 324, 324f S1 heart sound, 82t, 83 See also Heart sounds S2 heart sound, 82t, 83 splitting of, 86t, 91 S3 gallop, 95 S3 heart sound, 93t S4 gallop, 95 S4 heart sound, 93t Sacral contusion, 310 Sacroiliac compression test, 300, 300f Saluting hand, 266–267, 267f Saphenous hiatus, 290 Sarcoma See also Cancer Kaposi’s, 347–348, 347f Sartorius muscle, 289f, 290 Scabies, 350–351, 350f Scabs, 339t, 340 Scald burns, 368, 373, 373f Scalene muscles, 225f, 226 Scales, 339t, 340 Scanning speech, in ataxia, 183 Scaphoid, 255f, 256 fractures of, 266, 266f Scapholunate dislocation, 266, 267f Scapula, 105, 105f, 227–228, 227f anatomy of, 248 movements of, 237 Scapular winging, 248–249, 249f, 249t Scarlet fever, 357t, 358 Scars abdominal, 134–135, 134t, 135f keloid, 3, 3f, 4t, 362 lichen planus in, 136, 348 skin lesions in, 136, 348 thoracic, 76, 109, 109f Schamroth’s procedure, 119 Schamroth’s sign, 341, 341f Schirmer’s maneuver, 395 Schober’s maneuver, 109, 300, 300f Schwannomas, 361–362 Sciatica, 191, 192t, 300–303, 301f, 302f, 302t, 303t, 308 Sciatic nerve, 291 lumbosacral roots of, 293, 293t Scissors gait, 180 Sclera, 381 blue, 395–396, 396f Scleritis, 396 Scoliosis, 107t, 108, 298–299, 298f Scotomas, 382–383, 382t Scratch test for bladder obstruction, 48, 48f for infraspinatus injuries, 245, 246f for liver size/span, 137–138, 138f for subscapularis tendonitis, 241, 241f Scrotum acute, 43t, 47, 47f anatomy of, 39, 39f disorders of, 42–47, 43t, 44f–46f edema of, 43t, 45–46, 46f, 46t examination of, 42–43, 42f Scurvy, 18, 347, 347f Sebaceous cysts, auricular, 4t, Seborrheic dermatitis, 354, 354f of eyelid/eyebrow, 391, 391f of vulva, 54 Seborrheic keratosis, 364, 365f, 370 Semimembranous muscle, 203, 203f, 291, 292 examination of, 209–210, 210f Semimembranous sprain, 209–210, 210f Semimembranous strain, 308–309, 309f Seminal vesicles, 39 Semitendinous muscle, 203, 203f, 291 examination of, 209–210, 210f Sensory ataxia, 182t, 183–187 Sensory examination See also Neurologic examination monofilaments in, 185–187, 187f, 194–195 Septal deviation, 9, 9f, 9t Septal hematoma, 9, 9f, 9t Serous conjunctivitis, 392, 392f Serous otitis media, 6, 6t Serratoglossia, 23, 24f Sesamoiditis, 323, 331t Sesamoids, 315f Sexual development See Puberty Shifting dullness maneuver, 154, 155f Shoulder carrying position for, 233, 233f overuse injuries of, 245 Shoulder elevation, 161, 161f, 173 Shoulder examination, 225–251 in acute trauma, 249–251 anterior, 237–242 disorders in, 237–251 lateral, 242–247 neurologic examination in, 230–233, 230t, 231f–233f posterior, 248–249 range of motion in, 233–237, 234f, 235f, 236t surface anatomy in, 225–230, 225f–228f Shoulder impingement, 246, 247f Shoulder instability, 245–246, 245f–247f, 247f Shrugging, 161, 161f, 173 Shuffling gait, 188–190, 193t Shy-Drager syndrome, 189–190 Sialolithiasis, 15, 16f, 20 Sickle-cell anemia, acute chest in, 97, 125 Simmond’s maneuver, 334, 334f Sinuses, paranasal, 9, 9f Sinusitis, 10, 10b