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.

How to examine for Dorsalis pedis pulse:an OSCE guide

Dorsalis pedis pulse is  located on top of the foot, immediately lateral to the extensor of hallucis longus (dorsalis pedis artery).

The dorsalis pedis pulse is palpated in the groove between the first and second toes slightly medial on the dorsum of the foot (i.e., dorsolateral to the extensor hallucis longus tendon and distal to the dorsal prominence of the navicular bone) with the middle and/or index fingers

Feel the pulse lateral to the extensor hallucis longus tendon and proximal to the first metatarsal space.

Comment on the following

• Rate, rhythm, character, volume.
• Character of the vessel wall.
• Palpability of all vessels.

Clinical significance

Dorsalis pedis pulse is absent in condition of proximal vessel occlusion  such as embolism to popliteal artery or in peripheral vascular disease.

Physiology of Ocular Movement

There are 3 planes of movement of eyeball
Vertical plane 

• Adduction - Medial rectus 
• Abduction - Lateral rectus

Horizontal plane 

• Elevation - Superior Rectus and inf. oblique
• Depression - Inferior Rectus and Superior oblique

Diagonal plane 

• Intorsion - Superior rectus and Superior oblique
• Extorsion - Inferior rectus and Inferior oblique

Normal range of eye movement

• Abduction - 60°
• Adduction - 50°
• Depression - 50°
• Elevation - 30°

Types of  ocular movement

• Saccadic movement-jerky voluntary movement from an object to another
• Pursuit movement-smooth follow movement
• Fixation movement-move the head while the gaze is fixed
• Reflex movement-oculocephalic, oculovestibular movement.

Symptoms of ocular motor system
Diplopia, squint, ptosis, defective vision,dizziness (ocular vertigo).

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

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.

Dilatation (mydriasis) of pupil

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
• Application of mydriatics(atropine)
• Postictal state 
• Parinaud’s syndrome
• Coma.
• Severe raised intracranial tension.
• Cerebral anoxia.

Size of Pupils and clinical significance

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

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.

Ocular myoclonus clinical significance

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

What is Dyspepsia?

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

• Weight loss
• Anemia
• Vomiting
• Hematemesis
• Melaena
• Dysphagia
• Palpable abdominal mass.

Importance of past history in GIT

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

How to elicit Tenderness over the renal angle?

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

• Acute pyelonephritis
• Perinephric abscess
• Nephrolithiasis, 
• Tuberculosis of kidney

How to do palpation of kidney?

• Lower Pole of right kidney is normally palpable.
• 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.

Common causes of palpable kidney

Unilateral causes of palpable kidney

• Dropped kidney (can be pushed to its normal position).
• Unilateral hydronephrosis or pyonephrosis.
• Wilms' tumour.
• Hypernephroma.
• Large cyst (solitary) in kidney.
• Compensatory hypertrophy (other kidney damaged).

Causes of bilateral  palpable kidney:

• Polycystic kidney (irregular surface).
• Bilateral hydronephrosis.
• Bilateral dropped kidney.
• Diabetes mellitus.
• Amyloidosis.
• Scleroderma.
• Acromegaly.

Regions of abdomen and its contents

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

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 Liver

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.

Surface marking of Spleen

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

• 9th Left intercostal space – midclavicular line.
• 1.5" to the left of 10th spine
• 3.5" to the left of 1st lumbar spine

Surface marking of Gallbladder

Gall bladder is situated at the junction of 9th costal cartilage and outer border of right rectus abdominis muscle
Grey-Turner’s Method
Draw a line from left anterior superior iliac spine through umbilicus. At the junction of this and the costal margin, is the gallbladder, provided the shape of abdomen is normal. Gallbladder is better seen than felt when enlarged.

How to elicit Palatal reflex?

Ask the subject to open his mouth widely and then touch the mucous membrane covering the palate using a spatula. This produces reflex contraction of the palatal muscles which results in sudden elevation of the palate.

• Receptors : Touch receptors of the palatal mucosa
• Afferent limb : Glossopharyngeal nerve and Trigeminal nerve
• Centre : Vagus nucleus in the medulla
• Efferent limb : Vagusnerve
• Effector : Palatal muscle