In Joffroy's sign there is a lack of wrinkling of the forehead when a patient looks up with the head bent forwards Joffroys sign is a sign of hyperthyroidism.It is elicited as follows
1. Avoid offending an unduly modest patient, but this should
never prevent a complete examination.
2. In all the five positions, the patient should be symmetrically
positioned. Otherwise, apparent differences in the breast will result.
3. The nipple, areola and all four quadrants must be examined
In sequence in all the positions.
4. Examine in many positions to detect early changes
The pectoral muscles are relaxed in position (a) contracted in position (b) and stretched along
with the skin in position (c). The breasts are made pendulus In (d). A pillow
under the back in (e) makes the breast more prominent.
5. Since the breast is a frequent site of carcinoma, a general
examination is incomplete unless both the breasts have been Included.
These steps are very important for students preparing for USMLE and MRCP
Hypertelorism means the presence of wide spaced eyes. This is diagnosed when the inter inner canthal distance between the two eyes is more than half of the inter pupillary distance Causes of hypertelorism
Hypertelorism is a feature that can have many underlying etiology
This may be due to a mass pushing the two orbits apart
This is a severe type of flat foot with a protuberant heel.
It is characterised by a prominent calcaneus/heel and a convex rounded sole.
It has Persian slipper appearance
Calcaneus in fixed equinus
Achilles tendon is very tight
The hindfoot is in valgus
The head of the talus is found medially in the sole
The forefoot is abducted and dorsiflexed.
It is also known as a congenital vertical talus What is the pathology of Rocker bottom feet?
It occur from a dorsal and lateral dislocation of the talonavicular joint.
Seen in the following conditions Aneuploidic syndromic
Trisomy 13- Patau syndrome
Trisomy 18 also called Edward's syndrome, which may be associated with PDA
18q deletion syndrome
Non-aneuploidicsyndrome
Spina bifida
Arthrogryposis
What are the differential diagnosis ?
In the antenatal/neonatal period clubfoot is an important differential diagnosis
In the adult period differentail diagnosis considered is acquired rocker bottom deformity occurring secondary to:
Underlying neuromuscular disorder
Mydriasis is defined as Pupil size > 5 mm
Constrictors ol the pupil are supplied by parasympathetics via the oculomotor nerve while the dilator are controlled by sympathetic nervous system. Changes in the size of the pupil do not affect the vision
Unilateral mydriasis causes
Drugs—-anticholinergics-
Acute ciliary ganglionitis—following several days after infection/ trauma
3rd nerve palsy.
Holmes-Adies pupil or myotonic pupil.
Blindness due to Optic atrophy
Acute congestive glaucoma.
Head injury-Uncal herniation Unilateral pupillary dilatation is the most important physical sign in the unconscious patient, and until proved otherwise a dilated pupil indicates that a herniated temporal lobe is compressing-the ipsilatcral oculomotor nerve, and that immediate surgical action is required.
Bilateral mydriasis causes
Anxiety
Myopic eyes
Infancy
Thyrotoxicosis
Drug poisoning-antihistamine, phenolhiazinc, anticholinergics, Datura poisoning,Drugs like atropine and pethidine
Normal size of pupil varies from 3 to 5 mm.
Pupils < 3mm size in average condition of illumination are called miotic and pupils > 5 mm are called mydriatic. Pin point pupil is said to be present when the pupillary size is less than or equal to 1 mm.
Normal—3-5 mm
Mydriasis > 6 mm
Miosis < 2 mm
Pin point pupil < I mm
A difference of 0.5 mm between the two pupils is abnormal
Rapid involuntary conjugate saccadic movement of eyes
It is described as rapid, involuntary, multivectorial (horizontal and vertical), unpredictable, conjugate fast eye movements without intersaccadic [quick rotation of the eyes] intervals) Ocular myoclonus associations
Opsoclonus Myoclonus Syndrome (OMS) is also called as Opsoclonus-Myoclonus-Ataxia (OMA), is a rare neurological disorder which appears to be the result of an autoimmune process involving the nervous system
Seen in Postencephalitic syndrome
Neuroblastoma
It may be seen associated with viral infection ,perhaps St. Louis encephalitis, Epstein-Barr, Coxsackie B, enterovirus, or just a flu
OPM-palatal myoclonus when associated with abnormal eye movements,it is called "oculopalatal myoclonus", or OPM. A clicking sound is commonly heard in this symptom
Ocular dipping is an abnormal eye movement consists of cycles of eye movements occurring spontaneously, that are characterized by a slow conjugated downward deviation followed after a delay by a quick return to mid position.