Sister Mary Joseph’s nodule, 133t, 134 Sit-to-stand test, 176 Sit-up test, 308 Situs inversus, 126t auscultatory findings in, 118t Sixth disease, 357t, 359 Sjögren’s disease, 16, 395 Skene’s glands, 51, 52f abscess of, 55 Skier’s thumb, 266, 267f Skin, in pregnancy, 156 Skin appendages, 340 Skin cancer, 55–56, 55f, 368 basal cell, 360–361, 360f, 368, 370 Kaposi’s sarcoma, 346–347, 347t melanoma, 363–364, 364f, 365f squamous cell, 55–56, 55f, 361, 361f, 368 See also Squamous cell carcinoma Skin examination, 339–375, 368 bullae in, 372–374 exanthems in, 356–359, 357t, 358f hair disorders in, 344–345 hypopigmented lesions in, 362–363 lesion distribution in, 340 lesion types in, 339–340, 339t nail disorders in, 341–344 pigmented lesions in, 363–366 pink and red lesions in, 351–359 plaques in, 369–370 purple lesions in, 346–351 pustules in, 374–375 ulcers in, 366–368, 366f–368f vesicles in, 371–372 warty/papular lesions in, 360–362 Skodiac resonance, 115 4886.LWW.Berg.IDXpp411-426 07/29/05 2:01 PM Page 424 424 Skull fractures basilar, 9t, 11, 11f nasal fractures and, 9t Sleep apnea, 113, 113t Slit lamp examination, 387 See also Eye examination Small bowel obstruction, 44–45, 136t, 153, 153t bowel sounds in, 44–45, 136t, 137 Smell, assessment of, 168 Smiling, in facial nerve assessment, 169–170, 170f, 171f Snapping hip, 309–310 Snellen chart, 382 Snout reflex, 193–194, 194t Soft exudates, retinal, 397–398, 398f Soleus muscle, 318, 318t Spastic hemiparetic gait, 176–180, 178t, 193t Spasticity, 164 Spatula, for Pap specimen, 60, 61f Speculum nasal, 7, 7f vaginal, 58, 59f Speed’s test, 239, 240f Spermatic cords, 39 Sphygmomanometry arm, 92f thigh, 92f, 93 in transient arterial occlusion maneuver, 92 Spider angiomas, 346, 346f in end-stage liver disease, 143 Spina bifida occulta, 310 Spinal accessory nerve, 173 Spinal cord injury, reflexes in, 168 Spinal curvature, 298–299, 298f Spinal nerve roots, 293, 293t, 295b of shoulder, 230–232, 230t Spine cervical anatomy of, 248 fractures of, 249 compression fractures of, 298–299, 299t, 303, 303t, 310 examination of See Hip, back, and trunk examination thoracic, anatomy of, 248 Spinous processes, vertebral, 290 Spleen enlarged, 142, 144–146, 144f–146f, 145t examination of, 144–146, 144f–146f, 145t rupture of, 149–150, 152t Splenectomy, 144 Splenomegaly, 142, 144–146, 144f–146f, 145t Splinter hemorrhages, 342 Splinting, in rib fractures, 107t, 111 Sprains deltoid ligament, 326, 326f extensor digitorum longus, 327, 327f flexor digitorum brevis, 325 lateral collateral ligament, 210–211, 210t, 213, 214–215, 214f, 215t lateral tibiotalar ankle, 328–330, 328f, 329f medial collateral ligament, 210–211, 210t paraspinous, poker gait in, 192t, 193 peroneal tendon, 330–331, 331f tibialis anterior, 327, 327f ulnar collateral ligament, 285 Sputum, inspection of, 121–122, 121f, 121t Squamous cell carcinoma, 361, 361f of ear, 4, 4f, 4t of lip, 22, 22f Index of oral cavity, 20 of skin, 55–56, 55f, 368 of tongue, 