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IRFAN MIR

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CLINICAL CORRELATION
Prepared by Dr. IRFAN MIR

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Prepared by Dr. IRFAN MIR

ONLY FOR EDUCATIONAL PURPOSE

KICK THE CLINICAL CORRELATION

* Rapid change in wt over a few days suggest change in body fluid not tissue. * Wt loss with relatively high food In take suggest DM, Hyperthyroidism, mal absorption, consider also binge eating (bulimia) with clandestine vomiting. * Poverty, old age, social isolation, physical disability, emotional or mental impairment, lack of teeth, ill fitting dentures, alcohol or drug abuse increase the likely hood of malnutrition. * Tension and migraine headache are the most common kind of recurring headache. Progressively severe headache the likely hood of tumor or other organic cause. Extreme severe headache suggest subarachenoid hemorrhage or meningitis. * Nausea or vomiting are more common with migraine but also occur with brain hemorrhage and tumor. * Changing the position of head, cough, sneeze may increase the pain of brain tumor or sinusitis. * Refractory error most commonly explain gradual blurring, high sugar food may also cause blurring of vision. * Sudden visual loss suggest retinal detachment, vitreous hemorrhage or occlusion of the central retinal artery. * Slow central visual loss occurs in nuclear cataract, macular degeneration. Where as peripheral visual loss occur in advanced open angle glaucoma on other hand one side visual loss occur in hemianopsia and quadrantic defect. * Moving specks or strands suggest vitreous floaters, where as fix defect (scotomas)suggest lesion in the retina or visual pathway. * Flashing lights or new vitreous floaters suggest detachment of vitreous from retina. * Diplopia indicates the weakness or paralysis of one or more extra ocular muscles. Horizontal diplopia implicate the 3rd and 6th CN. where as diplopia in one eye with other closed suggest a problem in cornea or lens. On other hand vertical diplopia implicate problem in 3rd and 4th CN. * Hearing conduction loss result from problem in external and middle ear Where as sensori neuronal loss results from problem in inner ear, cochlear nerve & CNS. * Person with sensory neuronal hearing loss have particular trouble understanding speech, and complain that other noisy environment make it worst.(where as noisy environment may help in conduction hearing loss.) * Tinnitus is the common symptom increasing in frequency with age when associated with hearing loss and vertigo suggest Meniere,s disease. * Vertigo primarily point the problem in inner ear cochlear nerve or central connection. * Enlarge tender lymph node in neck often accompany pharyngitis. * A milky bilateral discharge from breast may be due to pregnancy or hormonal imbalance (Galactorrhea) where as non milky unilateral discharge suggest local breast dis. * Anxiety is the most common cause of chest pain In children. Among organic cause costochondritis is most common. * Pain over the sternum suggest angina pectoris. Where as finger pointing small area over heart suggest a non cardiac origin. A hand moving up and down from epigastria to neck suggest heart burn. * Orthopnea suggest left ventrical failure or mitral stenosis but may also accompany obstructive lung dis. * Paroxysmal nocturnal dyspnea describes as episode of sudden dyspnea and orthopnea that waken a pts from sleep. It suggest left ventricular failure or mitral stenos sand may be mimicking a nocturnal asmatic attack. * Wheeze a musical respiratory sound suggest airway obstruction. * Puffy eyelid and tight ring when associated with edema else where suggest, renal dis or hypoalbuminemia. * Cough is imp symptom of left side heart failure. * Hemoptysis originating in the stomach is usually darker than that from the respiratory tract. * Hemoptysis is extremely rare event in infant, children and adolescents seen most often in cystic fibrosis. * Dysphasia pointing to chest suggest esophageal disorder where as dysphasia pointing to the throat may occur in either a transfer or esophageal disorder. * Dysphagia of solid food suggest mechanical narrowing (obstruction) of the esophagus. Where as dysphgia of both solid and liquid suggest disorder of esophageal muscles.(eg.peristalsis problem). * Odynophagia describes as pain on swallowing. Sharp burning pain suggest mucosal inflammation vs. squeezing cramping pain suggest muscular cause. * Acute appendicitis exemplified both visceral perital pain. Early distention of inflamed appendix produce periumblical pain, which is gradually replaced by right lower quadrant pain due to inflammation of the adjacent perital peritoneum. * Visceral pain is poorly localized where as perital pain is caused by inflamed peritoneum and is steady aching pain that is usually more severe than visceral pain and also more precisely localized over the involved structure, aggravated by movement or cough. Pt with this kind of pain usually prefer to stay still. * Pain of duodenal or pancreatic origin may be referred to back. Where as pain from biliary tree may refer to the right shoulder or right poet chest. * Pain from pleurisy or acute MI may be referred to the upper abdomen. * Cramping (colicky) pain suggest the relationship to peristalsis. * Gastric juice is clear or mucoid.brownish or blackish vomitus with food particle like coffee ground suggest blood. * the frequency of bowel movement in normal adult is from 3 times a day to twice a week. * Occasionally constipation becomes complete with the passage of neither feces nor gas this is called OBSTIPATION it occur in intestinal obstruction. * Large diarrheal stool suggest disorder of small bowel or proximal colon. Where as small frequent stool with urgency to defecate suggest disorder of left 2 NOT FOR COMMERCIAL USE OR SALE

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colon or rectum. * Large yellowish or gray, greasy foul smelling and some time frothy and floating stool suggest steatorrhea (fatty stool) associated with mal absorption. * Relief by moving the bowel or by passing gas suggest a disorder in left colon or rectum. TENNESMUS suggest the problem in the rectum or anal canal. * Conjugated type hyperbilirubinemia is cause by viral hepatitis ,cirrhosis ,biliary cirrhosis drug induced homeostasis like oral contraceptives ,methyl testosterone ,chlorpromazine. * ACHOLIC stool (stool with out bile) are common in viral hepatitis or obstructive jaundice. * Itching favors cholestatic or obstructive jaundice. * Kidney pain felt at or below the costal margin posteriorly near the costovertebral angle may radiate anteriorly to ward the umbilicus. * Kidney pain is produce by sudden distention of renal capsule is typically dull, aching and steady. Where as urethral pain is severe colicky pain that originate in costovertebral angle and radiate around the trunk into lower quadrant of abdomen and into upper thigh, testicle, or labium. * Urethral pain results from sudden distention of ureter and associated distention of renal pelvis. * Bladder pain may cause supra pubic pain and is dull in quality and steady often due to infection. * Sudden over distention of bladder often cause agonizing pain where as chronic bladder distention is usually pain less. * Prostetic pain fell in the perinium and occasionally in he rectum. * Uretheritis and cystitis cause painful urination. * In women internal burning cause by arthritis or cystitis. * Urinary frequency suggest infection and irritation of bladder. * In man pain on urination without frequency or urgency suggest uritheritis. * urinary frequency with polyurea (day or night) suggest either a disorder of urinary bladder or impairment to flow or below the bladder neck. * Hematuria may cause by cystitis, malignancy, stone, trauma, tuberclosis, or acute glomerulonephritis. * Drug that may color the urine are laxatives (phenolophthaline), metronidazole, phenazopyridine. * Urinary incontinence (involuntary loss of urine) may occur when detrusor contraction are too strong, or poor general health or medication or environmental (functional incontinence).urinary incontinence also occur when intrauterine pressure is low (stress incontinence)or may be due to out let obstruction (over flow incontinence) which cause enlargement of bladder due to vol over load. * Stress incontinence occur while cough sneeze or laugh. * Hesitation ,dribbling ,or difficulty in start urine is commonly due to partial obstruction like BPH or urethral stricture. --------------------------------------------------------------------------------* Normal menstrual discharge is dark red where as excessive flow tend to be bright red and may include clots (not true fibrin clot). * Amenorrhea refer to the absence of menstruation. * Primary amenorrhea is failure to initiate menstruation. * Secondary amenorrhea is cessation of menstruation after have establishing it .(pregnancy ,lactation & menopause are physiologic form of secondary type). * Oligomenorrhea is infrequent menstruation common in first 2 year after menarche or menopause. * Polymenorrhea is frequent menstruation. * Menorrhagia is increase amount and duration flow. * Metrorrhagia is intermenstrual bleeding. * Postcoital bleeding occur after intercourse or douching. * Secondary amenorrhea occur due to low body wt mal nutrition, anorexia nervosa, stress, chronic illness, hypothalamic pituitary ovarian dysfunction etc. * postcoital bleeding suggest cervical disease like polyps, cancer, or in older women atrophic vaginitis or endometrial cancer. * Dysmenorrhea is pain with menstruation & usually felt a bearing down aching or cramping sensation in lower abdomen & pelvis. * PMS is refer to several symptom in some women during day 4 to 10 before periods. It include tension, nervousness, irritability depression, mood swing ,wt gain, abdominal bloating, edema and tenderness of the breast, and headache. these symptoms in some may be severe and disabling. * Amenorrhea followed by heavy bleeding suggest a threaten abortion, or dysfunctional uterine bleeding related to the lack of ovulation. * Dyspareunia is pain on intercourse. vaginismus is involuntary spasm of muscle surrounding the vaginal orifice that make penetration painful or impossible. (vaginismus may physiological or psychological). ----------------------------------------------------------------------------------* In erection disorder man cant attain or maintain erection that is adequate to complete the sexual activity. causes are organic psychogenic ,medication ,endocrine ,vascular, or Neurogenic.(a firm erection in any circumstances specially early in the morning suggest erectile dysfunction is psychogenic). * Premature ejaculation is very common in young man. * Reduce or absent ejaculation is less common & effect middle aged or older man, may be due to medication, surgery, neurologic deficit, or lack of androgen. * Lack of orgasm with ejaculation is usually psychogenic. ----------------------------------------------------------------------------------3 NOT FOR COMMERCIAL USE OR SALE

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* Severe pallor of finger often followed by cyanosis and than redness indicate Reynaud,s dis or phenomenon. * Aching cramping and possible numbness and severe fatigue that appears with walking and disappear with rest indicates intermittent claudicating. * Stretching or tearing of ligament called sprain. * Pain in small joints are sharply localized than large joints. Pain in hip joint is specially deceptive felt in groin or buttock or some time in ant thigh or solely in knee . * Hip pain felt in or near greater trochanter of the femur suggest trochantric bursitis. * Pain in only one joint suggest bursitis ,tendonitis, or monoarticular arthritis. * Rheumatic fever early gonnococcal arthritis often have a migratory pattern of spread, where as rheumatoid arthritis typically shows progressive or additive pattern and is symmetrical. * Usually severe and rapidly developing pain in a swollen joint not explain by injury suggest acute gouty or septic arthritis.( in children specially consider osteomyelitis that involve bone contigous to a joint) * Pain in the joint with out with out objective evidence of arthritis such as swelling, tenderness, or warmth are called arthralgia. * Stiffness after inactivity is common in degenerative joint dis but usually last only a few minutes .this is some time called gelling. where as Stiffness in rheumatoid arthritis and other inflammatory arthritis often last 30 min or longer. * Stiffness also accompanies ,fibromyalgia $, and polymyalgia rheumatica. * Tenderness, warmth and redness in a joint suggest acute gout , septic arthritis ,or possible rheumatic fever. * IMP CLUES IN MUSCULOSKELETAL DISORDER: Butterfly rash on cheek----------SLE Scaly rash ,pitted nail ,psoriasis---------------psoriatic arthritis. Few papules ,pustules ,vesicles on reddened base located on distal extremity ----------------gonococcal arthritis. An expanding erythmatous patch early in the illness---------------------lyme,s dis. Hives-------------------serum sickness and drug reaction. Erosion or scales on penis and crusting scaling papules on sole and palm---------------Reiter,s $ (Reiters $ also include arthritis uretheritis and conjunctivitis) Maculopapular rash of rubella--------------------arthritis of rubella Clubbing of finger nail----------------------hypertrophy osteoarthropathy. Red blurring and itchy eyes with arthritis---------------------Reiters $. Preceding sore throat----------------------------acute rheumatic fever and gonococcal arthritis. Diarrhea and abdominal pain---------------------------------arthritis with ulcerative colitis or regional arthritis. Symptom of arthritis---------------------------------------Reiters $ or gonococcal arthritis. ---------------------------------------------------------------------------------* In young people how loss consciousness temporarily consider vasodepressor syncope, hyperventilation, and tonic clonic seizures. Voices heard when passing out and coming suggest more vasodepressor syncope or hyperventilation. * Cardiac syncope starts and stops suddenly common in older person. * DYSESTHESIAS are distorted sensation in response to stimulus and may last longer than the stimulus it self. For example a person may perceive a light touch or a pin prick as a unpleasant burning or tingling. ----------------------------------------------------------------------------------* In pt with atherosclerosis anemia may decrease the threshold for angina pectoris or intermittent claudicating. * Patient with severe anemia may have headache, dizziness ,vertigo, syncope ,anorexia ,nausea ,intolerance to cold, amenorrhea ,menorrhagia, loss of libido, impotency. * Petechiae in skin and mucous mem and small bruises are common in pletelet disorder where as large bruises ,deep hematoma, hemarthrosis are seen in cloting disorder. * Obesity, weakness, fatigue, easy bruising, ankle edema, decrease or absent menstruation, suggest Cushing,s $. where as weakness, wt loss, nausea, vomiting darken skin and symptom of postural hypotension suggest Addison dis (adrenal in sufficiency). -----------------------------------------------------------------------------------HEADACHES * TENSION HEADACHES are aching and non painful tightness and pressure associated with anxiety ,tension, depression some time last weeks or month. * MIGRAINE HEADACHE are throbbing or aching often associated with nausea, vomiting, flashs of light ,blind spot, sensory disturbance, relieve by dark quiet room some time last one to two days. * TOXIC VASCULAR HEADACHE shows variable severity provoke by fever ,CO, hypoxia ,withdrawal of caffeine. * CLUSTER HEADACHE one sided study ache high in the nose and behind and over the eye abrupt onset often 2 to 3 hours. associated symptoms are unilateral stuffy runny nose and reddening and teasing of eye. * HEADACHE WITH EYE DISORDER are ache around and over the eye may radiate to the occipital. Causes are far sightedness, and astigmatism but not near sightedness. Pain relieve by resting other eye associated symptoms are sandy sensations in the eye and redness of conjunctiva. 4 NOT FOR COMMERCIAL USE OR SALE

