Significance of hand examination in systemic diseases

Examination of hand reveals specific features of systemic diseases.

• Cold clammy hand with peripheral  cyanosis indicate shock
• Cold moist hand in anxiety state
• Cold dry hand is a feature of myxedema
• Warm moist hand seen in thyrotoxicosis
• Pallor of palmar crease observed in anemia
• Wasting and fasciculation of hand muscles- is seen MND, syringomyelia
• Myotonic disorders can be associated with slow relaxation on shaking hand
• Cyanosis and clubbing together-Cyanotic CHD, ILD
• Nail-fold infarct and telangiectasia are seen in vasculitis. SLE, PAN, PSS
• Osier's node, splinter hemorrhage, Janeway suggestive of infective endocarditis
• Pigmentation is a feature of Addison's disease, megaloblastic anemia
• Arachnodactyly is a feature of Marfan's syndrome
• Deformed hand diagnostic of rheumatoid arthritis 
• Sclerodactyly in PSS, MCTD
• Heberden's node are characteristic of osteoarthritis
• Clawing of hand  in ulnar and median nerve lesion
• Dupyutren's contracture a feature of alcoholic liver disease, trauma
• Gottron's papule is seen in dermatomyositis
• Large spade hand in acromegaly
• Short 4th metacarpal- pseuda-hypopara thyroidismdism, reverse Marfan's syndrome (Weil-Marchesani syndrome)  and Turner's syndrome
• Long thumb-fingerization-Holt-Oram syndrome.

Ataxic Gait (Cerebellar Lesion)

• This gait is also called as reeling. staggering. drunken gait
• This type of gait is seen in patients with cerebellar lesion and alcohol intoxication
• The patient is ataxic and reels in any direction, including backwards and walks on a broad base.
• The unsteady feet are planted widely apart and placed irregularly.
• The steps are uncertain, some are shorter and some are longer than Intended, and the patient tends to fall or deviate to the side of cerebellar lesion.
• The ataxia is equally severe whether the eyes are open or closed
• The patient finds difficulty in executing tandem walking.
• Gait ataxia is seen in lesion of upper vermis and anterior lobe of cerebellum
• Titubant ataxia - ataxic gait with vertical oscillation of head and trunk. 

How to examine for Femoral pulse:an OSCE guide

The femoral pulse is palpated over the ventral thigh between the pubic symphysis and anterior superior iliac spine with the middle and index fingers.

How to examine for femoral pulse?

• Ask the patient to lie supine,
• Make the leg partially flexed: abduct and externally rotate the hip,
• Feel the pulse below the midinguinal point.

Comment on the following

• Rate, rhythm, character, volume.
• Character of the vessel wall.
• Palpability of all vessels.
• Radio-femoral delay.

Clinical significance

Examination of peripheral pulse is imporatant for detection of radiofemoral delay

This is very important for students preparing for USMLE and MRCP

Examination of skin lesions an OSCE guide

1. Use good lighting: preferably natural lighting.

2. Patient is adequately exposed.

3. Comment on:              

• Type of the lesion—primary and sequential: colour.
• Shape of the lesions.
• Arrangement of two or more lesions.
• Distribution of the lesions—examine specifically the hair, nails and mucous membranes.

4. Do palpation to confirm findings.

5 Tell the probable diagnosis.

6. Do or tell one specific test to clinch the diagnosis.

Note

1. Primary lesions They could lie

• Flat (in the plane of the skin): Macule.
• Elevated (above the plane of the skin): Papule, plaque, vesicle, bullae, pustule, cyst, wheal.
• Depressed (below the plane of the skin): Ulcer, erosion.

2. Sequential lesions (occur over a primary lesion) Scaling, dry or wet exudation or llchenification.

3. Shape Round, oval, annular, iris, serpiginous, umbillicated. polygonal or polycyclic.

4. Arrangement herpctiform. zosteriform. reticular, linear or serpiginous.             '

5. Distribution Symmetrical or asymmetrical, exposed areas, intertriginous areas, sites of pressure, local or generalised.