26–27, 26f of vulva, 55–56, 55f, 56t, 57 Squamous hyperplasia, vulvar, 54–55 Square-off sign, 250, 250f Squatting maneuver in aortic insufficiency, 92, 92t in hypertrophic obstructive cardiomyopathy, 84t, 88 in mitral valve prolapse, 88, 89f Staining, fluorescein, of eye, 390, 390t, 393 Stand to squat maneuver in hypertrophic obstructive cardiomyopathy, 84t in mitral valve prolapse, 88 Staphylococcal scalded skin syndrome, 373, 374 Stellwag’s sign, 31, 31f Stensen’s duct, palpation of, 16f Steppage gait, 190–191, 193t Stereognosis, 195 Sternoclavicular joint, 225f, 226 subluxation of, 238 Sternocleidomastoid muscle, 225f, 226 assessment of, 173, 173f Sternum, 106, 106f leukemic infiltration of, 97, 124t Stethoscope, 82–83, 82f, 116, 116f See also Auscultation Stevens-Johnson syndrome, 356, 374 Stingers, 242 Stomatitis, 22–23, 22f angular, 22–23, 23f aphthous, 20 herpetic, 22, 22f Stones kidney, 147 salivary, 15, 16f Stool examination, 138–139, 140t, 147, 148f Strabismus, 383–384 Straight leg raise test, for sciatica, 300–301, 301f, 302t Strains abdominis rectus, 306 adductor, 304, 304f biceps femoris, 214, 214f, 215t extensor hallucis longus, 327, 327f flexor hallucis longus, 323, 324f hamstring, 210t, 308–309, 309f latissimus dorsi, 249, 308 paraspinous, 299t, 300 poker gait in, 191–193, 192t, 300 quadriceps, 304 rhomboid, 249 semimembranous, 308–309, 309f teres major, 249 tibialis anterior, 327, 327f trapezius, 249 triceps, 283t, 284 Strangulated hernias, 43t, 44, 45t Stransky’s maneuver, 179, 180f Strawberry tongue, 26 Strength in abnormal gaits, 193t assessment of, 161–164, 161f–163f, 163t Streptococcal pharyngitis, 28, 28f, 29b, 29f Stress fractures, of metatarsal head, 328, 331t, 332–333 Stricture, urethral, 41 Stridor, 115t, 116, 118 Sturge-Weber syndrome, 346 Stye, 391–392, 391f, 402–403 Subacromial bursa, 228 Subclavian artery, 226 Subclavian vein, 226 Subconjunctival hemorrhage, 394, 395f Subcostal margins, 131, 131f Subcostal scars, 134–135, 134t, 135f Sublingual varicosities, 26, 26f Subluxation lens, 387 sternoclavicular, 238 Submandibular glands, 10f, 101 Subscapularis muscle, 225, 225f tears of, 241–242, 241f Subscapularis tendinitis, 241–242, 241f Subungual hematoma, 344, 344f of finger, 273 of toe, 333 Subungual melanoma, 342, 342f Sucking reflex, 193–194, 194t Sulcus test, 246, 247f Summation gallop, 95 Sunburn, 354, 354f Suntan, 365 Superficial peroneal nerve, 320, 320t Superficial radial nerve entrapment, 268, 285, 286f Superior gluteal nerve, lumbosacral roots of, 293, 293t Superior oblique entrapment, 384t Superior vena cava syndrome, 12, 78, 107t, 110–111 facies in, 12, 12f, 14t Supine position, for cardiac examination, 82 Supracalcaneal bursa, 318 Supracalcaneal bursitis, 333, 334f Supraclavicular fossa, 225f Supraclavicular lymph nodes, 226 enlargement of, 239, 240f Suprapatellar bursae, 201, 201f Suprapatellar bursitis, 206, 207t Suprapubic area, 132f, 132t, 133 Suprascapular nerve, 230t, 231 