Looking from above (standing behind the patient), over the shoulders or the upper part of the chest.If standing or sitting is not possible for the patient, inspect the chest in Iying down position, patient lies absolutely straight in the bed in supine position) inspect from the
Top.
Foot end of the bed.
The sides in profile.
Head end.
Back (try to turn the patient to any one side).
The following are the points to note :
Any deformity, fullness or depression (i.e. shape of the chest), apical impulse etc.
Back (winging of the scapula, drooping of the shoulder, kyphoscoliosis, gibbus. skin changes).
Whether both the sides of the chest arc moving simultaneously and symmetrically.
Classically winged scapula is found in paralysis of nerve to serratus anterior (C 6 ,7) and sometimes in facio-scapulo-humeral muscular dystrophy.
Assessment of the expansion of the upper lobes is better achieved by inspection
From behind the patient, looking down at the clavicles during moderate respiration.
Equal on both sides - normal
Reduced movement on one side - pleural disease ,pulmonary disease
Shift of trachea produces prominence of sternal head of sternocleidomastoid on the side to which the trachea is shifted. It is called Trail's sign.
The pretracheal fascia encloses the clavicular head of stemomastoids muscle on both sides. When the trachea is shifted to one side, the pretracheal fascia covering the stemomastoid muscle on that side relaxes, producing the clavicular head more prominent on the side of tracheal deviation. Causes of tracheal shift Pleural disease - Shift to opposite side
It is a very common cause of dizziness or syncope that is characteristically seen in response to the following.
Fear
Sudden emotional stress
Anxiety
Physical or mental exhaustion
Pregnancy
Anaemia.
Vasovagal syncope is always preceded by warning symptoms such as nausea. weakness, sweating, epigastric discomfort, blurred vision, headache, tinnitus, difficulty in concentrating, sighing and dizziness.
The heart rate decreases, and the patient appears pale. The syncope is transient,and last a few seconds to a few minutes, and this may be prevented by immediately lying down. Rarely, this type of syncope can occur when the patient is recumbent.
Orthostatic hypotension Orthostatic hypotension produces dizziness on arising or after prolonged standing and this can be related to reduction in effective blood volume, autonomic nervous system dysfunction, or rarely, to circulating vasodilator substances.
Causes are
Drugs-antihypertensive or antidepressant medications, vasodilators, and beta blockers
Diabetic autonomic neuropathy
Anaemia
Low blood volume
Large varicose veins
Pregnancy
Addison's disease (rare cause)
Secondary hypertension-pheochromocytoma.
Hypersensitive carotid sinus It is suspected when the patient describes dizziness or syncope after hyperextension of the neck, turning of the head, or pressure over the area of the carotid sinus from a necktie or during shaving. The syncope is evanescent, with rapid and complete recovery.
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.
Facial nerve is a Sensorimotor nerve with the following functions
Special visceral efferent (facial muscle)
General visceral efferent (submandibular, sublingual and lacrimal glands)
Special visceral afferent (taste from anterior two-thirds of tongue)
General somatic afferent (sensation from external auditory meatus, mastoid and pinna)
The upper half of the face has a bilateral representation ,whereas the lower half of the face has unilateral representation.
Nuclei of facial nerve are 4 in number
Motor nucleus contains dorsal and ventral group of cells and is situated in ventral pons
Superior Salivatory nucleus control salivation
Nucleus of tractus solitaries carry taste sensation from anterior 2/3 rd of tongue and sensation from external auditory meatus
Lacrimal nucleus. for lacrimation
There is two types of movements voluntary and reflexmovements Volitional movement
There is supranuclear connection for volitional movement
It is unique for facial nerve
For Volitional movement the fibers start from lower part of precentral gyrus , corticonuclear fibers descend to pons and cross to opposite facial nucleus. Nucleus for the superior half of facial muscles receiving ipsilateral and contralateral supranuclear fibers. Nucleus for the inferior half of facial muscles mainly receive contralateral supranuclear fibers .This explains why the upperhalf is spared in UMN lesion and only lower half is affected.
Variation
Occasionally lower half of face also has ipsilateral supranuclear innervation but it is less than contralateral innervation. This will result in only paresis of lower half in UMN lesion, if ipsilateral supranuclear innervation is also equal to contralateral innervation both upper half and lower half may escape in UMN lesion.
Rarely upper half will have innervation predominantly from contralateral fibers. Thus in UMN lesion there is extension of weakness to upper half of face also. For reflex movement
Fibers from premotor area, extrapyramidal center, basal ganglia, through separate pathway, innervate the Nucleus from both sides but predominantly from Right cortex.
Lesion of this pathway produce Mimic facial palsy. Nervus intermedius
It is the Sensory counter part of facial nerve,it carry fibers of Superior Salivatory nucleus, lacrimal nucleus, and Nucleus of tractus solitarius.
It subserves the following
Somatic sensation of mastoid region ,part of pinnae, external auditory canal
Secretomotor fibers to lacrimal gland, salivary glands - sublingual and submandibular and
Visceral sensation – taste sensation from ant. 2/3rd of tongue.
Greater superficial Petrosal nerve -supplies secretomotor fibers to lacrimal gland
Braches of Vertical mastoid segment
Nerve to stapedius
Chorda tympani -arise 5 mm above the stylomastoid foramen, carry taste sensation from anterior 2/3rd of tongue. It supplies secretomotor fibers to submandibular and sublingual gland
Branches at the level of Stylomastoid foramen
Posterior auricular braches-supplies occipitalis and auricular muscles
Digastric – Posterior belly of digastric
Stylohyoid supplies stylohyoid muscle
Branches in the Parotid region Temporofacial branch
Key anatomical area you should remember in relation to anatomy of the facial nerve are the following
Pons
CerebelloPontine angle
Internal auditory meatus
Middle ear
Stylomastoid foramen
Intrapontine segment Pons
Facial nuclei is situated in the pons
Sensory and parasympathetic fibers are carried by nervus intermedius
It curves around the 6th nerve nucleus to form facial collicullus and form the first genu around the 6th Cranial nucleus Cerebellopontine Angle
Nerve emerges at the ventrolateral portion of pontomedullary junction with Nervus intermedius and 8th nerve and lies in the cp angle Meatal segment
Enters the internal auditory meatus with the 8th nerve with the nervus intermiedius in between Labyrinthine segment
It dip into the facial canal in the floor of meatal canal, reaches the medial part of tympanic cavity form the 2nd genu - geniculate ganglion – receives the Nervus intermedius.
It curves posteriorly at the genu giving the Greater superfical petrosal nerve at the genu
Then it travels backwards in the horizontal direction (tympanic segment is above the middle ear) Mastoid segment
It turns back vertically downwards to emerge through stylomastoid foramen, then turns vertically in the vertical (mastoid) segment
It gives nerve to stapedius and chorda tympani nerve in the vertical part Parotid region
The facial nerve emerge through the Stylomastoid Foramen and enters the parotid region
It emerges at the stylomastoid foramen
Leaves the parotid gland by dividing to temperofacial and cervicofacial branches
finally divides into five terminal motor branches
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
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.