6. Specific tests Include microscopic examination of the scales, crusts or exudate. Tzanck test. Auspltz sign. Nikolsky's sign. Koebner's phenomenon, patch test. etc.

7. The manifestations of a few common diseases are:

• Iris lesion or target lesion: Erythema multlforme.
• Annular lesions with scaling: Dermatophytosts. psoriasis and pityriasis rosea.
• Annular lesions without scaling: SLE. Secondary syphilis.
• Bilateral symmetrical eruptions: Drug or endogenous  hypersensitivity
• On exposed areas: Pellagra, photosensitivity.
• On interlriginous areas: Candidiasis.
• On sites of pressure: Psoriasis.
• Velvety brown pigmentation of the axilla and groins: Acanthosis nigricans.

This is very important for students preparing for USMLE and MRCP

Examination of a joint an OSCE guide

1. Expose the Joint and the muscles acting on It.
2. Observe and note any deformity, swelling or muscle atrophy.
3. Palpate the Joint for synovial thickening, warmth, points of tenderness and any abnormal masses.
4. Elicit fluid thrill if swelling is present.
5.  Assess passive and active range of Joint movement.
6. Palpate during movement to elicit Joint crepitus.
7. Test the ligaments that stabilise the Joint.
8. Compare the two sides.

Note

Fluid thrill indicates effusion while a 'boggy feel" without a fluid thrill indicates synovial thickening. At times both may be present.

This is important for those students preparing for USMLE and MRCP

How to elicit Von Graefe's sign:an OSCE guide

Von Graefes sign is an important eye sign in hyperthyroidism.It is elicited as follows

• The patient looks straight ahead.
• Ask the patient to look down.
• Look for a lag of the upper eyelid.

It is the lagging of the upper eyelid on downward rotation of the eye and indicate  underlying  Graves' Disease

The terms lid lag and von Graefe's sign have been used interchangeably in the past; but, they are distinct signs of downgaze-related upper eyelid static position and dynamic movement, respectively.

How to elicit the signs of liver cell failure an OSCE guide

Following are the major signs of liver cell failure

1.Spider naevus

2.Asterixis or flapping tremor

3.Constructional Apraxia

4.Gynaecomastla

Presence of a Button-like' breast tissue on palpation below the areola In a male suggests early gynaecomastla.

5.Testicular Atrophy

If the testis is less than 3.5 cm in length, and feels soft or

Flabby on  palpation, it suggests testicular atrophy.

6.Loss of Axillary and Pubic Hairs

They become sparse initially and are totally absent in later stages.

This is very important for those students preparing for USMLE and MRCP

How to elicit Asterlxis or Liver Flap an OSCE guide

Asterixis is also called as  Flapping Tremor

1. Explain procedure to the patient.

2. Ask the patient to fully extend his/her arms and dorsiflex his/her wrists.

3. His/her fingers are held widely separated.

4. Holds In the same position for a few seconds.

5. Comment as asterlxis present or not.

Alternate Method for elicitation of flapping tremor

Asterlxis can also be elicited in the legs, head and the trunk.

Note the following

• The patient is elaborately positioned because the flap is best demonstrated in that position.
• Asterlxis Is said to be present if the wrist and fingers Involuntarily flex abruptly and irregularly: fhe patient compensates by extending the wrist but the correction is only partial, tlcxion and partial extension occur alternately so that In the end the wrist comes to a flexed position.
• Asterixis occurs because of non-rhythmic, transient loss of posture In the arms.

This sign is very important for those students who are preparing for USMLE and MRCP

How to examine for Spider Naevus an OSCE guide

Spider Naevus is a sign of liver cell failure.Sometime seen in healthy Individuals also.

1. Ask the patient to adequately expose.

2. Examine the- face. neck, arms and chest above the nipples

3. Blanch the spider naevus using the head of a pin or a glass slide.          

4. Release pressure to look for flushing.

5. Comment as present or not.

If present, significant or not significant.

Note the following

• Count the naevi above the level of the nipples i.e. in the drainage area of the superior vena cava.
• Less than 7 spider naevi are normal in young persons
• More than 7 occur in liver cell failure pregnancy  or in persons on oral contraceptive
• Spider naevus occurs because of the dilatation of a central arteriole (the body of the spider) which feeds the vessels radiating from it (the legs of the spider). If a red naevus does not blanch, it is purpura. Blanching occurs fully in erythema also and partially in telanglectasias.