Supraspinatus muscle, 226, 227f, 228, 228f tears of, 242–245, 243f–245f, 243t Supraspinatus tendinitis, 243–245, 243f, 243t, 244f Supraspinatus test, 244–245, 245f Surgical abdomen, 146, 152t Sutton’s nevus, 364, 364f Swallowing, in cranial nerve examination, 173 Swan neck contracture, 270, 270f Syndactyly finger, 273 toe, 333 Synergia, 182t, 183, 185f Syphilis alopecia in, 344–346, 345t Argyll-Robertson pupil in, 386 condylomata lata in, 56, 360 congenital, dental abnormalities and, 21 penile chancre in, 40, 40f vulvar lesions in, 56t, 57 Systolic heart failure, pulse in, 81t Systolic heart sounds, 84–92, 84b, 85b, 95–96 See also Heart sounds Tactile fremitus, 114t, 115–116, 115f, 126t Tactile sensation, assessment of, 185–187, 187f, 194–195 Talar tilt sign, 329–330, 329f Tandem walk, 181, 182t, 183f Tanner staging system breast development in, 70, 70t pubic hair in, 52, 53t Tarsal tunnel, 317f 4886.LWW.Berg.IDXpp411-426 07/29/05 2:01 PM Page 425 425 Index Tarsal tunnel syndrome, 323–324 Teeth disorders of, 21, 21f examination of, 21, 21f loss of, 18, 19f Telangiectasia, 346, 346f Temporal arteritis, 179f in polymyalgia rheumatica, 179f Temporomandibular joint dysfunction, 28 Tenderness displacement test, 215 Tendinitis Achilles, 333 bicipital, 239, 240f infraspinatus, 245, 246f subscapularis, 241, 241f supraspinatus, 243–245, 243f, 243t, 244f Tennis elbow, 285, 285f Tenosynovitis de Quervain’s, 267f, 268 of extensor compartments, 268, 268f Tension pneumothorax, 111, 127 See also Pneumothorax intercostal movements in, 108t, 111–112 tracheal deviation in, 112, 112t Teres major muscle, 226, 227, 227f strain of, 249 Teres minor muscle, 228 Terry’s heart failure nails, 97, 341, 342, 342f Testes anatomy of, 39 disorders of, 42–47, 43t, 44f–46f examination of, 42–47, 43t, 44f–46f small, in end-stage liver disease, 143 Testicular torsion, 43t, 46–47 Tetany, 12–13, 12f Chvostek’s sign in, 12–13, 13f facies in, 12, 14t Trousseau’s sign in, 12, 12f Tetraparesis, 163t Tetraplegia, 163t Thenar eminence, 255f, 256, 257t atrophy of, in carpal tunnel syndrome, 263, 263f Thenar eminence percussion test, 164–165, 165f Thigh, rodeo (horse rider’s), 304 Thompson’s maneuver, 334, 334f Thoracic ankylosis, 107t, 108–109 Thoracic outlet syndrome, 239, 240f, 242 digital clubbing in, 119, 120t Thoracic scars, 76, 109, 109f Thoracic spine, anatomy of, 248 Thorax See Chest; Chest wall Thrills, 84t, 85 Thromboangiitis obliterans, 348, 348t, 349f Thromboembolism, pulmonary, 97, 124 Thrombosed external hemorrhoids, 140, 140f Thrombosis central retinal vein, 399, 399f deep venous, 209, 334, 335f dorsal vein, 41 Thrush, 20, 23, 24f Thumb examination of See Hand, wrist, and thumb examination skier’s, 266, 267f Thumb base osteoarthritis, 271 Thyroglossal duct cyst, 15, 15f Thyroid anatomy of, 29, 29f examination of, 29f Thyroid disease, 15, 29–33, 30f–33f common peroneal nerve injury in, 191, 192t facies in, 13, 14t hair in, 344 heart sounds in, 91 reflexes