Periodic slow downward movements followed by fast Upward movement to the primary position Slow down-fast up
It is also called as inverse ocular bobbing Causes of ocular dipping
Ocular dipping is only described in unconscious patients, especially those in anoxic coma
Diffuse or multifocal encephalopathies
Diffuse structural brainstem damage.
Creutzfeldt-Jakob disease.
Spontaneous eye movements are useful clinical signs in coma, although they rarely have localizing value. The best-known exception to this rule is ocular bobbing,that is found in pontine lesions.
Dyspepsia is a term to denote a variety of alimentary symptoms arising form upper gastrointestinal tract. Symptoms includes
Upper abdominal pain ± related to food
Heart burn, regurgitation, water brash
Anorexia, nausea, vomiting
Early repletion and satiety after meals
Flatulence, belching and bloating.
Causes of dyspepsia Organic dyspepsia Functional dyspepsia Organic causes of dyspepsia
Peptic oesophagitis
Peptic ulcer
Upper GI malignancy
Hepatobiliary disease
C/c pancreatitis
Other system disorders - CRF, CHF etc.
Drugs - NSAID, corticosteroids
Alcoholism, pregnancy
Functional dyspepsia [nonulcer dyspepsiaI
It is due to motor dysfunction of upper gastrointestinal tract mediated by neurohumoral mechanism What are the Alarm features in Dyspepsia
Past history is very important in gastrointestinal system
History of Jaundice indicate viral hepatitis
Drug intake - history of drug intake such as rifampicin. INH. anabolic steroids pills are risk factors for jaundice .NSAID intake for melena or history of any herbal remedies
Blood transfusion or transfusion of any blood products (viral hepatitis C. D and G).
Recent tattooing or acupuncture: Drug abuse.to rule out viral hepatitis
Alcohol consumption predispose to cirrhosis
Tuberculosis can cause ascites due to tuberculous peritonitis.
Haematemesis or melena (peptic ulcer, ruptured oesophageal varices, gastric malignancy)-
Fever seen in tuberculosis, hepatocellular failure
Haematochczia occur due to lower G. 1. malignancy. haemorrhoid
Once the kidney is palpable examine for the folllowing
Site
Size.
Shape (ovoid normally).
Consistency (resilient or firm in feel).
Margins (rounded).
Surface (normally smooth surface: irregular in polycystic kidney).
Tenderness.
Movement with respiration (normally kidney shows slight movement with respiration).
Whether bimanually palpable and ballottable.
Renal angle tenderness
In case of left sided renal lump—Examine for band of colonic resonance over the lump (by
Remember, a kidney lump is bimanually palpable and ballottable. The kidney is ballottable
Because it is a posterior abdominal organ.
Patient is asked to sit and the angle formed by the 12th rib and lateral border of erector spinae muscle is pressed by the ball of the thumb—"Murphys kidney punch". This test is done on both sides. Renal angle is tender in the following conditions
Left kidney is usually not palpable unless either low in position or enlarged
Though kidney is retroperitoneally situated, it moves with respiration as it is related to the crus of the diaphragm posteriorly, the movement of the diaphragm is reflected to kidney producing restricted movement during respiration.
Use bimanual technique to palpate the kidneys.
How to palpate the kidneys?
The lower pole of right kidney is commonly palpable in thin patients for obvious reasons. Previously it was told that left kidney is palpated best from left side but nowadays no such dogma is present.
Both the kidneys are palpated from right side of the patient. The method of palpation goes like this :
Preliminary preparations of the patient are the same as done during palpation of liver. Always sit on a stool for palpation of kidneys.