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* TRIGEMINAL NEURALGIA is sharp short brief lightening like recurrent severe pain may disappear for months. Pain typically occur over the distribution of the 3rd division of trigeminal nerve 5. * GIANT CELL ARTERITIS is chronic inflammation of cranial arteries often temporal and occipital arteries shows throbbing or burning often recurrent severe pain may persist weeks months associated symptoms are tenderness of scalp, fever, malaise, fatigue, muscular ache or stiffness and visual loss or blindness . * CHRONIC SUBDURAL HEMATOMA shows steady ache of gradual onset weeks to month, often injury progressively severe but may be obscured by clouded consciousness. Associated symptoms are personality change, hemiparesis, injury is often forgotten. * POST CONCUSSION $ shows rapid onset of steady or severe pain (throbbing) tend to diminish over months or years. Associated symptoms are poor concentration, giddiness (dizziness), vertigo, restlessness, tenseness, and fatigue. * SUBARACHENOID HEMORRHAGE cause abrupt onset of severe generalized pain worst of my life .associated symptoms nausea, vomiting, possible loss of consciousness, neck pain. * BRAIN TUMOR cause aching steady pain often brief, intermittent but progressive over time .associated symptoms are neurologic deficit, mental symptoms, nausea and vomiting may develop .aggravated by coughing sneezing or sudden movement of head. -----------------------------------------------------------------------------------VERTIGOS * BENIGN POSITIONAL VERTIGO is sudden onset of vertigo with brief duration may persist for weeks. tinnitus is absent some time cause nausea and vomiting (hearing is not effected). * VESTIBULAR NEURONITIS (acute labyrinthinitis) cause sudden onset of vertigos may durate hours to days, may recur. tinnitus is absent also shows nausea and vomiting.(hearing is not effected). * MENIERE,S DIS cause sudden onset of vertigo last several hours to days may recur, shows sensorineuronal loss of hearing that improves and recur eventually progress to one or both sides. Tinnitus, nausea, vomiting, and fullness of effected side are associated symptoms. * DRUG TOXICITY (amino glycoside, alcohol intoxication) shows acute onset of vertigo with hearing impairment of one side, tinnitus present . Associated symptoms are related to pressure on CN5 ,CN6, CN7. * Atherosclerosis ,tumor ,multiple sclerosis, ischemia may also cause vertigo. -----------------------------------------------------------------------------------* Pericarditis and pleural pain presents sharp knife like severe pain aggravated by breathing and changing position. It can be differentiate by; that pericarditis relieves by sitting where as pleural pain relieves by lying on the involved side. -----------------------------------------------------------------------------------* Dyspepsia shows symptoms similar to peptic ulcer disease but has no ulceration ,common in young age 20-29 yrs. * Duodenal ulcer may wake pt at night ,common in age 30-60 yrs ,it may recur. * Gastric ulcer is common in older age. * In peptic ulcer disease or dyspepsia pain occur at epigastria region and may radiate to back. * Pain in cancer of stomach is at epigastric region and do not radiate, common in age 50-70. * Acute pancreatitis cause pain in epigastria region and may radiate to back pain aggravate by lying supine and relieve by leaning forward with trunk flexed. .where as chronic pancreatitis cause fibrosis of pancrease with epigastria pain radiating through the back, pain is typically steady and deep. Pancreatic cancer cause same symptoms. Remember only chronic pancreatitis shows diarrhea with fatty stool (steatorrhea) and DM. * Biliary colic is sudden obstruction of cystic duct or common bile duct by gall stone produce steady aching not colicky of rapid onset and usually subside in few hours. * Acute cholecystitis cause pain with gradual onset longer than pain in biliary colic and aggravate by jarring and deep breathing. * Acute diverticulitis pain is of gradual onset first crampy than steady ,cause initial brief diarrhea than constipation. * Acute mechanical intestinal obstruction commonly cause by adhesion or hernia, cancer, diverticulitis the pain is typically crampy. * Small bowel obstruction cause per umbilical pain, vomiting and constipation, V/S where as large bowel obstruction cause lower abdominal or generalized pain constipation (obstipation) first than vomiting. * Acute arterial occlusion produce crampy pain first periumbilically than steady and diffuse cause vomiting, bloody diarrhea, constipation than shock. * Melena (black tary shiny stool) cause by peptic ulcer, gastritis, or stress ulcer, esophageal or gastric varices, reflex esophagi is, Mallory weiss tear. * Black non sticky stool may cause by ingestion of iron, Pepto-Bismol, licorice, and even chocolate cookie. * Irritable bowel $ may cause small hard often with mucous stool, with period of diarrhea, abdominal cramping, stress aggravate it. where as constipation cause by cancer of rectum and sigmoid colon. Rectal cancer cause tennesmus abdominal pain bleeding and pencil shape stool. * Fecal impaction is large firm immovable mass most often in rectum common in children. * Diverticulitis, volvulus, intusseseption, and hernia may cause colicky abdominal pain, abdominal distention, and in intusseseption often current jelly stool(red blood +mucous). * Red blood in stool may cause by cancer of colon, polyps, diverticulas of colon , ulcerative colitis, infectious dysenteries, anal intercourse, ischemic colitis, hemorrhoids and anal fissure. -------------------------------------------------------------------------------------5 NOT FOR COMMERCIAL USE OR SALE

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* Acute non inflammatory infectious diarrheas watery caused by viruses ,toxin produce by E. coli ,staph aureus and giardia lamblia cause cramping. * Acute inflammatory infectious diarrhea cause by invasion of organism in intestinal mucosa produce loose to watery diarrhea often with pus blood and mucous. Rectal urgency, cramping, tennesmus may occur. * Chronic diarrhea:- Irritable bowel $ cause diarrhea which rarely wake the pt in night where as in ulcerative colitis and chrone dis diarrhea wake the pt in night .it also cause crampy pain, fever, anorexia, wt loss. -------------------------------------------------------------------------------------* Thirst is not present in polyurea if cause by excessive water in take. nocturia is usually absent in these cases. * Burning on urination, urgency, some time gross hematuria is because of bladder inflamation (due to infection, tumor, stone, forign body etc ) . it shows frequency with out polyurea. * Frequency with out polyurea may also cause by BPH, motor disorder of CNS like in stroke, urtheral stricture, peripheral neuropathy as in DM. it cause hesitancy in starting the urinary stream ,dribbling during or in the end of urination. * Nocturia with high vol may cause by CRF, bed time alcohol or coffee. * Stress incontinence :- in which urethral sphincter is weak (momentary leakage of small amount of urine occur with stress like coughing ,laughing ,sneezing when in upright position).on physical examination bladder is not detected, atrophic vaginitis may be evident desire of urination is not associated with pure stress incontinence. Common in women due to child birth and surgery, post menopausal atrophy of mucosa, or urethral infection. In man stress incontinence may follow prostate surgery. * Urge incontinence :- In which Detrusor contraction are stronger than normal and over come normal urethral resistance. The bladder is typically small and cant be detectable on physical exam. ( it is basically due to decrease inhibition from cerebral cortex to detrusor contraction, common in strokes, brain tumor, dementia and lesion in spinal cord above sacral level. It may cause by hyperexcitability of sensory pathway due to infection tumor fecal impaction. Another possible mechanism is reconditioning of voiding reflex due to frequent voiding at low bladder vol, ( pseudo stress incontinence ). * Overflow incontinence :- In which detrusor contraction are insufficient to over come urethral resistance. The bladder is typically large and tender on palpation even after the effort to void. It may due to obstruction of bladder out let as in BPH and tumor, nerve weakness at the level of sacral region, impaired bladder sensation that interrupt the reflex as in Diabetic neuropathy, also shows dribbling and decrease force of urinary stream. * Functional incontinence :- this is functional inability to get the toilet in time due to impaired health or environmental conditions. eg, arthritis, weakness, poor vision, unfamiliar setting (look for physical or environmental clue ). * Incontinence secondary to medication :- tranquilizers, anticholinergic, sympathetic blocker, and potent diuretics. * POLYURIA :* Decrease of ADH (diabetes insipidus), Nephrogenic diabetes insipidus (renal unresponsiveness to ADH) ,hypercalcemia, hypokalemic nephropathy, renal dis or drug like lithium results into polyurea, thirst, severe polydipsia, nocturia. * Nocturia with high vol cause by excessive fluid intake, before bed time coffee, alcohol, chronic renal insufficiency, CHF, nephrotic $, hepatic cirrhosis with ascitis ,chronic venous insufficiency, and causes of polyurea. * Nocturia with low vol may result from insomnia, pseudofrequency ( voiding with out real urge),and other causes of frequency with out polyurea. * FREQUENCY WITH OUT POLYUREA : * bladder sensitivity to stretch cause by inflammation due to infection, stone, tumor results into burning on urination frequent urgency with out polyurea and some time gross hematuria. * elasticity of bladder due scar or tumor also results into burning on urination, frrequent urgency with out polyurea and some time hematuria. * Motor disorder of CNS like stroke cause decrease cortical inhibition of bladder contraction cause frequent urgency with out polyurea. * Impaired emptying of bladder with residual urine in bladder due to obstruction, BPH, urethral stricture, results into hesitancy in starting the urinary stream, straining to void, reduced size and force of stream, dribbling during and at the end of urination, and frequent urine with out polyurea. It also cause by loss of nerve supply to bladder due to accident or DM. -----------------------------------------------------------------------------------* ARTERIAL DISORDER : * Pain occur in arteriosclerosis is fairly brief ,pain aggravate by work and relieve by rest in 1-3 min. pain usually occur in calf but may also felt in buttock, hip, thigh, and foot; depending on level of obstruction of large and middle size arteries. * Persistent pain at rest which worst at night and aggravate by elevation of feet (as in bed) is due to ischemia. Sitting with leg dependent may provide relief. * Acute arterial occlusion due to embolism and thrombosis possibly superimposed on atherosclerosis cause distal pain of sudden on set involving the foot and leg may associated with absent distal pulses . * VENOUS DISORDER : * Clot formation and acute inflammation of superficial vein cause superficial thrombophlebitis which produce pain locally along the course of involved vein, which last day or longer. It is associated with local redness, swelling, tenderness, palpable cord and possible fever. * Clot formation of deep venous vein cause deep venous thrombosis if pain present is usually in calf but process is most often painless and hard to determine. 6 NOT FOR COMMERCIAL USE OR SALE

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* Chronic venous engorgement secondary to occlusion or incompetency of venous valve may result into diffuse aching of leg; pain aggravated by prolong standing and relieve by elevation of leg .It may shows chronic edema, pigmentation ,possibly ulceration. -----------------------------------------------------------------------------------* Acute lymphangitis cause by acute bacterial infection usually streptococcus results into red streak on the skin with enlarge tender lymph node and fever. * Thromboangitis oblitrans (buerger,s dis) is inflammatory thrombotic occlusion of small arteries and vein in smokers result into intermittent claudication of the arch of foot (finger and toe) pain is fairly brief but recurrent may be worst at night, excersize aggravate it and rest gives relief. Associated symptoms are distal coldness, sweating, numbness, cyanosis, ulceration and gangrene at the tip of finger. * Raynaud,s dis cause pain which is relatively brief but recurrent in one or more finger some time ulcer develop. Numbness tingling are common, exposure to cold aggravate it and warm environment gives relief. * Acute cellulites and erythma nodosum mimic venous disorder (mistaken primarily for acute superficial thrombophlebitis). * Acute cellulites is bacterial infection of skin and subcutaneous tissue result into diffuse swelling, redness and tenderness with enlarge lymph node and fever. There is no palpable cord, do not mistaken with superficial thrombophlebitis. * Erythma nodosum a subcutaneous inflammatory lesion associated with variety of condition like pregnancy, acidosis, TB, streptococcal infection. Usually occur at ant surface of both lower legs manifest as raised red, tender, swelling with crops; with often malaise, joint pain, and fever. Do not mistaken with superficial thrombophebitis. -------------------------------------------------------------------------------------* Rheumatoid Arthritis : - Chronic inflammation of synovial mem with secondary erosion of adjacent tissue (cartilage and bone) and damage to ligament and tendon. It progress to other joint symmetrically. Associated symptoms are swelling, tenderness, warm but seldom red. Stiffness is prominent after a period of inactivity, limited motion, weakness, fatigue, wt loss and low fever are common. * Osteoartheritis is insidious onset of degenerative bone and cartilage dis. It progress to other joint but only one joint may be involve. Little swelling may be present it is seldom warm and red. Tenderness present with stiffness in morning & after inactivity may results into limited motion. * Acute gout is an inflammatory reaction to micro crystal of sodium urate commonly occur with first metatarsophalangeal joint (base of big toe) rarely occur in other joints. It produce pain of sudden onset often at night after injury, surgery ,fasting, excessive food, alcohol intake. typically the joint is tender hot and red. motion is limited due to pain, fever may be present. * Chronic tophaceous gout is accumulation of sodium urate in multiple joint and other tissue (tophi) with or without inflammation. Swelling present in joints, bursae, and subcutaneous tissue. Tenderness, warm, and redness may present with stiffness and limited motion. Pt may develop a symptom of renal failure, renal stone, and fever. * Polymyalgia Rheumatica is dis of unclear nature seen in people in more than 50 yrs of age specially women may be associated with giant cell arthritis. Pain occur in muscle of hip girdle and shoulder girdle symmetrically. Pain may be insidious or abrupt even appearing over night. Shows no swelling warm or redness, but may be tender specially in morning. limitation of motion is usually none may shows malaise, sense of depression, anorexia, and wt loss. * Fibromyalgia $ is a wide spread musculoskeletal pain may accompany other dis (mechanism unknown). Pain shift unpredictably in response to immobility, excessive move, or chilling. Pain is chronic with ups and downs without swelling, redness and warm; symmetric tenderness not recognized until examination. Stiffness present specially in morning there is no limitation of motion. ---------------------------------------------------------------------------------* Common lower back pain is often relieve by rest, common in teenage yrs to 40. Intervertibral disc is involve in many cases. Show percussion tenderness over spinous process. * SCIATICA :- is redicular nerve root pain radiate down to one or both leg usually below the knee with numbness, tingling, and pain worsen by spinal movement (like bending, coughing, sneezing, leg raising).loss of sensation in dermotomal distribution, decrease to absent reflexes specially affecting the ankle jerk. Dermotomal sign and reflexes may be absent when one root is involved. usual causes are herniated intervertebral disc with contraction and traction of nerve root, spinal tumor, abscess. * BACK PAIN OR SCIATICA WITH PSUEDOCLAUDICATION :- psuedoclaudication is a pain in the back or leg that worsen with walking and improve with flexing of spine or bending forward, causes include lumber stenosis which is combination of degenerative disc dis and osteoarthritis which narrow the spinal canal. common after age 60 (imp sign flexed posture). * CHRONIC PERSISTENT LOW BACK STIFFNESS :- may cause by ankylosing spondilitis, chronic inflammatory poly arthritis common in young man. Where as diffuse idiopathic skeletal hyperostosis which effect middle age and older man. it manifest by loss of normal lumbar lordosis, muscle spasm, limitation of ant and lateral flexion and immobility of spine of middle and older age man. * Aching nocturnal back pain unrelieved by rest usually case by metastatic malignancy from prostate , kidney, lung, breast, thyroid and multiple myeloma. Local bone tender may be present. * Back pain referred from abdomen and pelvis is usually deep and aching, spinal movement is not painful, range of motion is not effected, common causes are peptic ulcer, pancreatitis, pancreatic cancer, chronic prostitis, endometriosis, dissecting aortic aneurysm, retroperitoneal tumor. -----------------------------------------------------------------------------------* Simple stiffness is acute episodic localize pain in the neck often appearing on awakening and last 1 - 4 day . * Persistence dull aching in the back of the neck often spreading to occiput; common with postural strain, prolong typing, studying may also accompanying tension and depression when pain and tenderness are also present else where in the body consider fibromyalgia $. 7 NOT FOR COMMERCIAL USE OR SALE

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* CERVICAL SPRAIN :- acute and often recurrent neck pain that are often more severe and last longer than simple stiff neck may precipitate by whip lash injury, heavy lifting or sudden movement. There is no dermotomal radiation. * NECK PAIN WITH DERMOTOMAL RADIATION :- Is the neck pain as in cervical sprain but also radiate to dermotomal distribution(in arms, shoulder and back).the pain is typically sharp, burning and tingling in quality. Muscle spasm and tenderness with limited range of motion present. Pain increases with coughing, sneezing, and possible sensory loss with muscular atrophy. Causes include compression of one or more nerve due to herniated cervical disc or degenerative bone dis, Bony spurring, tumor or abscess. * NECK PAIN WITH COMPRESSION OF CERVICAL SPINAL CORD :- In this neck pain present with associated symptoms of paralysis of leg, loss of sensation and position, vibration in leg, less commonly loss of temp and pain in leg, bibinski response +, the neck pain may be mild or even absent, possible causes are spinal cord compression due to herniated cervical disc, degenerative dis, bony spurring, trauma, abscess or tumor. -------------------------------------------------------------------------------------SYNCOPE AND SIMILAR DISORDER * VASO DEPRESSOR SYNCOPE (common faint) :- Is a sudden peripheral vasodialation specifically in skeletal muscle with out compensatory rise in cardiac out put (BP falls). Causes are fatigue, hunger, hot humid environment which further precipitate by fear and pain. It manifest by restlessness, weakness, pallor, nausea, salivation, sweating, yawning. Always prompt return of consciousness occur when lying down. * POSTURAL (ORTHOSTATIC) HYPOTENSION :- Syncope due to inadequate vasoconstriction reflex in both arteriole and veins with resultant venous pooling, cardiac out put and decrease BP. Predisposing factors are peripheral neuropathies, or disorder of autonomic nervous sys, antihypertensive and vaso dialators, prolong bed rest. Prompt return to consciousness when person lying down.. * Postural (orthostatic hypotension may be cause by hypovolemia due to variety of situation eg, GI bleeding, diarrhea, vomiting, polyurea, dehydration, etc. it manifest by light headedness palpitation on standing. It improves on lying down. * COUGH SYNCOPE :- occur due to intrathorasic pressure due to severe paroxysm of coughing specially if person s muscular but prompt return to normal is usual. * MICTURITION SYNCOPE :- occur usually in elder or adult man with nocturia precipitate by emptying the bladder after getting out of bed to void (mech is unclear). Prompt return to normal is usual. * ARRHYTHMIAS :- too low < 35 - 40 B/min . or too fast > 180 B/min results into decrease cardiac out put. Prompt return to normal often occur. causes are organic heart problem, older age decreases the tolerance of abnormal rhythm. * Aortic stenosis and hypertrophic cardiomyopathy when cause syncope is because vascular resistance falls but cardiac out put fail to rise. Onset is sudden which usually ends up with prompt return to normal. * Myocardial infarction can cause syncope with sudden arrhythmias or cardiac out put . * massive pulmonary embolism cause syncope due to hypoxia or cardiac out put .predisposing factors are deep venous thrombosis. DISORDER RESEMBLING SYNCOPE * Hypocapnia due to hyperventilation cause constriction of cerebral blood vesels .predisposing factor are anxiety, dyspnea, palpitation, numbness, tingling, chest discomfort, recovery is slow after hyperventilation ceases. * Hypoglycemia disturbs cerebral metabolism with resultant epinephrine release and manifest by sweating, tremor, palpitation, hunger, headache, confusion, abnormal behavior, coma (true syncope is uncommon). Predisposing factors are metabolic disorder, insulin therapy, fasting. * Hysteria fainting due to conversion disorder (mechanism is symbolic expression of an unexceptable idea through body language under stress full situation). It manifest as a slump to floor recovery may be prolong . SIEZURES ** PARTIAL SEIZURES starts with focal manifestation indicate a structural lesion in cerebral cortex. A. Simple partial seizures with motor symptom :*Jacksonian seizures are tonic than clonic that start unilaterally in foot hand and face than spread to the other part of body on the same side but maintain normal consciousness. Where as other motor seizures cause turning of head and eye to one side or tonic and clonic movement of one arm or leg with out jacksonian spread but maintain normal consciousness. B. Simple partial seizures with sensory symptoms :- Manifest as numbness tingling, simple visual, auditory and olfactory hallucination such as flash light, buzzing or odor. Consciousness is normal. C. Simple partial seizures with autonomic symptoms :- Manifest as funny feeling in the epigastrium cause nausea, pallor, flushing, light headedness but normal consciousness. D. Simple partial seizures with psychic symptoms :- Manifest as anxiety or fear, feeling of dj vu or unreality, dreamy state, fear or rage, flash back experiences, more complex hallucination. Consciousness is normal. 8 NOT FOR COMMERCIAL USE OR SALE