in, 168 waddling gait in, 177t Tibialis anterior muscle, 316, 318, 318t strain of, 327, 327f Tibialis nerve, 316, 317, 317f, 318, 320, 320t injuries of, 335 Tibialis posterior artery, 318 Tibialis posterior muscle, 316, 317f, 318, 318t Tic douloureux, 169 Tics, 195–196, 196t Tietze’s syndrome, 80, 97, 112, 124t, 125 Tiger-striping edema, 154f Tinea barbae, 375, 375f Tinea capitis, 344, 345t Tinea corporis, 351, 352f, 370 Tinea cruris, 54, 351, 351f Tinea pedis, 351f, 352, 372 Tinea versicolor, 363, 363f Tinel’s test in carpal tunnel syndrome, 263, 263f in cubital tunnel syndrome, 282–283, 282f in lateral cutaneous nerve entrapment, 305–306, 306f in pronator teres syndrome, 282 in superficial radial nerve entrapment, 285, 286f in tarsal tunnel syndrome, 324, 324f in ulnar tunnel syndrome, 264 Tip-to-tip OK sign, 232f in carpal tunnel syndrome, 264f Toe(s), 331t See also Foot and ankle examination blue, 332, 333f, 348, 348t claw, 332 cock-up, 332 disorders of, 331–333, 331t hammer, 332, 332f stress fractures of, 328, 332–333 turf, 327, 327f Toe flexors, 315, 315f Tone, muscle, 164–165, 164f, 165f in abnormal gaits, 193t Tongue black, 26, 26f disorders of, 23–27 geographic, 25, 25f inspection of, 23, 24f movement of, 173–174, 173f strawberry, 27 white hairy, 23, 24f Tongue blade technique, in oral examination, 18f, 19f, 21 Tongue percussion test, 165 Tooth See Teeth Tophi auricular, 2–3, 2f, 4t digital, 272 great toe, 331, 331f olecranon, 283t, 284, 284f Torus mandibularis, 18, 20f Torus palatinus, 27, 27f Total bilirubin, in end-stage liver disease, 143, 143t Touch, assessment of, 185–187, 187f, 194–195 Toxic epidermal necrolysis, 373, 374 Toxic multinodular goiter, 33 Toxoplasmic chorioretinitis, 398, 399f Trachea auscultation of, 121f, 122 inspection of, 112, 112f, 112t Tracheal deviation, 112, 112f, 112t Trachoma, 392, 392f Transient arterial occlusion, 90 in aortic insufficiency, 92, 92t in mitral regurgitation, 88 Transillumination of hydrocele, 45, 45f of paranasal sinuses, 10, 10f Transverse abdominis muscle, 289 Trapezius muscle, 226, 227f assessment of, 173 strains of, 249 Traube’s triangle, 144, 144f, 146 Tremor ataxic, 182t, 183 cerebellar, 196t, 197 essential, 190, 190t, 196t, 197 intention, 196t, 197 Parkinsonian, 188, 190t, 196t physiologic, 196t, 197 pill-rolling, 188, 190t, 196t Trendelenburg test, 305, 305f, 308 Trepopnea, 123 Triangle of Traube, 144, 144f, 146 Triceps muscle, 227, 227f, 231, 231f, 277, 277f strains/tears of, 283t, 284 Triceps reflex, 165, 166f Trichomonas vaginitis, 61t, 62 Trichotillomania, 344, 345t Tricuspid regurgitation, 79, 89–90, 89f, 90t vs mitral regurgitation, 90t Tricuspid stenosis, 79 Tricuspid valve, 75, 75f Trigeminal nerve, 169, 169f, 381 Trigger finger, 265 Tripod sign, 176 Trochlear nerve, 169 abnormalities of, 384t Troisier’s node, 238, 239f Tromner’s maneuver, 179, 179f Tropias, 384, 384f Trousseau’s sign, 12, 12f Truncal ataxia, 182t, 183 Trunk See Hip, back, and trunk