These steps are very important for students preparing for USMLE and MRCP exams

How to examine an erythematous lesions the OSCE guide

1. Expose the skin adequately.

2. Use natural lighting.

3. Examine lor blanching on compression with a glass slide.

4. Comment on site, number, size and blanching on compression.

5. Tell the probable diagnosis.

Note

1. Blanching on compression occurs in erythema, telangiectasia, spider naevi and partially in senile

angiomas. Blanching does not occur in purpura.

2. Purpura is a term used for collection of blood in the skin.

• Petechiae are pin-point haemorrhages in the dermis.
• Ecchymosis is a large subcutaneous collection of blood.
• Haematoma is deeper and forms a palpable swelling.

These steps are very important for students preparing for USMLE and MRCP

How to examine exanthematous (rash) lesions-OSCE guide

Examination of exanthematous (rash) lesions

Elicit History

a. Duration of prodromal symptoms (including fever).

b. Onset and progression.

c. History of an epidemic in the locality.

Inspection and Palpation

1. Expose the patient adequately.

2. Ensure good lighting.

3. Observe and note down:

• Involvement of oral mucosa, conjunctiva and external genitalia.
• Distribution: centripetal, centrifugal, segmental.
• Stage of the lesions: macule, papule, vesicle, pustule, scabs, combined or crops.
• Regional lymphadenopathy.

Comment on:

Probable diagnosis.

Specific test to confirm diagnosis.

These steps are very imporatant for students who prepare for USMLE and  MRCP examinations

How to examine a patch lesion- OSCE guide

1 Elicit history of Itching, numbness, course of the lession.

2. Inspect and note: site. size, shape, number, margins (ill or well-defined).surface (flat or raised), pigmentation,scaling, central clearing.

3. Examine for sensory loss and regional nerve thickening (if relevant).

4. Comment on the possible diagnosis.

5. Do one specific test to confirm the diagnosis, e.g. sensory loss in Hansen's patch.

Note

1. Patch refers to a flat lesion with a colour different from the surrounding skin. It is large and > 2 cm in diameter. It is called a macule,  it is < 2 cm.

2.. Common causes of patch lesions are dermatophytosis. leprosy and psoriasis.

OSCE guide for Hess test (tourniquet test)

1. Expose one upper limb adequately.

2.Use adequate lighting.

3.Tie the sphygmomanometer ruff around the arm.

4.Mark out a circle of 3 cm diameter on the forearm about I cm below the cubital fossa (where there are no petechiae).

5. Raise the cuff pressure to midway between systole and diastole.

6. Maintain pressure for 5 to 7 minutes.

7. Deflate the cuff and wait for 2 to 3 minutes (for congestion to disappear).

8. Count the number of petechiae in the marked out area

Note

1.The diameter of an old one rupee coin is about 3 cms and it can be conveniently used to draw the circle

2. Normally, upto 10 petechlae can occur in the mentioned area. More than 20 arc definitely abnormal. Note that petechiac can vary in size from pin point to pin head or larger.

3.. The tourniquet test is positive in most cases of thrombocytopenia and in increased capillary fragility. It is anessential part of examination in any patient with bleeding disorder.

These steps are very important for those students who are preparing for USMLE and MRCP

OSCE guide for examination of thoracic outlet syndrome

OSCE steps for examination of thoracic outlet

1. Expose the- neck and upper torso well.

2. Palpate the supraclavicular fossae for tender spots,masses, muscle spasm and vascular thrill.

3. Perform Adson manoeuvre

• Patient sits with forearms supine and resting on the thighs.
• Palpate the radial pulse on the right side.
• Ask the patient to look up. turn the chin to the right and breathe deeply.
• Note transient disappearance of the radial pulse during deep inspiration.
• Repeat the lest on the left side.