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** COMPLEX PARTIAL SEIZURES with simple partial seizures or with impaired consciousness. Automatism may develop. The seizures may or may not start with autonomic or psychic symptoms rather with impaired consciousness and person may appear confused. Pt may remember initial automatic or psychic symptoms but is Amnesic for rest of the seizures. Temporary confusion and headache mat appear.(Automatism include automatic motor behavior like chewing, smacking lips, walking about, unbuttoning cloths, or skilled behavior such as driving a car). ** PARTIAL SEIZURES THAT BECOME GENERALIZED :- It resembles clonic seizures (grand mal). Pt may not recall focal onset. 2. symptoms indicate a partial seizures that has become generalized that is recollection of an Aura and unilateral neurologic deficit during post tictal period. ** GENERALIZED SEIZURES :- it begins with bilateral body movement or impaired consciousness or both suggest bilateral cortical disturbance either hereditary or acquired. Tonic clonic (grand mal) usually starts in childhood or young adulthood. They are often hereditary but when starts after 30 yrs often toxic or metabolic in origin. A. Tonic clonic seizures (grand mal) :- in which person losses consciousness suddenly and body stiffen into tonic extensor rigidity, breathing stops and person becomes cyanotic. Than a clonic phase of rhythmic muscular contractions follows, breathing resume and is often noisy due to excessive salivation. Tongue biting and urine incontinence may occur. After post tictal state (post seizure) confusion, drowsiness, fatigue, muscular aching and some time persistent but temporarily bilateral neurologic deficit such as hyperactive reflexes, bibinski response. The has amnesic during seizures and recall no Aura. B. Absence seizures :- A sudden breif lapse of consciousness with momentary blinking, staring, movement of lip and hands but no falling. Two types are recognized 1. Petit mal absence :---- last < 10 sec and stops abruptly, no aura recall . 2. Atypical absence :---- last > 10 sec post tictal cofusion occur. C. Atonic seizures or drop attack :- sudden loss of consciousness but no movement occur. Either prompt return to normal or brief period of confusion occur. D. Myoclonus :- sudden brief rapid jerks involving the trunk or limb associated with variety of disorder. ** PSEUDOSEIZURES :- these may mimic seizures but are due to conversion reaction (psychologic disorder). The movement may have personally symbolic significance and often dont follow neuroanatomic pattern often variable post tictal state. -------------------------------------------------------------------------------* Lethargic pts are drowsy but open there eye and look at you respond to question and than falls a sleep. Where as obtunded pts open there eye looked at you but respond slowly and are some what confused. * Tense posture, restlessness, and fatigue suggest anxiety. * Crying, pacing, hand wringing, occur in agitated depression. * Hopeless, slump posture, and slowed movement, occur in depression. * Singing, dancing, and expensive movement occur in manic episode. * Grooming and personal hygiene may deteriorate in depression, dementia, and schizophrenia. * Excessive fastidiousness (overly difficult to please) seen in obsessive compulsive disorder. * One sided neglect occur from lesion of opposite prietal lobe cortex (usually non dominant side). * Anger, hostility, suspiciousness, or evasiveness occur in paranoid pt. * Elation (fill with joy) and Euphoria (marked feeling of well being) occur in manic $. * Flat effect and remoteness occur in schizophrenia. * Apathy (lack of emotion with detachment and indifference) occur in dementia, depression, and anxiety.. -----------------------------------------------------------------------------* Dysarthia refer to defective articulation (like bar with dar and pen with den). ** TESTING FOR APHASIA :- (disorder of language) * Word comprehension :- ask pt one stage command (point to your nose), or two stage command (point your mouth than your knee). * Repetition :- ask pt to repeat a phrase of one syllabus word (no, if, and, but). * Naming :- ask the pt names, like parts of watch. * Reading :- ask pt to read loud. * Writing :- ask pt to write a sentence (a person who can write correct sentence does not have aphasia.). -------------------------------------------------------------------------------VARIATION & ABNORMALITY IN THOUGHT PROCESS * Cercumstantiality :- speech characterize by indirection and delay in reaching the point because of unnecessary detail. Observe in obsessional person. (many people speak circumstantially with out mental disorder). * Derailment (loosing of association) :- speech in which person shift from one subject to another that are unrelated or obliquely related without realizing that subject are not meaningfully connected. Observed in schizophrenics, manic episode and other psychiatric disorder. * Flight of ideas :- an almost continuous flow of accelerated speech in which person changes abruptly from topic to topic and idea do not progress to sensible conversation, But speech changes are usually understandable association. found in mania. * Neologism :- Invented and distorted word with new and highly idiosyncratic meanings observed in schizophrenia, psychotic disorder and aphasia. * Incoherence :- speech that is largely incomprehensible because of lack of meaningful connection. Shift of meaning occur with in clauses. It observed into 9 NOT FOR COMMERCIAL USE OR SALE

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severely disturbed psychotic person usually schizophrenic. * Blocking :- sudden interruption of speech In mid sentence or before completion of an idea, it may occur in normal people phenomenon may be striking in schizophrenics. * Confabulation :- fabrication of facts or events in response to question, to fill in the gap in an impaired memory. Common in amnesia. * Perseveration :- persistent repetition of words and ideas. Occur in schizophrenic and other psychotic disorders. * Echolalia :- repetition of the word and phrases of others ,occur in manic episode and schizophrenia. * Clanging :- speech in which person chooses a word on the basis of sound rather than meaning , eg my beautiful eye in your tie. Occur In schizophrenia and manic episode. ------------------------------------------------------------------------------* Thought process asses the logic, relevance organization, and coherence by word and speech. * Thought content can provide more information about the pts idea or thought by asking question like ,what do you think about it in time difficult like that ? Or what do thing suppose to be done in that situation?. Etc. ** ABNORMALITIES OF THOUGHT CONTENT : * compulsion :- repetitive behavior or mental act that a person feel driven to perform in order to produce or perform some future affair. Although expectation of such an effect is unrealistic. Compulsion often associated with neurotic disorder. * obsession :- recurrent uncontrollable thoughts, images, or impulses that a person consider unacceptable and alien. Obsession often associated with neurotic disorder. * phobias :- persistent irrigational fear accompanied by compelling desire to avoid the stimulus. Phobias are often associated with neurotic disorder. * anxiety :- apprehension, tension, fear, or uneasiness that may be focused (phobia) or free floating (a general sense of ill defined dread or impending doom). Anxiety often associated with neurotic disorder. ------ vs. ----* feeling of unreality :- a sense that thing in the environment are strange, or unreal. Feeling of unreality is often associated with psychotic disorder. * feeling of depersonalization :- a sense that one self is different, changed , unreal, or has lost identity or become detached from ones mind or body. Feeling of depersonalization is often associated with psychotic disorder. * delusion :- false, fixed, personal belief that are not shared by others; delusion is often associated with psychotic disorder. - delusion of persecution - grandiose delusion - delusion of jealousy - delusion of reference :-person belief that external events, objects, or people have particular unusual personal significance .eg . Television might be commenting or giving instruction to a person. - delusion of being controlled by out side forces. - somatic delusion :- delusion of having a dis, disorder, physical defect. - systematized delusion :- cluster of delusion around single theme. -------------------------------------------------------------------------------* Perception :- can be inquired by asking for eg when you heard those voices what did it says ? Or how did it make you feel ? ** ABNORMALITIES OF PERCEPTION :*illusion :- misinterpretation of real external stimuli. It may occur in grief reaction, delirium, acute and post traumatic stress disorder, and schizophrenia. * hallucination :- subjective sensory perception in the absence of relevant external stimuli. The person may or may not recognized the experiences as false. hallucination may be auditory, visual, olfactory, gustatory, tactile or somatic ( false perception associated with dreaming, falling a sleep, and on awakening are not classified as hallucination). Hallucination may occur in delirium, dementia (less commonly), post traumatic stress disorder, and schizopherenia. -------------------------------------------------------------------------------* Insight :- is whether a pt is aware about his illness. Pt with psychotic disorder often lack insight into there illness. Denial of impairment may accompany some neurologic disorder. Always ask question like what bring u to the hospital ? What do u think is wrong to explain your illness or problem? * Judgment :- assess pts response to family situation, job, use of money, interpersonal conflict. It can be assess by asking pt that how you will manage if you loss your job? Or what will you do if your class neighbor will threat you? Judgment may be poor in delirium, dementia, mental retardation, psychotic state. judgment can also be effected by anxiety, mood disorder, intelligence, education, socioeconomic state, and cultural values. ---------------------------------------------------------------------------------** COGNETIVE FUNCTION :* orientation :- can be determined by asking time, place, person. disorientation occur when memory or attention is impaired. as in delirium. * attention :- test the pt ability to concentrate by adding, subtracting, spelling back ward, zip code, tel #, repeat number backward (person should be able to repeat at least 5 digit forward and 4 backward normally). Attention is poor in delirium, dementia, mental retardation, depression, anxiety and education. 10 NOT FOR COMMERCIAL USE OR SALE

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* remote memory :- inquire about birthday. Anniversaries, social security, name of school attended, job, best friends name. remote memory impairment occur in late stage of dementia. * recent memory :- is events of the day. Ask question about it and note if he is confabulating. Recent memory is impaired in dementia, delirium, amnestic disorder, anxiety, depression, and mental disorder. * new learning ability :- give the pt 3 or 4 word and ask pt to repeat; than after three or five min ask pt to repeat the those words again. Normally person remember if not suffering from amnestic disorder. -----------------------------------------------------------------------------** HIGHER COGNETIVE FUNCTION :* information and vocabulary :- gives rough estimate but is fairly good indicator of persons intelligence. You can ask about name of president, governor, last 4 - 5 president large cities or countries, etc. information and vocabulary are usually effected in severely psychiatric disorder, and mental retardation. Where as in mild to moderate dementia information and vocabulary is fairly well preserved. * calculating ability :- eg 9 x 4 = ? .poor performance is may be the sign of dementia, aphasia, education. Ask simple other calculations like charging 55 cents out of dollar how much you give back ? * abstract thinking :- can be testing by two ways. - proverbs :- ask pt what people means when says eye for an eye or squeaking wheel gets the grease or early to bed early to rise etc where as average pt should give abstract or semi abstract reason. (eye for an eye is concrete where as justice is an abstract reason). - similarities :- ask pt about the similarities of things like how following are alike, pencil and a pen, helicopter and a plan, child and a dwarf etc. helicopter and plane both fly is abstract but they both have tail is concrete. * Concrete response is given by person with mental retardation, delirium, dementia, or a little education. Schizophrenics may respond concretely or with personal irrelevant or nonsense interpretation. * constructional abilities :- can assess like copying figure like circle, triangle, rectangle, square, clock. If vision and motor ability is intact, poor construction ability suggest dementia or parietal lobe damage. * mini mental state examination ( MMSE ) :-score < 24 increases the likelihood of dementia. (out of max score of 30, 24 - 30 consider normal). --------------------------------------------------------------------------** MOOD DISORDER :* major depressive episode :- in which depressed mood (irritable mood in children and adolescent), markedly diminish interest or pleasure are always present. Beside that pt may shows significant wt gain or loss, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue loss of energy, feeling of worthlessness or guilt, inability to concentrate, indecisiveness, recurrent thought of death or suicide ( or specific plan to attempt suicide ). In severe cases hallucination and delusion may occur. Major depressive episode usually last 2 weeks. * manic episode :- in which distinct period of abnormally and persistently elevated, expensive, or irritable mood occur. During episode 3 of the following symptoms must present and persist at least for a week, inflated self esteem or grandiosity, decrease need for sleep, more talkative than usual, flight of ideas racing thoughts, distractibility, increase goal directed activity, or psychomotor agitation, excessive involvement in pleasurable high risk activity. In sever cases hallucination and delusion may occur. * mixed episode :- last one week meet criteria for both manic and depressive episodes. * hypomanic episode :- symptoms resemble those in manic episode but less impaired last less than a week. * dysthymic disorder :- is depressed mood and symptoms over at least 2 yrs (1 yr in children and adolescent). Freedom from the symptoms last not > 2 mo. * cyclothymic disorder :- is a numerous period of hypomanic and depress symptom that last for at least 2 yrs (1 yr in children and adolescent). Symptom free period is no more than 2 month at a time. ----------------------------------------------------------------------------** ANXIETY DISORDER :- cause great distress and impaired function, affected one are not psychotic. * panic disorder :- defined by recurrent, unexpected panic attack, period of intense fear or discomfort which develop abruptly and peak with in 10 min .panic attack include at least 4 of the symptoms, palpitation, sweating, trembling, shortness of breath or sense of smothering, feeling of chocking, chest pain or discomfort, nausea abdominal distress, dizziness fainting, feeling of unreality or depersonalization, fear of going crazy, fear of dying, paresthesia, chill or hot flashes. * agoraphobia :- is anxiety about being in place or situation where escape may be difficult or help for sudden symptom may unavailable. Such situation are avoided or requires companion. * specific phobia :- marked persistent fear of specific object, situation, eg dogs, injection. Specific phobia impaired the persons normal routine. * social phobia :- marked persistent fear one or more social or performance situation that involve exposure to unfamiliar people or scrutiny by others. Exposure create anxiety or possible panic attack and person avoid precipitating situation. Social phobia impair normal routine and relation ship. * obsessive compulsive disorder (OCD) :- involve obsession or compulsion that cause marked anxiety or distress. Pt recognize it as excessive and 11 NOT FOR COMMERCIAL USE OR SALE

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unreasonable. OCD may interfere with persons normal routine and relation ship. * acute stress disorder :- the traumatic event that threatened death or serious injury to one self or to other with resultant response of intense fear, helplessness or horror. During or immediately after this event person has at least 3 of the following symptoms. Numbness, detachment, absence of emotional responsiveness, reduce awareness of surrounding as in daze, feeling of unreality, feeling of depersonalization, amnesia for an event (imp part). The event is persistently reappeared. Person tries to avoid situation that provoke the memories of event. Symptoms occur with in 4 weeks of event and last 2 days to 4 weeks. * posttraumatic stress disorder :- is traumatic event and fearful response and persistent experiencing of traumatic event as resembles acute stress disorder. Hallucination may occur, person tries to avoid stimuli that may provoke response. The disturbance cause marked distress, impair social and occupational functions. PTSD last more than month. * generalized anxiety disorder :- excessive anxiety and worry which person find hard to control with at least 3 of the following symptoms; feeling restless, fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, insomnia or unsatisfied sleep. Generalized anxiety disorder impair social, occupational, and other imp functions. -----------------------------------------------------------------------------------* negative symptoms are flat affect, alogia (lack of content in speech), avolition (lack of interest, drive and ability to set and pursue goal), contiguous sign of disturbance must persist for at least 6 months. ** PSYCHOTIC DISORDER :- psychotic disorder impair reality testing. * schizophrenia :- schizophrenia impairs major functioning at school, work, or in interpersonal relationship or self care. The person must manifest 2 of the following for a significant part of one month; these are delusion, hallucination, disorganized speech, disorganized catatonic behavior (psychomotor abnormalities like stupor, mutism, purposeless activity, bizarre posture, excited ), and negative symptoms. * schizophreniform disorder :- has symptoms similar to schizophrenia but they last less than 6 months. Functional impairment may not be present unlike schizophrenia. * schizoaffective disorder :- has a symptoms of both major mood disturbance and schizophrenia. The mood disturbance (depressed manic or mixed) is present during most of the illness and most of the time being concurrent with schizophrenic symptoms. During same period of time there must be delusion or hallucination for at least 2 weeks with out prominent mood symptom. * delusional disorder :- characterized by non bizarre delusion that involve situation In real life such as having a disease or being deceived by lover. Delusion persist for at least a month, person functioning is not markedly impaired and behavior is not odd or bizarre. Symptom of schizophrenia is not present except tactile and olfactory hallucination. * brief psychotic disorder :- in which one of the following psychotic symptom must be present; these are delusion, hallucination, disordered speech, frequent derailment or incoherence, grossly disorganized or catatonic behavior (psychomotor abnormality). The disturbance last at least one day but less than one month and person return to its prior function level. * psychotic disorder due to medical condition :- prominent hallucination and delusion may be experienced during medical illness. ( for this Dx should not occur exclusively during the course of delirium) * subs induced psychotic disorder :-prominent hallucination or delusion may be induced by intoxication or withdrawal from subs such as alcohol, cocaine, opioids etc. (for this Dx should not occur exclusively during the course of delirium) ---------------------------------------------------------------------------------* DELIRIUM AND DEMENTIA :*delirium :- is characterize by decrease level of consciousness, behavior decreased (somnolence) or increased (agitated or hypervigilence), hesitancy or rapid speech, disorganized incoherent thought process, delusion, illusion, hallucination often visual, impaired judgment, disoriented, unable to concentrate, and impair immediate and recent memory. Causes are -- delirium tremens(alcohol withdrawal), uremia, acute hepatic failure, acute cerebral vasculitis, atropine poisoning. * dementia :- is characterized by usually normal level of consciousness(until late in course), normal to slow may be inappropriate behavior, difficulty in finding words(aphasia), often flat depressed mood, impoverished thought process, delusion, hallucination, judgment impaired over the course of illness, Fair orientation and attention (until late in course),recent memory specially new learning impaired. Causes -- vit B12 deficiency, thyroid disorder ------------------> causes reversible dementia Alzheimers dis, vascular dementia ( due to infarct or trauma) ---------------------> cause irreversible dementia. * Delirium may superimposed dementia some time.