examination Tuberculosis cough in, 122 percussion in, 113t, 115 tactile fremitus in, 116 Tuboovarian abscess, 69 Tuft fractures, 333 Tumors See also Cancer; Masses atrial, 93t frontal lobe, 168 Pancoast, 110–111 skin, 360–362 uterine fibroid, 68 Warthin, 15 Tuning fork tests for hearing, 170–172, 171f, 172f for vibratory sensation, 187, 187f Turf toe, 327, 327f, 331t Two-tongue blade technique, in oral examination, 18f, 19f, 21 Tylomas (calluses), 332, 362, 369–370, 369f crack pipe, 368, 368f Tympanic membrane anatomy of, 1–2, 2f perforation of, 6t, Tympanoplasty tubes, Typewriter contracture, 270, 270f Ulcers oral, 20 penile, 40, 40f 4886.LWW.Berg.IDXpp411-426 07/29/05 2:01 PM Page 426 426 Ulcers (continued) peptic, 147, 151t skin, 339, 339t, 366–368, 366f–368f vulvar, 56–57, 56t Ulnar artery, 255f, 256 Ulnar collateral ligament, 278, 279f sprains of, 285 Ulnar nerve, 230t, 232, 255, 255f, 256b, 258t, 277, 278, 279, 279f Ulnar tunnel, 255, 255f Ulnar tunnel syndrome, 263f, 264–265, 264f Ultraviolet light–related keratitis, 390 Umbilical hernias, 141, 141f Uncal herniation, pupils in, 385t, 386 Upper airway obstruction, 126t, 127 auscultatory findings in, 115t, 117t, 118 stridor in, 118 Upper motor neuron disease, 164–165, 167 motor deficits in, 175–180, 178t spastic hemiparetic gait in, 176–180 Upright position, in cardiac examination, 76, 76f, 82–83 Urethra, 39 Urethral carbuncle, 55 Urethral meatus female, 51 male, 39, 39f Urethral prolapse, 65 Urethral stricture, 41 Urethritis chlamydial, 41, 47 gonococcal, 41 Urinary bladder distention, 132f, 142, 156 in prostate disease, 48–49 scratch test for, 48, 48f Urine, blood in, in pyelonephritis, 147 Urticaria, 339t, 340, 355, 355f Uterus anatomy of, 65–67 examination of, 66–67 See also Gynecologic examination fibroids of, 68 position of, 66–67 pregnant, palpation of, 156 prolapsed, 65, 65f Uvea, 381 Uveal melanoma, 397 UV-related keratitis, 390 Uvula bifid, 27, 27f in cranial nerve examination, 172, 172t Vagina, 51, 52f, 147, 148f examination of, 58–62, 58f–61f See also Gynecologic examination Vaginal adenosis, 62 Vaginal discharge, 60–62, 61t Vaginal masses/nodules, 62 Vaginal speculum, 58–60, 59f Index Vagus nerve, 172–173, 172t Valgus stress test, 210, 211f, 281 Valsalva’s maneuver in cardiac examination in hypertrophic obstructive cardiomyopathy, 84t, 87, 87f in mitral regurgitation, 90 in mitral valve prolapse, 88 in pelvic examination, 64 Valvular disease, murmurs in See Heart sounds; Murmurs Varicella, 371, 371f, 375 Varicosities, sublingual, 26, 26f Varus stress test, 211, 211f, 214–215 Vastus obliquus medialis muscle, 201, 201f Venous collaterals from inferior vena cava obstruction, 134 from portal hypertension, 134 Venous stasis dermatitis, 354, 355f, 367–368, 367f Venous thrombosis, 209, 334, 335f Ventricular septal defect, 90 Verruca vulgaris, 360, 360f Vertebrae See also Hip, back, and trunk examination compression fractures of, 298–299, 299t, 303, 303t, 310 spinous