To palpate the right kidney, place the right hand horizontally in the right lumbar region anteriorly and the left hand is placed posteriorly in the right loin region (bimanual palpation)
Push the right hand in a backward, upward and inward direction, and ask the patient to take deep inspiration. A firm mass may be felt in between the two hands (if kidney is enlarged).
Next, a sharp tap is given by the left hand placed in the loin region. The anteriorly placed right hand now feels the kidney and the kidney then falls back (by gravity) on the posterior abdominal wall which is felt by the left hand. This is ballottement. Firm pressure is exerted by both hands at the height of inspiration to trap the palpable kidney between the two hands, otherwise it will prevent the descend of kidney by the diaphragm
The left kidney is then palpated by placing the right hand anteriorly and the left hand posterior- the left loin.
It is heard in perisplenitis or perihepatitis due to microinfarction and inflammation.
Splenic rub is heard in the following conditions:
Chronic myeloid leukaemia
For purposes of description abdomen is conveniently divided into 9 regions by the intersection of imaginary planes there are 2 horizontal and 2 sagittal planes. The horizontal planes
The upper horizontal plane[transpyloric] lies at a level midway between the suprasternal notch and the symphysis pubis,that is at the level of L1 vertebra (transpyloric plane)
The lower plane passed through the upper borders of the iliac crests at the level of tubercles of the iliac crest. The sagittal planes or vertical planes
The sagittal planes are indicated on the surface by lines drawn vertically midway between the pubis and anterior superior iliac planes. You have to drop two vertical lines from the mid point of clavicle on either sides. The regions of abdomen are:
Right hypochondrium
Left hypochondrium
Epigastrium
Right lumbar region
Left lumbar region
Umbilical region
Right iliac fossa
Left iliac fossa
Hypogastrium.
Contents of different regions of abdomen
Right hypochondrium - Right lobe of liver, gallbladder, hepatic flexure of colon
Epigastrium - Left lobe of liver, stomach, transverse colon, lower end of oesophagus and oesophagogastric junction
Left hypochondrium - Fundus of stomach, spleen, tail of pancreas, splenic flexure of colon
Right lumbar region - Right kidney and its suprarenal gland, right ureter, ascending colon
Umbilical region - Aorta, IVC, portions of stomach, head and body of the pancreas, duodenal loop, mesentery, small intestinal loops, lymph nodes
Left lumbar region - Left kidney and its suprarenal gland, left ureter and descending colon, spleen if it enlarges grossly
Right iliac fossa - Caecum, appendix, part of ascending colon, lymph nodes, right ovary and fallopian tube
Hypogastrium - Urinary bladder, uterus in females, sigmoid colon and rectum
Left iliac fossa - Part of the descending colon, part of sigmoid colon, left ovary and fallopian tube, lymph nodes.
Surface marking of kidney is done by drawing the Morris parallelogram .
Two parallel horizontal lines are drawn on the back at the levels of 11 th thoracic and 3rd lumbar spines.
These two horizontal lines are intercepted by 2 vertical lines drawn 3.75 and 8.75 cm respectively from midline.
Surface marking of upper border of liver
Upper border of right lobe corresponds to the level of 5th rib, 2.5 cm medial to the right midclavicular line.
5th Right intercostal space - Midclavicular line
7th Right intercostal space – Midaxillary line
9th Right intercostal space - scapular line -Inferior angle of scapula
Upper border of left lobe is at the level of 6th rib in left mid clavicular line.
In men, it corresponds to a line joining a point about 1 cm below the right nipple to a point about 2 cm below the left nipple. Surface marking of lower border of liver
Lower border follows the right costal margin, in the epigastrium, it is from the tip of the 9th Right costal cartilage to the tip of the 8th costal cartilage on the left by an oblique line midway between the xiphisternum and umbilicus.
The left lobe extends to the left of the sternum about 5cm.
Spleen is situated behind 9th, 10th and 11th ribs with its long axis along the line of 10th rib; anteriorly it extends to mid axillary line while posteriorly its superior angle is 4 cm lateral to 10th thoracic spine. It is separated from 9th, 10th and 11th ribs by the diaphragm. Surface marking of spleen can be done by joining 3 points