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SKIN, HEAD, AND NECK * Very short stature found in turners $, achondroplasia, renal or hypopituitary dwarfism, where as long limbs in proportion to the trunk found in hypogonadism, marfans $. * Generalized fat found in simple obesity, where as trunkal fat found with relative thin limb found in cushings $. * Wt loss found in malignancy, DM, hyperthyroidism, chronic infection, depression, diuresis, successful dieting, anorexia nervosa, bulimia. * Pt with left heart failure prefer sitting up right, where as pt with COPD prefer leaning forward with arm braced. * Fast frequent muscular movement found in hyperthyroidism, where as slowed activity found in my edema. * Cold intolerance found in hypothyroidism. * Stare found in hyperthyroidism, where as immobile face found in Parkinsons dis. * Hypothermia refer to below 35 degree C or 95 degree F of temperature. * Hypothermia may cause by starvation, hypothyroidism, hypoglycemia. * Dry skin (asteatosis) is flaky rough and often itchy. It is frequently shiny specifically on legs. * Cyanosis depend in level of oxygen in arterial blood. If this level is low cyanosis is central if its level is normal cyanosis is peripheral. Central cyanosis is best identify in lips, oral mucosa, and tongue. * Central cyanosis is cause by advanced lung dis, congenital heart dis, hemoglobinopathies. * Peripheral cyanosis occur in venous obstruction, CHF(with pulmonary edema it may also be central). * Dryness, roughness of skin occur in hypothyroidism, where as oiliness occur in acne. * Lift a fold of skin and note the ease with which it lift up (mobility), and speed with which it return to its place (turgor). * Decreased mobility of skin occur in edema and scleroderma and decreased turgor found in dehydration. * Lichenification is thickening and roughening of skin with increased visibility of normal skin furrows, eg atopic dermatitis. * Excoriation is an abrasion of scratch mark. It may be linear or round as in scratched insect bite. * Atrophy is thinning of skin with loss of normal skin furrows the skin look shinier and more translucent than normal eg arterial insufficiency. * Burrows of scabies look like short, linear or curved gray line and may end in the tiny vesicle ( burrow is slightly raised tunnel). * Comedo refer to black head. * Unlike jaundice carotene does not effect sclera which remains white. * Increase in melanin may be due to Addisons dis (hypofunction of adrenal cortex) or pituitary tumor. * Caf-Au-lait spot in six or more in quantity of diameter >1.5 cm suggest neurofibromatosis. * Spider angioma is fiery red with radiating legs almost never occur below the waist suggest liver dis, pregnancy, vit B deficiency, also occur in normal person. * Cherry angioma has no radiating legs occur with increase age. * Purpura (petechia 1- 3 mm, purpura are larger) suggest bleeding disorder and emboli to skin. * Ecchymosis (is of purple color) are often secondary to trauma, also seen in bleeding disorder. * Basal cell carcinoma seldom metastasize initially a translucent nodule spreads leaving a depressed center and firm elevated border and telengiectatic vessel around it usually over age 40 in fair skin persons. Ulceration may occur. * Squamous cell carcinoma occur in sun exposed skin look redden and firmer than basal cell carcinoma usually occur over age 60 in fair skin person. It may develop actinic keratosis. * Actinic keratosis is superficial, flattened papule, covered by dry scale occur in fair skin old person. It is benign & may give rise to summons cell carcinoma. * Seborrheic keratosis is benign yellow to brown raised lesion that feel slight greasy, velvety, or warty, usually occur in trunk and face of older people or young black women. * Clubbing of finger suggest chronic hypoxia due to cancer of lung etc. * Terrys nail are mostly whitish with a distal band of reddish brown suggest aging, liver cirrhosis, CHF, DM type 2. * Small pit in the nail may be a early sign of psoriasis but not specific. * Beaus lines in the nail are transverse depression associated with acute severe illness. --------------------------------------------------------------------------------------EYES, EAR, NOSE, MOUTH * Palpable fissure is refer to opening b/w the eye lid. * Muscle of eye movement :- superior rectus } 3rd CN superior oblique } 4th CN rd CN Inferior rectus } 3 lateral rectus } 6th CN rd CN Medial rectus } 3 Inferior oblique } 3rd CN * Vibration sound passes through the air transmitted to the ear drum to ossicles of the middle ear to the cochlea of middle ear to and than cochlea of inner ear. * Sound passes from external ear to middle ear this is known as conductive phase, where as when sound passes from cochlea to cochlear nerve known as sensorineuronal phase. 13 NOT FOR COMMERCIAL USE OR SALE

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* Air conduction describes normal conductive phase, where as bone conduction stimulate cochlea describe normal sensorineuronal phase. In normal person air conduction is more sensitive. * Labyrinth with in the inner ear sense the position and movement of the head and help maintain balance. * Submandibular gland opens on papillae via Whartons duct that lies on the each side of lingual frenum, where as each parotid gland empties into mouth near upper 2nd molar via stensen duct. * Ant triangle of neck is bound, above by mandibles, laterally by stern mastoid, and medially by mid line of neck. * Post triangle of neck is bound, interiorly by sternomastoid muscle, posterior by trapazius, & inferiorly by clavicle. * Loss of accomodation power is called Presbyopia usually become noticeable in ones 40 where as hearing loss in aging is called Presbycusis. * In elderly the lens continuous to grow it may push the Iris forward, narrowing the angle b/w Iris and Cornea and increase the risk of Narrow Angle Glaucoma. * Lens thicken and yellow with age thats why older people need more light to do fine work. * Fine hair found in hyperthyroidism where as coarse (inferior quality) hair found in hypothyroidism. * Enlarge blind spot occur in condition affecting the optic nerve, eg glaucoma, optic neuritis & papilledema. (normal blind spot occur at 15 degree - temporal). * Abnormal protrusion of eye occur in graves dis or occular tumor. * Underlying skin of eye brows with scalyness suggest seborrhea dermatitis. * Lateral sharpness of eyebrows suggest hypothyroidism. * Blephanitis is inflammation of eyelid along with lid margin often with crusting or scaling. * Excessive tearing may be due to increase production, impaired drainage, conjuctival inflammation, corneal irritation, nasolacrimal duct obstruction, or Ectropion (outward drop of lower eyelid). * Normally reactive equal pupil is called Isocoria .inequality of less than 0.5 mm is consider normal however one should rule out Horner $, Occulomotor nerve paralysis, and tonic pupil. * Pupilary inequality called Anisocoria. * LIGLAG is when eye move from above downward found in hyperthyroidism. * In paralysis of left 6th nerve, eye can conjugate in right lateral gaze but not in left lateral gaze. * In paralysis of left 4th nerve, left eye cannot look down left. * In paralysis of left 3rd nerve, ptosis, papillary dilatation occur, left eye look out ward in effort to look straight, also upward downward inward movement is impaired. * In lidlag of hyperthyroidism, a rim of sclera is seen b/w the upper lid and Iris and the lid seems to lag behind the eye ball. * Poor convergence is also found in hyperthyroidism. * Mydriatric drops are contraindicated in head injury, narrow angle glaucoma, coma. * Absence of red reflex while using ophthalmoscope suggest cataract, detached retina, retinoblastoma (in children), artificial eye. * In refractive error, light do not focus on retina. In Myopia light focus ant to retina; In hyperopia light focus post or behind the retina; Retinal structure in myopic eye look larger than normal while using ophthalmoscope. * Enlarge cup in optic disc suggest chronic open angle glaucoma. * The presence of venous pulsation at the optic disc suggest but does not prove that the CSF is normal. * In retinal examination arteries are light red and veins are dark red in appearance. * Lesion of retina can be related to optic disc and are measured as disc diameter for eg cotton wool patches at 2 and 3 o clock, less than half disc diameter or more than one disc diameter or two times than disc diameter, etc. * when optic nerve is damage, the sensory (afferent) stimuli to brain is reduced so the pupil respond less vigorously and become dilated. This respond is afferent papillary defect called Marcus gunn pupil. the opposite eye respond consensually. * Occlusion of the branch of central retinal artery may cause horizontal (altitudinal) defect. - superior branch occlusion ---------------> lower eye field defect - inferior branch occlusion ---------------> upper eye field defect

(diagram here)

* Non tender swelling cover by normal skin-deep into the ear canal suggest Exostosis, these are non malignant over growth which may obscure the drum. * Red bulging drum occur in Acute purulent otitis media where as Amberdrum occur in serous effusion. * Serous effusion of middle ear cause by otitis media(viral) ; or by sudden change in atmospheric pressure from flying or diving called Otitic Baro trauma. * Bullous myringitis is a viral infection characterize by painful hemorrhagic vesicle on tympanic mem. Shows blood tingled discharge from ear. * Unusually prominent short process of Malleus or more horizontal short process of Malleus suggest a retracted drum. * WEBER TEST is the test for lateralization to find out the hearing loss from turning fork. * With weber test sound can be hear in impaired ear suggest unilateral conductive hearing loss, where as if sound can be hear in good ear suggest sensorineuronal hearing loss . * In conductive hearing loss sound is heard through bone as long as or longer than it heard through air, where as in sensorineuronal hearing loss sound is 14 NOT FOR COMMERCIAL USE OR SALE

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heard longer through ear. * In conductive hearing loss pts own voice tend to be soft, vs. where as in sensory hearing loss pts own voice tend to be loud. * RINNE TEST compare the air conduction and bone conduction by tuning fork. * In viral rhinitis the nasal mucosa is reddened and swollen where as in allergic rhinitis it may be pale bluish or red. * In nasal septum fresh blood or crusting may suggest septal perforation, trauma, surgery, cocaine or amphetamine use. * Nasal polyps are pale semi translucent masses that usually come from middle meatus. * Transillumination technique is useful in Dx of sinusitis. * Redness of the gum occur in gingivitis where as black line of gum occur in lead poisoning. * Asymmetric tongue or deviated tongue suggest lesion of the 12th CN. * Failure to rise soft palate by saying Ah or yawn suggest 10th CN lesion. Also the uvula deviated to opposite side. * Enlargement of the supraclavicular node specially to the left suggest possible metastasize from thoracic and abdominal malignancy. * Tender node suggest inflammation where as hard and fixed node suggest malignancy. * Small, mobil, discrete non tender node are frequently found in normal person. * Tracheal deviation may signifies mass in the neck, mediastinal mass, telecasts or a large pneumothorax. * A localize systolic or continuous bruit may be heard in hyperthyroidism. * Regurgitation of mucopurulent fluid from the punta of the eye with increase tearing suggest nasolacrimal duct obstruction. * Cushing $ (increase adrenal hormone) produce moon face excessive hair growth may be present in mustaches or chin. * Myxedema (severe hypothyroidism) has puffy dull facies, periorbital edema that does not pit with pressure. Where as Hair and eye brows are dry coarse, with thin and dry skin. * Chronic unilateral enlargement of parotid gland suggest neoplasm where as a chronic bilateral enlargement of parotid gland associated with obesity, diabetes, cirrhosis, etc. * Ptosis is the drooping of upper eyelid suggest Myasthenia gravis, Horner $. Wt of herniated fat may cause senile ptosis. * Exophthalmos suggest Grave dis, hyperthyroidism, unilateral exophthalmos may suggest, tumor , inflammation of orbit. * Retracted eyelid or lid lag often suggest hyperthyroidism, it may occur in normal person. * Epicanthal fold normal in many Asians it may also suggest Down $. * Ectropion (outward turning of lower eyelid) and Entropion (inward turning of upper eyelid); common in elder may cause irritation or increase tearing. * Periorbital edema suggest allergy, local inflammation, myxedema and nephrotic $. * Pinguewla is yellowish some what triangular nodule in the bulbar conjunctiva appear with aging and is harmless. * STY is the painful tender red infection look like pimple around follicle of eyelashes. * CHALAZION is chronic inflammatory lesion meibomiam gland it usually point inside the eyelid and is painless. * Swelling b/w lower eyelid and nose suggest inflammation of lacrimal sac. * Xanthelasma suggest hypercholesterolemia. * Acute iritis, acute glaucoma, and sub conjunctival hemorrhage in which occular discharge is absent. * Corneal Areus is thin grayish white arc or circle at the edge of cornea. It accompanies normal aging but not in black where as in young people corneal areus suggest possibility of hypolipoprotinemia. * Corneal scar is superficial grayish white opacity secondary to old injury or infection. * PTERYGIUM is triangular thickening of bulbar conjunctiva that grows slowly across the outer surface of cornea. * when Anisocoria ( unequal pupil ) is greater in bright light, the larger pupil cannot constrict properly suggest trauma, open angle glaucoma, impaired parasympathetic nerve supply to eye, or coulometer paralysis. vs. where as when Anisocoric is greater in dim light the smaller pupil cannot dialate properly suggest Horner $, and interruption of sympathetic nerve fiber. * Horner $ in which Iris is lighter than its fellow called Hetrochromia. * Light in a good eye produce direct reaction to the eye and consensual reaction to blind eye where as light direct to blind eye cause no response to either eye. * Small irregular pupil that do not react to light but do react to near effort indicate Argyll Robertsonian pupil it suggest neuro syphilis. * The Physiologic cup is a small whitish depression in the optic disc from which the retinal vessel appear to emerge. Grayish spot often seen at its base. * Ring and crescent are not the part of optic disc and is normal variation. * Medullated nerve fiber appear as irregular white patch with feathered margin obscure the disc edge and retinal vessel it has no pathological significance . * In optic atrophy tiny disc vessels are absent. * Glaucoma may result into increased cupping (depression) of disc and atrophy. * The retinal arteries are normally transparent; In HTN arteries wall thickened and become less transparent. * Papilledema in which venous stasis engorge and swell the vessel with resultant swollen disc and blurred margin. * Copper wire arteries shows bright coppery luster when reflect to light and Silver wire arteries occur after narrowing of arteries with no blood visible in it both condition found in HTN. * when artery loses its transparency the vein beneath it cant be seen ; its occur in HTN. 15 NOT FOR COMMERCIAL USE OR SALE