processes of, 290 Vertigo, benign positional, vestibular ataxia in, 187–188, 188f Vesicles, 339, 339t, 371–372 Vesicular breath sounds, 116, 117t Vestibular ataxia, 182t, 187–188 Vestibule, vaginal, 51, 52f Vibratory sensation, tuning fork test for, 187, 187f, 195 Vienna speculum, 7, 7f Viral exanthems, 356–359, 357t, 358f Viral rhinitis, 168 Virchow’s node, 238, 239f Virilization, hirsutism in, 52 Visceral conjunctiva, 381 Vision testing, 169, 382–383, 382f Visual accommodation, 386, 387t Vitamin B12 deficiency, common peroneal nerve injury and, 191, 192t Vitiligo, 362–363, 362f in scars, 136 Vitreous hemorrhage, 402 Vitreous humor, 381 Vitum’s maneuver, 89 Vogt-Harada-Koyanagi syndrome, 403 Voice, in cranial nerve examination, 172 Volar plates, 255f, 257 Von Graefe’s sign, 31, 31f Von Recklinghausen’s disease, Lisch nodules in, 361, 396, 396f Von Recklinghausen’s maneuver, 12 Vulva disorders of, 54–57, 56t examination of, 53–57, 53f See also Gynecologic examination ulcers and erosions of, 56–57, 56t Vulvar dystrophy, 54–55 Vulvar intraepithelial neoplasia, 55 Waddling gait, 175–177, 176f, 177t, 193t Wallace stretch test, 308–309, 309f Walleye, 384, 384f, 384t Wartenberg’s sign, 181 Wartenberg’s syndrome, 268, 285, 285f Warthin tumor, 15 Warts common, 360, 360f genital, 55, 55f, 360, 360f penile, 41 plantar, 360, 360f Waterhammer pulse, 81, 81t Watson’s stress test, 266, 267f Weakness, 163t waddling gait and, 175–176, 177t Weber test, 170–172, 171f Wegener’s granulomatosis, nasal involvement in, 8–9, 8f Wet mount, for vaginal secretions, 61 Wharton’s duct, sialolithiasis of, 20 Wheezes, 115t, 116 White hairy tongue, 23, 24f White pupil, 388t Whitlow, herpetic, 371–372, 371f Whoops, 118 Wickstram’s striae, 348 Wide-based gait, 175, 175f, 176 Wilms’ tumor, 388t Wilson’s disease, 396 Winging stress test, 248–249, 249f Winking ear lobe, 90 Worsmer’s procedure in carpal tunnel syndrome, 263, 263f in ulnar tunnel syndrome, 264 Wrist disorders of, 266–268 examination of See Hand, wrist, and thumb examination extensor compartments, 257–258, 257f, 258t tenosynovitis of, 268, 268f fractures of, 266–267, 267f ganglion cyst of, 271–272, 271f golfer’s, 265 Wrist extensor muscles, 277 Writing, in ataxia, 183 Xanthelasma, 370, 370f, 402 Xiphoiditis, 124t Xiphoid process, 106 Yergason maneuver, 239, 240f Zygomatic fractures, 9, 11f, 14t ... middle of V1, V2, and V3 areas ■ Tic douloureux: severe pain on touching in V1, V2, or V3 distribution, usually V2 or V3 ■ V1 or V2 or V3 problem: decreased sensation muscle (Fig 7 .22 ) To assess... vibrating tuning fork (5 12 Hz is best, but 25 6 Hz is acceptable) to the base of the mastoid process (Fig 7 .23 ) When the patient can no longer hear the sound of Figure 7 .20 Active smile (A) or puff... on side opposite defect 4886.LWW.Berg.ch07pp161 -20 0 07/18/05 10: 42 AM Page 1 72 1 72 Chapter A B Figure 7 .24 Technique for Rinne test, using a 5 12- Hz fork Excellent bedside method to differentiate