4. Observe and note any small muscle wasting or sensory loss of C8segment.

5. Ask the patient to abduct and externally rotate the shoulder, and note Intensification of sensory symptoms and signs

This examinations steps are very important for those students preparing for USMLE and MRCP clinical examination

Tuberculoma may manifest as chorea

Chorea is defined as a syndrome characterized by abrupt involuntary movements

resulting from a continuous flow of random muscle contractions2. 

HIV and its complications are the most commonly reported infectious cause of chorea. 

In one study of 42 consecutive patients with non-genetic chorea, AIDS was the cause in 12% of the patients. 

Common  Infectious causes for chorea  are the following

·          HIV encephalopathy,

·         Toxoplasmosis,

·          Cysticercosis,

·           Diphtheria,

·           Bacterial endocarditis,

·           Neurosyphilis,

·           Viral encephalitis (mumps, measles, varicella) are the described causes causes.

There are only two case reports of striatal tuberculoma presenting as hemichorea so far in literature

Hence is the significance of our discussion

Hypertrichosis -clinical significance

Hypertrichosis is a condition where there is excessive growth of hair in generalized or localized pattern but this is not of male pattern of distribution.

Congenital hypertrichosis is seen in porphyria cutanea tarda, 

Hurler's syndrome, 

Giant pigmented naevus also called as [bathing suit naevus]

Acquired hypertrichosis is seen in the following conditions

• Malignancy-bronchogenic carcinoma
• Drugs-phenytoin, steroids,minoxidil, diazoxide, streptomycin.
• Endocrine causes
• Sexual precocity
• Hypothyroidism
• Adrenal hyperplasia or neoplasm

Causes of Miosis

Miosis is defined as Pupil size is < 2 mm
Following are the common causes of miosis

• Old age
• Homer's syndrome
• Drugs or toxins
• Neostigmine
• Morphine
• Organophosphorous poisoning
• Pontine haemorrhage.

Unilateral miosis causes

• Homer’s syndrome• Paralysis of cervical sympathetic - Horner's syndrome
• Drugs
• Irritation of parasympathetic system
• Drugs - Morphine, organophosphate poisoning, levodopa
• Deep coma, increased-OLpontine hemorrhage
• Rowland Payne syndrome - Consists of Horner's syndrome, phrenic nerve and recurrent laryngeal nerve involvement. It is caused in metastatic tumor at neck from malignancy like carcinoma breast.
• Old age.
• Argyll Robertson pupil.
• Application of pilocarpine drops : overdose of neostigmine.
• Iritis.

Bilateral miosis causes

Pin-point pupil.

• Morphine or barbiturate poisoning, 
• heat stroke (hyperpyrexia)

How to differentiate between patients with pin point pupil

• Pontine haemorrhage—There is coma, hyperpyrexia and long tract signs (ie. sings ol pyramidal tract lesion).
• Organophosphorus poisoning— It is diagnosed by history, absense of long tract signs, and sign of respiratory depression. The patient may be unconscious but there is absense of pyrexia.

Irregular pupils are due to 

• Coloboma.
• Neurosyphilis
• followlng eye operation.
• Sometimes, it is seen in normal healthy subjects.

Anatomical peculiarities of 3,4,6th cranial nerve

The 3rd cranial nerve-oculomotornerve
The oculomotor nuclear complex is located in the the middbrain at the level of superior colliculus. This has one unpaired and four paired nuclear columns.
The unpaired column constitute

• Edinger-Westphal nucleus
• Subnucleus for levator palpebrae superioris. 

The paired nuclei constitutes

• Subnuclei for superior, inferior and medial recti and inferior oblique.

4th cranial nerve-Trochlear nerve

• Trochlear nerve passes posteriorly and the fibres from the right and left trochlear nuclei decussate on the dorsum of mid brain. 
• This is the only cranial nerve that emerges dorsally from the brainstem. 
• The left trochlear nucleus sends fibres to the right superior oblique muscle and vice versa.

6th cranial nerve-Abducent nerve 

• Abducent nerve has a very long intracranial course and supplies the lateral rectus muscle..
• Because of its long intracranial course, this  nerve  is affected in conditions producing raised intracranial tension, hence producing a false localizing sign.