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* Superficial retinal hemorrhage are flame shaped seen in HTN, papilledema, occlusion of retinal vein vs. Where as retinal hemorrhage of small round, or dot shape found in DM. * Preretinal hemorrhage develop when blood escape into space b/w retina and vitreous. In erect pt RBC settles create a horizontal line in hemorrhage. Causes include sudden increase in intracranial pressure. * Retinal micro aneurysm are tiny red spot found in Diabetic retinopathy. * Retinal neovascularization found in late stage of Diabetic retinopathy. * Retinal exudate is hard and yellow occur in HTN and DM. * Cotton wool patches result from infracted nerve fiber seen in HTN, also called soft exudates. * Drusen are yellow tiny spot and is normal with aging. * Actinic cheilitis in which lips loses its normal redness and may become scaly thickened and slightly everted cause by solar damage in fair skin people. * Angular cheilitis is softening of the skin at the angle of mouth cause fissuring. May be due to vit B deficiency. * Torus Palatinus is mid line bony growth in the hard palate and is harmless. * Kopliks spots are rash of measles (rubeola) resemble to grain of salt on the red back ground appears with in days of infection. * Fordyce spots are normal sebaceous gland appear as small yellowish spot in the buccal mucosa or on lips. It is harmless. * Gingival hyperplasia caused by Dilantin therapy, puberty, pregnancy, and leukemia. * Epulis is a pregnancy tumor originate in interdental papilla with accompanying gingivitis. * Hutchinsons teeth (W W) are sign of congenital syphilis . Side of teeth are tapered toward the biting edge. * Tori mandible is bony over growth that grow from the inner surface of the mandible like Torus platinus ; it is harmless. * Multiple nodular goiter suggest metabolic rather than neoplastic process. * Simple nodule in thyroid gland is may be a cyst or benign neoplasm specially if there is rapid growth hardness and immobility. ------------------------------------------------------------------------------THORAXIC CAVITY AND LUNG * 2ND rib and sternal angle is on same line ; Inferior angle of scapula ends at 7th rib ; 5th intercostals space is in the line of Xyphoid process ; coastal cartilage of only first 7 ribs articulate with sternum. * 7th cervical and thoracic spinous of vertebrae are most prominent processes . * The lower boarder of lung crosses 6th rib at mid claviicular line and 8th rib at mid axillary line and posterior at 10th thoraxic spinous process on inspiration it descends further. * Trachea bifurcate at the level of sternal angle interiorly and 4th thoraxic spinous process posterior. * Visceral pleura is a serous mem cover the lung, it also lines the inner rib cage and upper surface of diaphragm where it is called parietal pleura. Space b/w perital pleura and visceral pleura is pleural space. * When diaphragm contract it descends.(diaphragm is primary muscle of inspiration). * During exercise accessory muscle join the inspiratory effort. Sternomastoid is more imp among these. Abdominal muscle assist in expiration. * Age may accentuate the dorsal curve of the thorax spine producing KYPHOSIS result in barrel chest (increase anteroposterior diameter of the chest) . However barrel chest has little effect on function. * In chest always inspect first than palpate and percuss and at last auscultate. (normal breathing is 14 - 20 times/min). * Prolong expiration suggest narrow lower airway. * Stridor is inspiratory wheeze suggest airway obstruction in the larynx or trachea. * Trachea may displace laterally by a pleural effusion , pneumothorax , telecasts, or tumor. * Increase anteroposterior diameter of chest (barrel shape chest) may suggest COPD. * Watch the Divergence of your thumb during inspiration at post chest wall at the level of T10 unilaterally diminish expiration suggest chronic fibrotic dis, lobar pneumonia, bronchial obstruction. (Divergence is to feel the range and symmetry by your hand and finger of respiratory movement). * Fremitus is palpable vibration transmitted through the bronchpulmonary tree to the chest wall when pt speaks. It decreases or absent when transmission of vibration from larynx to surface of chest is impeded. It suggest obstructed bronchus, pleural effusion, fibrosis (pleural thickening), pneumothorax or tumor. * Fremitus increases when transmission of vibration increases, suggest consolidated lung of lobar pneumonia, * Fremitus is typically more prominent in interscapular are than in lower lung and in right than left in normal subject. Always hear frimitus from post chest. * Dullness replaces by Resonance when fluid or solid tissue replace air containing lung or occupies the pleural space beneath your purcussing finger, causes are lobar pneumonia, emphysema, tumor, fibrous tissue. * Generalize hyper resonance may be heard over the hyper inflated lung of emphysema or asthma. Unilateral hyper resonance suggest pneumothorax or large air filled bullae in the lung. * Diaphragmatic excursion may be estimated by noting the distance b/w dullness on full expiration and full inspiration. Normal distance is 5 - 6 cm. Altered distance may suggest, atelactasis , or diaphragmatic paralysis. ** Normal lung sound :* vesicular sound :- It is inspiratoey sound that last longer than expiratory and has soft intensity, low pitch, heard over the most of the lung * Broncho vesicular sound :- Inspiratory and expiratory sound are equal with intermediate expiratory intensity and pitch often in the 1st and 2nd space interiorly 16 NOT FOR COMMERCIAL USE OR SALE

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and b/w the scapula posterior. * Tracheal sound :- Inspiratory and expiratory sound are equal with loud intensity & high pitch heard over the trachea in neck. * Bronchial sound :- Expiratory sound last longer than inspiratory, intensity of expiratory sound is loud with high pitch heard over monubrium. * If Bronchvesicular or bronchial breathing heard in location distal from the normal hearing site suspect that air filled lung has been replaced by fluid filled or solid lung tissue. * Breath sound may be decrease when air flow is decreased eg obstructive pulmonary dis or muscular weakness. * Transmission of voice sound is poor when there is pleural effusion, pneumothorax, and emphysema. * Crackles are intermittent, non musical & brief like a dot in time suggest pneumonia, fibrosis, CHF, bronchitis & bronchiactasis. * Wheeze occur due to narrow airway has high pitch and have a hissing, shrilling quality suggest asthma, COPD, Bronchitis. * Ronchi are low pitch and have snoring quality suggest secretion in large airway. * stridor is a predominantly inspiratory wheeze suggest partial obstruction of larynx or trachea demand immediate attention. * Pleural rub or Friction rub sound is often cracking due to inflamed or rough pleural surface typically heard in both phases of respiration. When inflamed surface separated by fluid sound often disappears. * Clearing of crackle, wheeze, or ronchi by cough suggest that secretion cause them. eg as in Bronchitis. * In some normal people crackle may be heard at the base of the lung after max expiration. * Increase transmission of voice sound in lung (Bronchophony) suggest air filled lung has become air less. * Pt with COPD often prefer to sit leaning forward with lips pursed during expiration,& arm supported on there knee or table. * Abnormal retraction of the lower intercostals space during inspiration suggest asthma, COPD, upper airway obstruction. * Dullness replaces resonance when fluid or solid tissue replace air containing lung or occupy the pleural space (and posteriorly In supine pt). only a large effusion detected anteriorly. * Hyper resonance of emphysema may tatally replace cardiac dullness. * Lung affected by COPD often displaces the upper boarder of liver downward. It also lower the level of diaphragmatic dullness posteriorly. * Forced expiration time of 6 sec or more suggest obstructed pulmonary dis. (test always after deep inspiration). * Prolong expiration of 6 sec or more suggest asthma, COPD, chronic bronchitis. * Compress sternum with one hand and thoraxic spine with other at the same time, increase local pain distant from your hand suggest rib fracture rib fracture rather than soft tissue injury. * Normal respiration rate is 14 -20 resp/min and 44 resp/min in infant. * Tachypnea (rapid shallow breathing) suggest restricted pulmonary dis, pleuritic chest pain, elevated diaphragm. * hyperpnea /hyperventilation (rapid deep breathing) suggest anxiety, metabolic acidosis, in comatose pt consider infarction, hypoxia, hypoglycemia (affecting mid brain or pons). * Kussmaul Breathing is deep breathing due to metabolic acidosis. It may be fast normal or slow in rate. * Bradypnea (slow breathing) is secondary to diabetic coma, Drugs, and increase intracranial pressure. * Cheyne-stokes Breathing is a period of deep breathing alternate with period of apnea (no breathing).it is normal in children and old people other causes are heart failure, uremia, ,drugs, brain damage (typically both side of cerebral hemisphere or diencephalons). * Biots Breathing (Ataxic breathing) has unpredictable irregularity. It may be shallow or deep or stop for short period. It suggest brain damage typically at medullary level and respiratory depression. * Sighing respiration (long and loud breathing) may suggest hyperventilation $, a common cause of dyspnea and dizziness. Occasionally sigh are normal. * Barral shaped chest (increase anteroposterior diameter) suggest COPD, may be normal in infant and old age. * Traumatic flial chest suggest rib fracture; injured area caved inward on inspiration and more outward on expiration. * Funnel chest ( pectus Excavatum ) caused by depression in the lower portion of sternum may compress heart, great vessel (may cause murmur). * Pigeon chest ( pectus Carinatum ) caused by ant displacement of sternum. Costal cartilage adjacent to the protruding sternum are depressed. * Thoraxic Kyphoscoliosis is abnormal spinal curvature and vertebral rotation deform the chest with resulting distortion of lung. * In airless lung (eg in lobar pneumonia) spoken word heard louder and clear called Bronchophony. ee sound heard as aa called Egophony, whispered sound word heard loud and clear called Pectoriloquy. Tactile frimitus increases. vs. * In normal air filled lung resipitory sound are predominantly vesicular. Spoken word muffled and indistinct spoken ee heard as an ee, whispered word faint and indistinct, Tactile frimitus normal. * Late inspiratory crackles usually at the base of the lung suggest interstitial lung dis or early CHF. vs. * Early inspiratory crackles soon after inspiration (do not continous late in inspiration) suggest chronic bronchitis or asthma. vs. * Mid inspiratory & expiratory crackles heard in Bronchiectasis wheeze and ronchi may be present. * Wheeze occur in asthma may be expiratory or both expiratory and inspiratory. * In chronic Bronchitis wheeze and ronchi often clear with cough. * Hammans sign (mediastinal crunch) is series of precordial crackles synchronous with heart beat not with respiration best heard in left lateral position is due to mediastinal emphysema (often a medical emergency0. * In chronic bronchitis and early CHF lung is Resonant, respiratory sounds are normal, tactile fremitus and transmitted voice sound is normal. 17 NOT FOR COMMERCIAL USE OR SALE

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* Consolidation of lung replace normal resonance and produse dullness over the airless area. Breath sounds are bronchial over involved area produce Bronchophony, Egophony, with whisper Pectoriloquy and late inspiratory crackles.occur in pneumonia, pulmonary edema, or pulmonary hemorrhage. * Atelectasis ( collapsed alveoli ) result into shift of trachea toward involved side, produce dullness on percussion, Tactile fremitus and transmitted voice sound is absent. There is no advantitious sound. ( remember breath sound, tactile fremitus, and transmitted voice sound is present only when atelactasis is in right upper lobe). * Advantitious lung sound are crackles (fine or coarse), wheeze, ronchi, pleural rub * In pleural effusion trachea shift toward opposite side, dullness on percussion occur, tectile fremitus and transmitted voice sound may be reduced to absent but may be present near the top of the large effusion. Adventitious sound is not present except a possible pleural rub. * In Pneumothorax trachea shift toward opposite side, hyper resonance over the pleural air. breath sound, tactile fremitus, and transmitted voice sound are reduced to absent. There is no adventitious sound except a pleural rub. * Emphysema results in hyper resonance (diffuse), breath sounds are decreased to absent; tactile fremitus and transmitted voice sound is decreased. Adventitious sound from non to crackles,wheeze, or ronchi from associated chronic bronchitis. * Asthma shows normal to diffuse hyper resonance with wheezing breath sounds. Tactile fremitus and transmitted voice soud is decreased. Adventitious sound may be wheeze and crackles are present. ----------------------------------------------------------------------------------------------CARDIOVASCULAR SYSTEM * Inspiration prolongs ejection of the blood from right ventricle but shorten ejection from left ventricle thats why S2 split (A2 P2) is physiologic on inspiration. * S1 is a mitral valve closure suggest systole. * S2 is aortic valve closure suggest diastole.(split occur on inspiration called A2 and P2). * S3 rapid ventricular filling suggest diastole (normal in young but suggest vetricle failure in old). * S4 atrial contraction suggest Diastole. Not often heard if heard suggest heart dis inold. * Ej early systolic ejection sound by aortic valve opening it is pathologic. * OS opening snap sound usually silent but produce sound in mitral stenosis. * Cardiac output = heart rate x storke vol. (vol of blood ejected in one min) * Storke vol = vol of blood ejected with each heart beat. * Preload is boold load that stratches the heart muscle prior to contraction. Inspiration increase and expiration decrease the preload. * Afterload is vascular resistance against which ventricle must contract. * Pathologic increase in preload called vol overload. vs. where as Pathologic increase in after load is called Pressure overload. * The difference b/w Systolic and diastolic pressure pressure is known as Pulse pressure. * Venous pressure ultimately depend upon left ventricle contraction. Venous pressure falls when when left ventricle out put or blood vol significantly reduced. It rises when right heart fails or due to increase pressure in pericardial sac which impede the return of blood into right atrium. * Regardless of position sternal angle remains roughly 5 cm above the right atrium. * The pressure in internal jugular vein can easily be detected when pt is sitting in 60 degree angle. Pressure more than 3 - 4 cm above the sternal angle consider elevated. ( always prefer to check right internal jugular vein). * Atrial functional sequence :-Atrial contraction ( a wave ), than atrial relaxation ( x wave ), than atrial filling ( v wave ), than atrial emptying or atrial pressure fall ( y wave ). * S3 over age 40 strongly suggest ventricular failure or vol overload due to valvular heart dis like mitral regurgitation. * S4 over age 40 may be normal or suggest heart dis. * Late in pregnancy or during lactation many women have so called mammary souffl secondary to increase blood flow in breast. * A murmur of mitral valve cannot be consider innocent. * Jugular venous hum common in childhood in young adult. * In older people systolic bruit in carotid artery suggest partial atherosclerotic obstruction in young it is usually innocent. * In arteriosclerosis large arteries become stiffen result in increase systolic pressure (systolic hypertension) and widened pulse pressure. * The tortuous aorta occasionally raises the pressure in the jugular vein on the left side of the neck by impairing there drainage with in the thorax. * Avoid carotid sinus pressing which lie at the level of the top of the thyroid cartilage. Which may cause reflex drop in pulse rate & BP. * Thrill are huming vibration that feel like throat of the purring cat during palpation over carotid sinus but if you can feel with stethoscope is called bruit. * A carotid bruit with or without thrill in a middle aged or older person suggest but not prove arterial narrowing. An aortic murmur may radiate to the carotid artery and sound like bruit. * Cuff that are too short or narrow may give false high reading. Using a reg size cuff in a obese arm may lead to false Dx of HTN. * If the brachial is much below heart level BP appear falsely high and pts own effort to support the arm may raise the BP. A lose cuff or a bladder that balloon out side the cuff may lead to false high reading. * Ascultatory gap is a silent interval that may be present b/w systolic and diastolic pressure. Unrecognized auscultatory gap may lead to serious 18 NOT FOR COMMERCIAL USE OR SALE

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underestimating of systolic pressure or overestimating of diastolic pressure. ( if you find auscultatory gap record your finding completely eg BP 200/ 98 with auscultotory gap from 170 - 150 ). * During deflating the cuff sound first muffled than disappear. In aortic regurgitationsoung never disappear. if there is more than 10 mmHg difference record both eg 150/80/68 mmHg. * If femoral pulse is smaller & later than the radial pulse suggest coarctation of aorta or occlusive aortic dis .BP is lower in legs than in the arm in this condition. * Korotkoff sound ( sound produse by sphigmomamometer) estimate the systolic pressure by palpation; consider technical fault, shock or arrythmia. * Internal jugular vein give more accurate reading for jugular venous pressure and pressure in right atrium. * In pt with obstructive lung dis venous pressure may appear elevated on expiration,the vein collapse on inspiration ;the finding does not indicate CHF. * Venous pressure > 3 or 4 cm above the sternal angle consider elevated. * Unilateral distention of the external jugular vein is usually due to local kinking or obstruction. Occasionally even bilateral distention has a local cause. * Prominent a wave indicate increase resistance to the right atrial contraction suggest tricuspid stenosis, hypertrophied right ventricle (which is more common). * a wave disappearance suggest atrial fibrilation. * Large v wave suggest trcuspid regurgitation. * Sequence of cardiac examination :- first supine with head elevated with 30 degree, than left lateral decubitus, than supine with head elevated 30 degree again than last sitting leaning forward after full exhalation. * Leaning forward position enhance detection of aortic insufficiency. * S1 is louder at apex where as S2 is louder than S1 at base. * S1 is decrease in First degree heart block where as S2 is decrease in aortic stenosis. * Tectile fremitus are felt best through bone - press firmly ball of your hand against the chest. * Cardiac impulse lateral to the mid clavicular line suggest cardiac enlargement or displacement. * Apical impulse often is most easily felt in the left lateral decubitus position, if not than ask the pt to exhale and stop breathing for a few second. * Apical impulse of diameter > 3 cm indicate left ventrical enlargement. * Amplitude of apical impulse is usually small and feel like a gentle tap, Increase amplitude (hyperkinetic impluse) may suggest hyperthyroidism, severe anemia, pressure overload (eg aortic stenosis), vol over load (eg mitral regurgitation). --------------------* The normal impulse last through first 2/3 of systole but never continuous to the 2nd heart sound (S2), if it continous to S2 called sustained high amplitude impulse, it suggest left ventricular hypertrophy from pressure over load. * To figure out amplitude of impulse either hyperkinetic or sustained high amplitude type auscultate heart and palpate pulse together. * If sustained high amplitude impulse is displaced laterally consider vol over load . ____________ * A sustained low amplitude impulse may be due to dilated heart of cardiomyopathy. * A brief mid diastolic impulse indicate S3 and just before the systolic apical beat it self indicate S4. ____________
Normal impulse

_____________
hyperkinetic impulse

_____________
sustained high amp impulse

_____________
sustained low amp impulse

* Systolic impulse of right ventricle can be felt over left sternal boarder at 3, 4, 5, interspace, breath out may improve observation. * Marked increase in amplitude of systolic impulse of right ventricle suggest vol overload of right ventrcle eg in atrial septal defect. vs. an impulse with increase amplitude and duration occur with pressure overload of the right ventricle suggest pulmonic stenosis or pulmonary hypertension. * Heart sound often heard best in epigastric area (subxiphoid), In pts with emphysema ask pt to inhale and stop for few sec. * A palpable S2 over left 2nd interspace suggest pulmonary hypertension. vs. A palpable S2 over right 2nd interspace suggest dilated or or aneurismal aorta. * Rolling the pt to left side accentuate S3 and S4 and specially mitral valve murmur. * Leaning forward with breath out accentuate the aortic murmur. * When either A2 or P2 is absent as in valvular dis, S2 is persistently single (normal split can be heard late in inspiration). * Expiratory split suggest abnormality for eg a loud P2suggest pulmonary hypertension. * Systolic click is common in mitral valve prolapse. * Midsystolic murmur (cresendo decresendo murmur) ___________ is due to blood flow across semilunar valve. * Pansystolic (holosystolic) murmur _____________ is often due to regurgitation across atrioventricular valve . * Late systolic murmur _____________ is murmur of mitral valve prolapse. 19 NOT FOR COMMERCIAL USE OR SALE

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* Early diastolic murmur (decresendo murmur) * Mid diastolic murmur (pre systolic murmur)

_____________

occur in aortic regurgitation or across semilunar valve.

