Radiofemoral delay is an important clinical sign that help
to detect the coarctation of aorta
How to elicit radiofemoral delay?
To detect the radiofemoral delay you have to palpate the
radial and femoral artery simultaneously.Normally the time taken for the pulse
wave to reach the radial artery after the cardiac systole is 80 milliseconds
and for the femoral artery it is 75milleseconds.If the femoral pulse is delayed
compared to radial pulse it is called as radiofemoral delay.
The common carotid artery is palpated
on the neck below the jaw and lateral to the larynx/trachea (that is mid-point
between your earlobe and chin) using the middle and index fingers.
It can be felt between the anterior border of the sternocleidomastoid muscle, above the hyoid bone and lateral to the thyroid cartilage
Precaution on palpating the carotid artery
The carotid artery should be palpated gently
The patient should be in sitting or lying down posture.
Stimulating its baroreceptors with low
palpitation can result in severe bradycardia or even stop the heart in some
sensitive persons.
Two carotid arteries of a person should not be palpated
at the same time. as it may limit the flow of blood to the head, possibly
leading to fainting or brain ischemia.
How to examine for carotid pulse?
Ask the patient to
look straight ahead
Use your thumb and press it backwards
The pulse is felt at the level of the medial border of the
sternomastoid muscle and lateral to the thyroid cartilage.
Comment on the following
Rate, rhythm,
character, volume.
Character of the vessel wall.
Palpability of all vessels,
This is very important for students preparing for USMLE and MRCP
Brachial artery pulse is located on the inside of the upper arm
near the elbow
The brachial artery is palpated on the anterior aspect of
the elbow by gently pressing the artery against the underlying bone with the
middle and index fingers.
Clinical significance
This pulse is commonly used to measure blood pressure
with a stethoscope and sphygmomanometer
How to examine for brachial artery pulse?
Partially flex the elbow,
Feel the pulse over the elbow with thumb or fingers
Radial artery pulse is located on the lateral of the wrist ,
it can also be found in the anatomical snuff box
The radial pulse is palpated immediately above the wrist
joint near the base of the thumb (i.e., common site), or in the anatomical
snuff box (i.e., alternative site), by gently pressing the radial artery
against the underlying bone with the middle and index fingers.
Clinical significance
The examination of radial pulse is very useful in the following condition
Radioradial delay-seen in thoracic inlet syndrome and takayasu disease
Radiofemoaral delay in Coarctation of aorta How examine for radial pulse
Semipronate the forearm,
Flex the wrist
Feel the pulse near the wrist,
Comment on the following
Rate, rhythm,
character, volume.
Character of the vessel wall.
Palpability of all vessels,
Radio-femoral delay.
This is very important for students preparing for USMLE and MRCP
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
Comment on position, size, shape, surface, pulsations.
overlying skin and movement on deglutition and protrusion of
the tongue.
Neck Measurements
Measure the circumference of the neck at the most prominent
part of the swelling.
Palpation
Patient's neck is slightly flexed (to relax muscles).
Examine from the
front or from behind the patient.
Otto's method: Place the thumb and fingers on the thyroid.
Palpate the thyroid when the patient swallows.
Lahey's method -Push the thyroid to one side Palpate the
lobe on the side which becomes prominent.
Comment on position, size. shape, surface, consistency (uniform,
variable, cystic, solid, firm. hard), mobility (Hortzontal and vertical),
tenderness and on the рутаmidal lobe If present
Auscultation
For thyroid bruit
Others
1. Carotid pulse. Present or absent on each side.
2. Horner's syndrome.
3. Kocher's test: Press the lateral lobes of the thyroid (stridor
occurs In compressed trachea).
4. Lymph nodes for secondaries.
General Examination
1. Relevant examination to elicit-symptoms and signs of hyper
or hypothyroidism.
The patient raises both his/her arms
until they touch the ears.
Hold up for sometime.
Look for congestion of the face, cyanosis and distress in
a retrosternal goitre.
This sign demonstrate the presence of latent pressure in the thoracic
inlet
Pemberton's sign was named after Dr. Hugh Pemberton
A positive Pemberton's sign is seen insuperior vena cava syndrome (SVC), asa result of a mass in the mediastinum. the
sign is most commonly described in patients with substernal goiters where the
goiter “corks off” the thoracic inlet.this maneuver is veryuseful in any patient with adenopathy, tumor,
or fibrosis involving the mediastinum
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
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.
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
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
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