_____________ suggest turbulent flow across atrioventricular valve.

* Late diastolic murmur (cresendo murmur) _____________ * A loud murmur of aortic stenosis often radiate into neck. * Emphysematous or obese person diminish the intensity of murmur. * Murmur can be graded from 1 - 6 ; pitch as high, med, or low ; Quality as blow, harsh, rumbling, or musical. * When person squats it increase the left ventricular vol due to increase venous return which decreases the prolapse of mitral valve, it delay click and murmur and decreases intensity. vs. on other hand same squatting increases stroke vol & intensity of murmur of aortic stenosis. vs. In contrast increase in left ventricular vol decreases the out flow obstruction in hypertrophy cardiomyopathy and decreases the intensity of murmur. * The decrease of left ventricular vol occur when a pt stands from squatting position it increase the tendency of mitral valve prolapse. * Presystolic murmur or cresendo murmur ------------------------------------------> mitral stenosis. * Early diastolic murmur (decresendo murmur) ------------------------------------> aortic regurgitation * Mid systolic murmur (cresendo decresendo murmur) --------------------------> aortic stenosis (may be innocent). * Pan systolic murmur (holosystolic or plateau murmur) -------------------------> mitral regurgitation. * Decrease left ventricular vol increases the obstruction of hypertrophy cardiomyopathy and also increases the murmur and intensity. vs. In contrast murmur of of aortic stenosis decreases. * Valsalva maneuver decreases the venous returnto right heart with resultant decrease in left ventricular vol and arterial BP. Release of maneuver has opposite affect. (these changes mimick the squatting to standing position). * Pulsus paradoxus (> 10 mmHg) indicate cardiac temponade, constrictive pericarditis,( more common) obstructive airway dis. * Atrial or nodal premature contraction is beat of atrial or nodal origin come earlier than the next normal beat a pause follow and than a rhythm resumes. P wave is present. ( S1 and S2 sounds are normal ). * Ventricular premature contraction is beat of ventricle origin comes earlier than the next normal beat ,a pause follow than rhythm resumes. P wave is absent ( S1 and S2 likely to be split ). * Sinus arrythmia in which heart usually speeds up with inspiration and slows down with expiration. S1 may be vary with heart rate . * Atrial fibrillation and Atrial flutter with varing AV Block shows irregular ventricular rhythm. ( for short run ventricular rhythm may seen regular). S1 varies in intensity. * Normal pulse pressure is abt 30 - 40 mmHg counter is smooth and round, notch on the desending slope is not palpable. * Small weak pulse suggest hypovolemia, decreases stroke vol, increase peripheral resistance due to cold or CHF, aortic stenosis. * Large bounding pulse is strong suggest increase stroke vol, decrease peripheral resistance, fever, anemia, hyperthroidism, aortic regurgitation, AV fistula, Patent ductus arteriosus, bradycardia due to increase stroke vol, derease compliance of aortic wall, atherosclerosis, aging. ( note rapid and brief peak ) * Bisferiens pulse is increase pulse with double systolic peak. Suggest pure aortic regurgitation or combine aortic regurgitation, aortic stenosis, hypertrophy cardiomyopathy. ( note double systolic peak ) * Pulsus alternans is alternate in amplitude from beat to beat even though rhythm is regular but shows one strong and one weak pulse suggest left ventricular failure. (note one weak and one strong pulse) * Bigeminal pulse is rhythm disorder cause normal beat alternate with alternate premature contraction. * Paradoxical pulse can be detected by palpation, and is decrease in pulse amplitude on inspiration. Or with sphigmomamo meter which shows decrease of systolic pressure by > 10 mmHg on inspiration. It suggest pericardial temponade, constrictive pericarditis, obstructive lung dis. 20 NOT FOR COMMERCIAL USE OR SALE

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* Normal S1 is softer than S2 in 2nd right and left interspace where as S1 is louder than S2 at apex. * Accenuated S1 ____________ suggest tachycardia due to exersize, anemia, hyperthyroidism, and mitral stenosis. * S1 is diminished ____________ in first degree heart block (delayed conduction from atria to ventrical), mitral valve calcification, mitral regurgitation, or when LV contraction is diminished as in CHF or coronary heart dis. * S1 split some time heard at the apex but consider also an S4, aortic ejection sound, early systolic click. Abnormal splitting of both heart sounds (S1 & S2) may be heard in right bunddle branch block (RBBB), and premature ventricular contraction. * Normal splitting of S2 heard on inspiration and disappeares on expiration but in young person it may be audible during expiration. * Wide splitting of S2 through out respiratory cycle suggest delay plutonic valve closure due to RBBB, or early aortic valve closure due to mitral regurgitation. RBBB may also cause splitting of S1 (tricuspid valve), atrial septal defect, right heart failure. * Paradoxical or reverse splitting is refer to splitting of S2 which appears on expiration and disappears on inspiration suggest delayed aortic closure P2 before A2 occur in Left bundle branch block (LBBB). * Increase intensity of A2 in right 2nd interspace suggest systemic hypertension because of increase pressure or when aortic root is dilated. * Decrease or absent A2 in right 2nd interspace suggest calcific aortic stenosis. * If P2 is equal or louder than A2 suggest pulmonary HTN, dilated pulmonary arteries or atrial septal defect. * Decreased or absent P2 result from plutonic stenosis, increased anteroposterior diameter of chest in old age. **EXTRA HEART SOUND DURING CONTRACTION (SYSTOLE) :* Ej (early systolic ejection sound) occur shortly after S1, it has high pitch, clicking quality, it suggest cardiovascular disease.

-------------------------* Aortic ejection sound heard best at apex and base, not vary with respiration it suggest dilated aorta and aortic stenosis. * Pulminic ejection sound heard best at 2nd and 3rd left interspace. S1 is usually soft in this area when appear to be a loud you may instead hearing plutonic ejection sound, its intensity decreased by inspiration causes include dialation of pulmonary artery, pulmonary HTN, or pulmonary stenosis. * Systolic click ( C1 ) is usually due to mitral valve prolapse. It is high pitch and clicking in quality. The click is often followed by late systolic murmur usually cresendo upto S2, which indicate mild mitral regurgitation. murmur increase in time when person stands from squatting position. ______________ _______________
Standing

_______________
Squatting

** EXTRA HEART SOUND DURING RELAXATION (DIASTOLE) :* Opening snap is very early diastolic sound with high pitch suggest mitral stenosis (produce by opening of mitral stenitic valve) It may radiate to plutonic area. -----------------------------------------------------------------------* S3 a physiologic 3rd heart sound is frequent in children may persist in young adult upto age 35 - 40 yrs, common in 1st trimester. It occur early in diastole during rapid ventricular filling.it occur little later than opening snap with dull or low pitch. It heard best at left lateral decubitus position. -----------------------------------------------------------------------* A pathological S3 or ventricular gallop sound is just like physiologic S3 sound but heard in pt after 40 yrs of age, heard best at left lateral decubitus position. This sound suggest decreased myocardial contractility, myocardial failure, vol overload of ventricle due to mitral or tricuspid regurgitation. On other hand right side S3 heard best below typhoid process. It is louder on inspiration. (term gallop comes from cadence of the 3rd heart sound specially at rapid heart rate ) * S4 (atrial sound or atrial gallop) ocuur just before S1 it has dull and low pitch. it occasionally heard in normal person, other wise it is due to decrease compliance of ventricle, coronary artery dis, aortic stenosis, cardiomyopathy. Left sided S4 heard best at apex in left atrial position, where as right side S4 heard best at left sternal boarder below typhoid. It is often louder with Inspiration. Causes of right side S4 is pulmonary stenosis and hypertention. -----------------------------------------------------------------------* S4 is also be associated with delayed conduction b/w atria and ventricle. S4 is never heard in the absence of atrial contraction, eg in atrial fibrillation. * Summation gallop occur when pt has both S3 and S4 sound mixing with S1 and S2 producing Quadruple sound. **MIDSYSTOLIC MURMURS:* Innocent murmur result fro turbulent flow probably generated by left ventricular ejection of blood into aorta usually decrease or disappears on sitting, heard best at 2nd& 4th left interspace. very common in children & young adult may also be heard in old people. ---------------------(heard best in 2nd and 4th left interspace) 21 NOT FOR COMMERCIAL USE OR SALE

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* Physiologic murmur results from turbulance due to temporary increase in blood flow to ventricle, anemia, pregnancy, and hyperthyroidism. ---------------------- (similar to inocent murmur) * Pulmonic valve stenosis increases the afterload on right ventricle it is congenital and most often found in children. Heard best in 2nd and 3rd left interspace. ------------------------heard best in 2nd and 3rd left interspace) * In severe pulmonic stenosis S2 is widely split & P2 is diminished no splitting is heard, early ejection sound is common heard best at 2nd & 3rd left interspace. * Pathologically increase flow across pulmonic valve may mimic the murmur of pulmonic stenosis. The systolic murmur is associated with atrial septal defect, sound originate from flow. * Pathologically increase flow across pulmonic valve may present right side S4. Right side ventrical impulse often increase in amplitude and may be prolong. * Aortic stenosis cause turbulance and increase after load on left ventricle result into decrease and delayed A2 merging with P2 sound. S4 reflects the decrease compliance of hypertrophied left ventricle. An aortic ejection sound if present suggest congenital cause, Carotid artery impulse rise slowly with small amplitude. Causes include congenital, rheumatic and degenerative heart dis, other causes that may mimic the murmur of aortic stenosis are aortic slerosis, bicuspid aortic valve, dilated aorta (marfans $) .

-------------------------- (best heard in right 2nd interspace) * Massive hypertrophy of ventricle muscle is usually associated with rapid ejection of blood durind systole. Obstruction to flow may coexist. S3 may be present S4 present at apex unlike mitral regurgitation. The carotid impule rise unlike aortic stenosis. Sound decreases when squatting and increases with straining down. ------------------------- (best heard in 3rd&4th left interspace). ** PANSYSTOLIC (HOLOSYSTOLIC) MURMUR :* Mitral regurgitation cause the left ventricle vol overload with resultant dialation and hypertrophy. It present with diminished S1 and S3 which reflects overload. Inspiration does not affect sound. Best heard at apex with blowing quality and may radiate to left axila.

----------------------------(best heard at apex may radiate to left axila) * Tricuspid regurgitation presents increased right ventricular impulse, audible S3, increased jugular vein pressure(large v wave) . Unlike the murmur of mitral regurgitation the intensity may increase with inspiration. usual causes are pulmonary HTN, left ventricular failure. ----------------------------(best heard at lower left sternal boarder) * Ventricular septal defect in which A2 amy observed by loud murmur with high pitch, abnormality is usually congenital. Heard best in 3rd,4th,5th,left interspace with wide radiation. -------------------------(heard best in 3rd,4th,5th,lsft interspace)

** DIASTOLIC MURMUR :* Aortic regurgitation results into left ventricular vol overload. Two other murmur may associate midsection murmur because of increase forward flow across aorta; and mitral diastolic murmur (Austin flint) due to impingement of regurgutant on mitral leaflet. Ejection sound may be present, arterial pulse often lage and bounding. S3 S4 if present suggest severe regurgitation. Midsystolic flow murmur on Austin flint suggest large regurgitation. Murmur is of blowing quatilty best heard at 2nd&4th left interspace with pt sitting, leaning forward and berath hold after expiration. ---------------------------* In mitral stenosis, valve fail to open sufficiently in diastole the murmur has two component. 1. Mid diastolic murmur during rapid venricular filling 2. Presystole murmur during atrial contraction. ________________ (presystolic murmur disappear in atrial fibrillation) It present with accentuated S1 at apex, and opening snap often follow S2. In pulmonary hypertention P2 is accentuated and right ventricle impulse become palpable. Mitral regurgitation and aortic valve dis may be associated with mitral stenosis. Murmur heard best in pt with left lateran position with breath held in expiration. 22 NOT FOR COMMERCIAL USE OR SALE

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** CARDIOVASCULAR SOUND WITH BOTH SYSTOLIC AND DIASTOLIC COMPONENT :* Pericardial friction rub produce by inflammation pericardial sac usually heard best in 3rd left interspace. The sound has scratchy and scraping quality with high pitch. Intensity increase with pt leaning forward and exhaled the sound has 3 component. __________________________
1. Ventricular systole 2.ventricular diastole 3. Atrial systole

* Patent ductus arteriosus the sound is loud in late systole and silent in late diastole and is typically harsh and machinery like with loud intensity. S2 obscure. Heard best in 2nd left interspace and radiate towad left clavicle. ------------------------------------------------* Venous hum is benign sound produse by turbulance of blood flow in jugular vein. Common in children. It presents continuos murmur with silent interval, loudest in diastole. The huming roaring with soft intensity heard best above the medial third of the clavicle specially on right & radiate to 1st and 2nd interspace. ------------------------------------------------( continous murmur defind as one that begin in systole and continuos to 2nd sound into all or the part of diastole) -------------------------------------------------------------------------------------------------------------------------------BREAST AND AXILLAE * 2/3 of female breastis superficial to pectoralis major muscle and about 1/3 is superficial to serratus anterior muscle. * Lymph node :1. Supraclavicular lymph node. 2. Infraclavicular lymph node. 3. Lateral lymph node---------------------------- drain most of the arm 4. Central lymph node---------------------------- deep in axila 5. Subscapular lymph node (post)----------- drain post chest wall and portion of arm 6. Pectoral lymph node (ant)------------------- drain ant chest wall and much of breast * Breasts glandular tissue is supported by the fibrous tissue, including suspensory ligament that is connected to both, the skin and fascia ( that underlies the breast). * Surface of areola has small rounded elevation are sebaceous gland called the gland of Montgomery. * Extra breast along milk line has no pathologic significance. * Axillary hairs usually appears about 2 yrs after pubic hairs. * Breast development is defined as Tanners sex maturity rate (SMR) from stage 1 - 5. * Menarche usually occur when girl is in SMR stage 3 or 4. * Black girls tend to develop breast, pubicand axillary hair before white girls. * 1 out of 12 girls develop breast at different rate with considerable asymmetry which is usually temporary. Reasurance is indicated unless it is very marked. * In Adolescent male boy 2 out of 3 develop gynecomestia of one or both side, it resolves spontaneously with in year or two. * Risk factor for breast cancer include increase age, prior cancer in opposite breast, mother or sister with breast cancer, early menarche, late or no pregnancy, late menopause and exposure to ionizing radiation. * Local infection or inflammatory carcinoma cause redness of breast. * Thickening of skin and prominent pores suggest breast cancer. * Flattening of normally covexed breast suggest cancer. * Recent or fixed flattening, or depression of nipple (inverted nipple) suggest underlying cancer. long standing inversion is usually a normal variant. * Asymmetry of the direction of nipple suggest cancer. * Dimpling or the retraction of the breast suggest cancer.(suspensory ligament are connected to skin and fascia of underlying breast when disturbed by cancer cause dimpling). * Tender cords suggest mammary duct ectasia, benign sometime painful condition with dilatation of the duct and inflamation around them. Masses may be 23 NOT FOR COMMERCIAL USE OR SALE

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associated. * Hard irregular poorly circumscribed nodules fixed to skin or underlying tissues strongly suggest cancer. * If the mobile mass in breast become fixed when pt presses her hand against hips suggest the mass is attached to pectoral fascia where as if it is immobile when pt is relaxed suggest attachment to the rib and internal coastal muscle. * thickening of the nipple and loss of elasticity suggest cancer. * Milky discharge unrelated to prior and lactation is called non puerperal galactorrhea, causes are hormonal or pharmacologic. * Non milky unilateral discharge suggest local breast dis, cusetive agent is usually benign (benign intrductal papiloma) but it may be malignant in elderly women. * In male hard ,irregular, eccentric, or ulcerating nodule is not gynecomestia and suggest breast cancer. * Sweat gland infection (hideradinitis supurativa) commonly found in maxillae. * Deeply pigmented, velvety axillary skin suggest Acanthosis. * Central lymphnodes are most often palpable they are small and <1 cm and non tender in normal person. * Enlarge axillary node suggest infection of hand and arm. Or may be part of lymph adenopathy look for other nodes in this case. * Lymphnode >1 cm in diameter, firm and hard, or matted together or fixed to the skin or to the underlying tissue suggest malignant involvement. * As breast cancer advances, it causes fibrous scar tissue. Shortening of scar tissue cause retraction with resultant dimpling, change in contour, retraction or deviation of nipple. Other reasons that ca causes of retraction sign include fat necrosis and mammary duct ectasia. * Edema due to lymphatic blockage appear as thickened skin and enlarge pores called Peau - d - orange sign it first appear in the lower portion of breast and areola. * Peget dis of the nipple is uncommon form of cancer that usually start as eczema like lesion, skin may also weep, crust or erode. Suspect paget dis of any persistent dermatitis of nipple or areola. * Simple and multiple cyst often round and tender with absent retraction sign, regresses after menopause. Its consistency is soft to firm and mobile and well delineated. * Fibroedenoma single or multiple occur in puberty and young adulthood upto age 55. It is round disc like or lobular soft or firm, well delineated, non tender mobile and retraction sign is absent. * Cancer most commonly occur from 30 - 90 yrs of age usually single but may coexist with other nodules, irregular or stellate, firm and hard not clearly delineated with surrounding tissue usually not tender, retraction sign may be present. ------------------------------------------------------------------------ABDOMEN * Lower pole of right kidney an be feel in right upper quadrant but little deep. * Ant edge of the S1 vertebrae (sacral promontory) feel like a stony hard out line in supra pubic area do not mistaken as a tumor. * Another stony hard lump that can some time mislead is normal xiphoid process. * Most of the normal gallbladder lies deep to the liver from which it can not be distinguished clinically. * Doudenum and pancrease lie in the upper abdomen normally not palpable. * Examine painful and tender area at last; distract the pt with conversation when necessary. * Always examine in following pattern in abdomen 1.Inspection 2.auscultation 3.percussion 4.palpation in end. * Striae these are silver stretch marks and are normal vs. where as pink or purple striae are of cushings $. * A dilated veins of the abdominal area, suggest hepatic cirrhosis or inferior vena cava obstruction. * Increase peristaltic wave suggest intestinal obstruction. * Increase pulsation of abdominal aorta suggest aortic aneurysm or increase pulse pressure. * Normal bowel sound consist of click and gurgles. Normal frequency of which is 5 - 34 / min. * Borborygmi is loud prolong gurgle occur because of hyper peristalsis. * Always listen bowel sound in all quadrant. * Bruit in the epigastric area and each upper quadrant in hypertensive pt with both systolic and diastolic component strongly suggest renal artery stenosis as a cause of HTN. * Epigastric bruit confined to systole only, may be heard in normal subject. * Friction rub over liver and spleen suggest infection (eg goncoccal) or splenic infarction respectively. * A protuberant abdomin that is lymphatic through out ,suggest intestinal obstruction. * Tympany (resonance sound) dominate in the area with gas in GI tract. Where as dullness (absence of resonance) is due to fluid or feces both sound should be assess by percussion carefully. * Dullness in both flank indicate further assessment of asites. * Involuntary rigidity of abdominal muscle (muscular spasm) typically persist despite all relaxing maneuvers, suggest peritoneal inflammation. * Abdominal pain on cough or with light percussion suggest peritoneal inflammation . * Rebound tenderness suggest peritoneal inflammation. If tenderness occur else where than the place you are trying to elicit rebound than that area must be 24 NOT FOR COMMERCIAL USE OR SALE

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the source of problem. * Span of liver dullness may increase in hepatomegaly or may decrease sue to CHF, hepatitis. * Span of liver dullness decrease when free air is present below the diaphragm as from perforated hollow viscus. * span of liver dullness displaced downward because of low diaphragm or COPD. Spans however stays normal. * Liver span is greater in man than in women and in tall than in short person. * Liver spans 4 - 8 cm in mid sternal line and 6 - 12 cm in right mid clavicular line . (always measure in vertical manner) * Dullness of the right pleural effusion or consolidate lung, if adjacent to the liver may falsely increases the estimated liver size. vs. Where as gas in the colon may obscure liver dullness and falsely decreases the estimated liver size. * Liver can be palpated by your right hand under right 11th and 12th rib at back with hand pushing upward while your left hand can palpate the liver tell your pt to take deep breath while you feel. * During palpation firmness & hardness of the liver, bluntness & rounding of its edges & irregular contour suggest abnormal liver. * Obstructed distended gallbladder may form a oval mass below the edge of the liver and merging with it. It is dull to percussion. * Hooking technique is helpful in obese pt. Hook the right abdomen below the border of liver dullness with your finger up toward the coastal margin. Ask a pt to take a deep breath. (sue both hands) * Normal spleen should stay posterior below the mid axillary line in pt with supine position. * Traubs space ( area b/w lung resonance above and coastal margin below) is good place for spleen percussion in supine pt. This area is usually tympanic. If spleen is normal the area remains tympanic with and without inspiration. * Fluid and solid food in stomach may produce dullness in Traub;s space do not misinterpretate it. * Tympany to dullness on inspiration lateral to left ant axillary line suggest splenic enlargement. This is +ve splenic percussion sign. dullness typically exceeds ant axillary line suggest splenomegaly. * The splenic percussion sign may also be +ve when pt is normal. * The inspiration move spleen from superior to inferior position. * Spleen can also be palpable while asking apt to lying down at right lateral side with hip & knee some what flexed. Gravity may bring spleen forward in this position. Palpable spleen below the left costal margin on deep inspiration suggest splenomegaly. * Feel kidney deep into right upper quadrant just below the coastal margin place your left hand at the back than press tour right hand against your left hand in ant right upper quadrant (RUQ), at the same time ask pt to take deep breath and hold, while you try to hold the kidney; now ask the pt to expire or release breath you may feel the contour size and tenderness. * Kidney enlargement suggest hydronephrosis, cyst, tumor; bilateral involvement suggest polycystic kidney. * In assessment of the mass in the left flank, that favors enlarge kidney over enlarge spleen are the preservation of normal tympani in LUQ. Remember when kidney is enlarge the tympany stays same where as when spleen is enlarge tympany turn into dullness. * Pain with fist percussionist costovertebral angle suggest kidney infection but it may also have musculoskeletal cause. * In person over age 50 aorta is not more than 3.0 cm, try to estimate by pressing deeply in the upper abdomen with one hand of each side of aorta. * In older person a periumbilical & upper abdominal mass with expansile pulsation suggest aortic aneurysm or dilation of aorta. * Aneurysm is usually painless, pain may herald its frequent complication -- the rupture of aorta. * In ascitis dullness shift to more dependent side while tympany shift to the top. * Straighten and stiffen the finger of one hand together place on the abdominal surface and make a brief jabbing movement directly toward the organ (liver) can reveal the surface of an organ, so its size. * The pain of appendicitis classically begins near umbilicus and than shift to the RLQ. Coughing increases the pain more pronounce in young than in adult. * Localize tenderness any where in RLQ even in the right flank may indicate appendicitis. Search carefully. * Right sided rectal tenderness in women may be cause by Inflamed adnexa or inflamed seminal vesicle, as well as by an appendix (in women). * Rebound tenderness suggest peritoneal inflammation as from appendicitis. * Rosvings sign is said to be +ve when cause Pain in the RLQ during the left side pressure it suggest appendicitis. Where as pain in RLQ due to quick withdrawal of pressure called rebound tenderness. * Place your hand just above the pt right knee and ask the pt to raise that thigh against your hand than ask turn on to the left side, than flex the leg at the hip that make psoas muscle to contract. Increase pain on either maneuver constitute the Psoas Sign +ve it suggest appendicitis. * Flex the right thigh at the hip with knee bent, rotate the leg internally at hip, this maneuver contracts the obturator muscle. Increases pain during this maneuver constitute the Obturator Sign +ve . It suggest inflamed appendix. * Cutaneous hyperthesia is pain when you pick gently the fold of abdominal wall b/w your thumb and finger with out pinching it. This is not painful normally but pain suggest appendicitis. * Hook your left thumb or right finger under the costal margin at point where lateral border of the rectus muscle intersect with the costal margin, ask the pt to take deep breath; a increase in tenderness with sudden stop in inspiratory effort constitute Murphys sign of acute cholecystitis. Hepatic tenderness may also increase with the maneuver but is less localized. * Hernia in the abdominal wall exclusive of groin hernia can be seen by asking a pt to raise both head and shoulder off the table. 25 NOT FOR COMMERCIAL USE OR SALE

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* To distinguish abdominal mass from abdominal wall mass ask the pt to raise head or shoulder to tighten the abdominal muscle by this abdominal wall mass remain palpable (eg lipoma, hernia, diastesis recti) where as abdominal mass will obscure eg intra abdominal tumor. * Umbilical hernia in infant usually close spontaneously with in a year or two. * Incisional hernia protrude through an original scar. * Epigastric hernia is a small midline protrusion through a defect in linea alba some where b/w xiphoid process and umbilicus. * Diastesis recti is a separation of the two rectus abdominis muscle through which abdominal contents buldge to form midline ridge. * Gas distention may cause by certain food or more serious are intestinal obstruction or paralytic (adynamic) ileus. Distention become more marked in colonic than in small bowel obstruction. * High pitch sounds coincides with abdominal cramp indicate intestinal obstruction. * Hepatic bruit suggest carcinoma of liver or alcoholic hepatitis. * Arterial bruits with both systolic and diastolic component suggest partial occlusion of aorta or large arteries. * Before announcing absent bowel sound sit down and listen for at least two min. * Venous hum (rare) is a soft huming noise with both systolic and diastolic component, it indicates increase collateral circulation b/w portal and sys venous system due to hepatic cirrhosis. * Friction rub is grating sound with respiratory variation it indicates inflammation of the peritoneal surface of the organ due to liver tumor, Chlamydia or gonococcal perihepatitis, splanic infarction, recent liver biopsy. * When systolic bruit accompany the hepatic friction rub, suspect carcinoma of liver. * Abdominal tenderness in abdominal wall persists when pt raises head and shoulder where as tenderness from deep abdominal lesion decreases when pt raises the head and shoulder. * Tenderness due to acute pleurisy may be due to pleural inflammation when unilateral may mimic acute cholecystitis or appendicitis; rebound tenderness and rigidity are less common. Chest signs are les common. * Tenderness due to acute salpingitis occur just above inguinal ligament, rebound tenderness rigidity may be present. It is frequently bilateral. * Tenderness associated with peritoneal inflammation is usually more severe than visceral tenderness. * Local cause of peritoneal inflammation include acute cholecystitis, acute pancreatitis, acute appendicitis, or acute diverticulitis. * Acute diverticulitis most often involve the sigmoid colon. * Downward displacement of the liver due to emphysema in which liver span is typically normal. * In some normal people specially those with larky build (tall & thin) right lobe of the liver may extend downward till right illiac crest it is called Riedels lobe. It represent variation in shape not in size or vol. * Cirrhosis may produce an enlarge liver with the firm non tender edge, vs. where as smooth enlarge tender liver suggest inflammation due to hepatitis, venous congestion, right sided heart failure or block. * Enlarge liver with firm hard irregular edge suggest malignancy there may be one or more nodules, & may or may not be tender. -----------------------------------------------------------------------------------MALE GENITALIA AND HERNIAS * Normal testicle range from 3.5 - 5.5 cm in size in adult. where as left testicle lies some what lower than right. Noticeable increase in size of testis begin with 9.5 - 13.5 yrs of age. * Epididymus locate poster lateral surface normally but in 6 - 7 % male it locate anteriorly. * Vas deferens a cord like structure begin at the tail of the epididymus ascend with in scrotal sac and passes through the external inguinal ring > inguinal canal > internal inguinal ring on its way to abdomen and pelvis then behind the bladder join by duct to form seminal vesicle and enter the urethra with in prostate gland. * Vas deferens, seminal vesicle, blood vessel all together make the spermatic cord. * The internal inguinal ring is locate about 1 cm above the mid point of the inguinal ligament. Neither canal nor inguinal ring is palpable through abdominal wall. * When loop of bowel forces their way through weak area of inguinal canal they produce inguinal hernia. Another potentiating route for a herniating mass is femoral canal it is below the inguinal ligament. * Boys often begin experience ejaculation as they approach SMR 3 (sex maturing rate stage 3) and some time mistaken nocturnal emission of urine or a discharge of STD. * If boys testis reaches the size of 2.5 cm or pubic hair to SMR 2 you can pronounce start of sexual development. * Delayed puberty is often familial or related to chronic illness. It may also be due to abnormalities in the hypothalamus, ant pituitary gland or testes. * Phimosis is a tight prepuce that can not be retracted over the glan. vs. Where as Paraphimosis is a tight prepuce that once retracted cannot return result in edema. * Balanitis is inflammation of gland vs. where as Balanoposthitis is inflammation of gland and prepuce. * Pubic and genital excoriation ------------- > possibilities of lice and scabies. 26 NOT FOR COMMERCIAL USE OR SALE

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* The discharge of gonnococcal urethritis tend to be profuse and yellow vs. where as non gonococcal urethritis tend to be scanty white and clear. * Induration of the ventral surface of the penis suggest a urethral stricture or carcinoma. Tenderness of the induration suggest periurethral inflammation due to urethral stricture. * Poorly developed scrotum on one or both side suggest cryptoorchidism (undescended testis). * Scrotum swelling caused by indirect inguinal hernia, hydrocele, and scrotal edema. vs. Where as scrotal swelling with pain suggest epididymitis, acute orchitis, torsion of spermatic cord, strangulated inguinal hernia. * Any painless nodule in the testis raise the possibility of testicular cancer. Peak incidence b/w 20 - 35 yrs of age. * Chronically infected vas deferens may feel thickened or beaded. vs. A cystic structure in the spermatic cord suggest hydrocele. * Swelling that contained serious fluid such as hydrocele Tran illuminate (they light up with the red glow) . vs. where as those that contain blood or tissue such as normal testis, tumor, hernia do not Tran illuminate . * A bulge that appear on straining suggest hernia. * Invaginate scrotal skin to reach external inguinal ring (triangular slit like opening) and ask pt to cough or strain down note if you can feel any herniating mass with your finger. * Place the finger on ant thigh in the region of femoral canal ask pt to cough or strain down, while you note any palpable mass swelling or tenderness. * Scrotal herniated mass return to abdomen as pt lies down if not get your finger above the mass in the scrotum if you suspect hydrocele, if not listen for bowel sound in herniated mass if you can hear it , its hernia not hydrocele. * In hydrocele finger can get above mass where as in hernia it cant. * Hydrocele is fluid fill mass in tunica viginalis it transilluminate. * Indirect inguinal hernia is common in both sexes often in children; originate from internal inguinal ring often into scrotum. Hernia comes down in inguinal canal and touches the finger tip during cough and straining. When in the scrotum finger cant get above herniated mass auscultate bowel sound. * Direct inguinal hernia is less common usually over age 40 yrs, rare in women. Originate near the external inguinal ring and rarely into the scrotum. Hernia bulges anteriorly and pushes the side of he finger forward. * Femoral hernia less common, more in women than men, originate below the inguinal ligament in the femoral ring. It is hard to differentiate from lymph node (auscultate bowel sound). * A hernia is Incarcerated when its content cannot be returned to the abdominal cavity. When hernia is strangulated the blood supply to the entrapped content is compromised . Suspect strangulation in the presence of nausea tenderness and vomiting. * Chancre is painless but when secondarily infected is painful. * Venereal wart most often mal odorous cause by HPV called Condyloma accuminata. * Non indurated ulcer on red bases suggest HSV infection it is painful. * Carcinoma appears as indurated nodules or ulcer that is usually not tender it is rare and usually in uncircumcised person. * Palpable non tender hard plaque just beneath the skin usually along the dorsum of the penis with crooked painful erection suggest Payronies dis. * Testicular cancer is painless nodule do not transilluminate may feel heavier than normal in late stage. * Spermatocele and cyst in epididymus is pain less moveable mass just above the testis they both Transilluminate. * Vericocele refer to the varicose vein of the spermatic cord usually feel like a soft bag of worms. * Tuberculous epididymitis produce a firm enlargement some time tender with thickening and beading of vas deferens. * Epidermoid cyst is firm yellowish non tender cutaneous cyst up to 1 cm in diameter they are common and often multiple. * An acute orchitis (inflamed testis) is painful tender and swollen difficult to distinguish from epididymitis. The scrotum may be reddened look for evidence of mumps (like parotid swelling) or other less common infectious causes. * Acute epididymitis is tender swollen difficult to distinguish from acute orchitis. Scrotum may be reddened and vas deferens may be inflamed. Common in adult. Coexist with UTI and prostitis. * Torsion of spermatic cord is acute, swollen, painful and retracted upward in the scrotum. Scrotum become red and edematous, common in adolescent. It obstruct circulation. * Testis consider small in adult if it is < 3.5 cm causes include Klienfelters $ (firm and < 2 cm), vs. where as soft < 3.5 cm Cirrhosis myotonic dystrophy, hypopituitarism, estrogen in take and post mumps status. * Cryptorchidism (undescended testis) lies in the inguinal canal or abdomen. It increases the risk of testicular cancer. * Scrotal edema may become taut with pitting associated with venous obstruction, CHF, nephritic $. ----------------------------------------------------------------------------------------FEMALEGENITALIA * Post portion of the vaginal opening is Introitus in virgins may be hidden by hymen. * Bartholin glands are situated more deeply. * The uterus body (corpus) and cervix is joined together by the Isthmus. * The cervix protrude into the vagina dividing the fornix into ant, post, and lateral fornices. * Normal ovary size average about 3.5 x 2 x 1.5 cm. 27 NOT FOR COMMERCIAL USE OR SALE

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* Adnexa refer to the ovaries, tubes, and supporting structures. * normal Ovary is tender and produce ova and hormones.( estrogen, progesterone, testosterone). * Delayed puberty is often familial or due to chronic illness, it may also be due to abnormality in hypothalamus, ant pituitary gland or ovaries . * For pap smear make sure pt is not menstruating or have held intercourse, douching, or suppositories during last 24 - 48 hrs. * A yellowish discharge on cervical swab suggest a mucopurulent cervicitis commonly due to Chlamydia trachomatis, N gonorrhea, HSV. * Stool in the rectum may stimulate a rectovaginal mass, but unlike a tumor mass can usually be dented by digital pressure. * Normal cervix can be moved with out pain where as pain on the movement of the cervix togather with adnexal tenderness suggest PID. * Nodules on palpation on uterine surface suggest myomas. * 3 - 5 yrs after menopause, ovaries are usually atrophied & no longer palpated if you can feel the ovary consider tumor or cyst. * Adnexal mass include ovarian cyst, tumor, the swollen fallopian tube of PID, tubal pregnancy, a uterine myomas may simulate adnexal mass. * To relax anal sphincter ask the pt to strain down. * Indirect inguinal hernia is the most common inguinal hernia that occur in women groin. Femoral hernia is rank 2nd to frequency. * Slightly raised flat round and oval papule covered by the gray exudates suggest condylomata lata ( Sec syphilis). * Small firm and round cyst nodule sometime yellow in the labia, suggest epidermoid cyst, look for dark punctum marking the blocked opening of the gland. * Shallow small painful ulcer on red bases suggest herpes. * A ulcerated red raised vulvar lesion in elderly women indicate vulvar carcinoma. * Cystocele is the bulge of the ant vaginal wall together with the bladder above it, that results from weakened supporting structure. (the upper 2/3 vagina is involved) * Cystourethrocele is the bulge from entire ant vaginal wall together with the bladder and urethra involved. A groove some time define border b/w urethrocele and cystocele but is not always present. * A rectocele is bulging of the post vaginal wall together with the rectal wall behind it, weakened supporting structure are cause. * Bartholin gland infection include causes are gonococcal, Chlamydia, it appear as a tender hot very tense abscess. * Urethral caruncle is a small red benign tumor visible on the post part of the urethral meatus, occur in the post menopausal women with no symptoms. rule out carcinoma and check for inguinal lymphadenopathy. * Prolapsed urethral mucosa look like swollen red ring around the urethral meatus usually occur before menarche or after menopause. * When columnar epithelium is transformed into squamous epithelium (metaplasia) this change may block the secretion of columnar epithelium thus cause retention cyst called Nabothian cyst. these have no pathological significance. * Early frequent intercourse, multiple partner, and HPV infection increase the risk of cervical cancer. (in late stage may look like a cauliflower like growth). * Bright red soft and rather fragile polyp type growth arise from end cervical canal and becoming visible when protrude out of cervical os is cervical polyp. It may bleed. * Mucopurulent cervicitis produce yellow purulent drainage from cervical os usually due to C. trachomatis, N. gonorrhea, or herpes infection may present with or with out signs and symptoms. * Daughter of women who took DES during pregnancy may show no of abnormality. 1. Columnar epithelium (red & plushy) that covers the most or all of cervix. 2. Vaginal adenosis :- extension of this epithelium to the vaginal wall. 3. A circular collar or ridge of the tissue of varying shape b/w cervix and vagina. 4. Less common is carcinoma of upper vagina. * Trichomonas vaginitis is often but not always acquired sexually. It presents yellow, green, or gray,frothy and mal odorous with pruritis and dyspareunia. Also shows petechiae on vaginal mucosa ( Dx with saline wet mount). * Candida albican (normal vaginal flora) when cause moniliasis, or candida vaginitis, may show curdy white thin or thick layer and is typically not mal odorous. It also present pruritis, soreness and dyspareunia.( Dx with KOH potassium hydroxide preperation). * Bacterial vaginitis shows gray or white thin mal odorous coat of vaginal wall ( fishy or musty genital odor ) previously known as gardenella vaginitis. Vaginal mucosa is usually normal. * Atrophic vaginitis manifest after menopause (due to decrease estrogen), presents pruritis burning and dyspareunia. Vaginal mucosa is dry, pale, atrophic, petechial, it may bleed easily. * Physiologic vaginitis may contain white clumps of epithelial cells but it is not mal odorous. * Myomas of uterus (fibroids) may be single or multiple outside or inside the uterus. * Prolapse of the uterus result from weakening of the supporting structure it is often associated with cystocele and rectocele. In progressive stage the uterus become retroverted and descend down to the vaginal canal to the out side. 1. In 1st degree prolapse cervix still well deep into the vagina. 2. In 2nddegree prolapse cervix is at introitus. 3. In 3rd degree prolapse cervix and vagina is out side the introitus. * Retroversion of the uterus is refer to tilting backward of entire uterus. It is common variant in 1 out of 5 women and cannot be palpable. It can be felt posterior either through post fornix or through rectum. 28 NOT FOR COMMERCIAL USE OR SALE

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* Retroflexion of uterus refer to the backward angulation of the body of the uterus In relation to cervix. It is normal variant. * Adnexal mass results from fallopian tube or ovarian disorder. eg ovarian cyst, ruptured tubal pregnancy, PID. * Ovarian mass (cyst or tumor) tend to be soft in cyst and hard incase of tumor. Uncomplicated cyst or tumor are not tender. Cyst mass < 6 cm in young women are usually benign and often disappear after next menstrual period. * Ruptured tubal pregnancy spills blood into peritoneal cavity causing severe abdominal pain and tenderness, fainting, syncope, Nausea, vomiting, tachycardia and shock may be present reflecting the hemorrhage. * PID may cause salpingo oophoritis, acute dis may associated with very tender bilateral adnexal masses. Although pain and muscle spasm make it imposible to delineate them. Movement of cervix produce pain. Infection may also follow after gynecologic surgery or delivery of baby. -------------------------------------------------------------------------------------PREGNANT WOMEN * Normal pregnancy last 38 - 42 weeks. * In pregnancy hyperplasia of thyroid gland and breast occur. * From mid to late pregnancy Colostrums may expressed from the nipple. * Muscle tone diminished as pregnancy advances. Diastasis recti is seperation of rectus muscle at the mid line of the abdomin is noticeable in late pregnancy. * In early pregnancy vagina takes bluish or violet color, mucosal thickening, and secretion of vagina increases. Vaginal PH typically become acidic due to lactobacillus action on glycogen stored in vaginal epithelium. * Increase glycogen store may contribute the higher rate of candida infection in pregnancy. * Hagers sign refer to palpable softening of isthmus is an early diagnostic sign of pregnancy. * By the end of pregnancy uterus has a capacity of 10 liters apex. * Chadwicks sign is Pronounced softening and cyanosis of cervix appear very early after conception and continuous through out pregnancy. * Cervical canal is filled with protective tenacious mucous plug to protect fetus from infection. * Red velvety mucosa around the os during pregnancy is normal. * Nausea, vomiting in 1st trimester is due to hormonal changes which slows peristalsis through out GI tract. (its normal). * Breast tenderness, tingling in 1st trimester is due to hormones causing growth of breast tissues and increases blood flow. Upper back also aches due to increase in wt. (its normal) * Urinary frequency, fatigue, heartburn, constipation, backache, all is normal during pregnancy. * Leukorrhea a milky white discharge is also common during pregnancy. * Corpus luteum (ovarian follicle) may be felt on ovary as a small nodule usually disappear by mid pregnancy. * Conception age is refer to the date of conception in order to calculate the EDC (Expected date of confinement). * Menstrual age refer to 1st day of the last menstruation period (LMP) to calculate EDC. * If women does not remember LMP, dating the pregnancy is done by palpation and subsequent monitoring of growth curve. * Best position for examining the pregnant women is semi sitting position with knee bent slightly. But prolong period of lying in this position should be avoided. It can interfere blood circulation. * Beside pelvic exam all other examination position should be done in sitting or left side lying position. Tender area should be avoided until the end of examination. * The vaginal wall are relaxed during pregnancy they may felt medially. * The cervical brush is not recommended for pap smear in pregnancy due to increase vascularity of mucosa ,it ay cause bleeding for that reason Ayre wooded spatula or cotton tipped aplicator are appropriate. * In early and mid pregnancy BP is normally lower than the non pregnant state. * High BP prior to 24 weeks indicate chronic HTN. * In 1st trimester wt loss is due to nausea & vomiting & is common but should not exceed 5 lbs, if exceeds suggest hyperemesis. * Chloasma is the mask of pregnancy presents brownish patches around eyes and across the bridge of the nose its normal. * Facial edema after 24 weeks suggest pregnancy induced hypertension (PIH). * Some minor hair loss may be noted in pregnancy where as localized patches of hair loss should not be attributed to pregnancy. * Nasal congestion and nose bleed is common in pregnancy. Look for sign of cocaine use. * Gingival hyperplasia is common in pregnancy. Symmetrical enlargement is expected in pregnancy but marked enlargement or asymmetrical hyperplasia is not due to pregnancy. * Nipple and areola are darker in pregnancy nad Montgomery gland become prominent. * Palpate apical impulse it may be slightly higher because of Dextro rotation of the heart due to higher diaphragm. * Soft blowing murmur are common in pregnancy, may also accompany anemia. * Purplish straie and linea alba are normal in pregnancy. 29 NOT FOR COMMERCIAL USE OR SALE

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* If fetal movement cannot felt by or after 24th week consider error in calculating gastation, fetal death, or morbidity of false pregnancy. * Prior to 37th week regular uterine contraction with or without pain or blood are abnormal suggest preterm labour. * Measure fundal height with tape if women is more than 20 week pregnant. * If fundal height is > 2 cm than expected consider multiple gastation, big baby, extra amniotic fluid, or uterine myomatas. * If fundal height is < 2 cm than expected consider missed abortion, transverse lie, growth retardation, false pregnancy or small product. * After 20 week measurement in centimeters should roughly equal the weeks of gastation. * Fetal HR is audible after 12th week with doptone. * Fetal HR is audible after 18th week with fetoscope. * The HR is usually in 160s during early pregnancy and than slows to 120 - 140 near term. * Fetal HR (FHR) if near term drops noticeably with fetal movement could indicate poor placental circulation. * 10 - 15 B/min variance over 1 - 2 min is normal (late in pregnancy). Lack of beat variability late in pregnancy suggest fetal compromise. * Some women have labial varicosities that become tortous and painful they may bleed. * Cystocele and rectocystocele may be pronounced due to muscle relaxation in pregnancy. * Vaginal infection are more common during pregnancy and specimen may be needed for Dx. * A pink vagina suggest a non pregnant state. * A parous cervix may look irregular because of leceration. * Anteflexion or retroflexion of uterus is lost by 12th week and become globular. * Irregular shaped uterus suggest myomatas or Bicornuate uterus (two distinct uterine cavities). * Early in pregnancy it is imp to rule out tubal pregnancy (actopic pregnancy). * General inspection may be done with the women seated or lying on left side. * Obtain knee and ankle reflexes, after 24 weeks reflexes greater then 2 + may indicate pregnancy induced HTN. * Leopolds maneuvers are imp to figure out the fetal position for successful birth and evaluate adequate growth. * 1st maneuver (upper pole) :- Palpate for fetal buttock or head in upper pole. buttock are irregularly softer than head which is firm and round. * 2nd maneuver (sides of abdomen) :- Place one hand on each side try to capture fetus body, one hand should stay steady and other to palpate fetus body. Feel back smooth and firm and front irregular and may be kicking. * 3rd maneuver (lower pole) :- Feel and palpate area just above symphisis pubis feel the head or buttock with both hand. * 4th maneuver (confirmation of presenting part) :- Grab the part of the fetus of the upper and lower pole at the same time you can distinguished b/w head and buttocks. For eg head in upper pole moves some what independently than rest of body. ANUS, RECTAUM AND PROSTATE * Anorectal junction ( Pectinate or dentate line ) refer to boundary b/w somatic and visceral nerve supply. It is not palpable but can be visible on proctoscopy . * Prostate can be palpable as rounded heart shaped structure about 2.5 cm in length. Its two lateral lobes are separated by median sulcus or groove. * Seminal vesicle shape like rabbits ear above prostate and are not normally palpable. * Through the ant wall of female rectum a uterine cervix can be felt. * Rectal wall contain 3 inward folding called the Valve of Houston. lowest line can be felt at pts left side. * Soft palpable tags of redundant skin at the anal margin are common due to post anal surgery, previously thrombosed hemorrhoids. * Note the sphincter tone while digital finger examination. Normally the anal sphincter close snugly around finger. It may be tight due to anxiety, inflammation scarring. Or may be laxity (lose) in some neurologic dis. * Induration of anus may suggest inflammation, scarring, or malignancy. * Irregular bordered lesion in or around anus suggest malignancy. * Palpating prostate may provoke desire to urinate tell pt not to do so. * Normal prostate is rubbery or non tender. * In female rectal exam is usually done after genitalia; cervix and uterus may be palpable. * Pilonidal cyst and sinus is fairly common probably a congenital abnormality located to mid line superficial to coccyx or the lower sacrum. It is clinically identified by opening of the sinus tract. It may exhibit small tuft of hair or surrounded by hollow of erythma. It is normally. It is normally asymptomatic may show infection. * Anorectal fistula is tract or tube b/w skin or viscus to anus or rectum often inflammatory. * Extend your finger above the prostate gland to the region of seminal vesicle and peritoneal cavity if tenderness occur may suggest peritoneal inflammation or peritoneal metastasis. * Anal fissure is very painful oval ulceration of anal canal most commonly on midline posterior; inspection may shows Sentinel Skin Tag just below it. If sphincter is spastic and painful local anesthesia may required. * External hemorrhoids are tender, swollen, bluish oval mass and is visible at anal margin due to dilated vein that originate below the pectinate line and are covered with skin. * Internal hemorrhoids occur below the pectinate line and it may cause bright and red bleeding, it may prolapse through anal canal and appear as reddish 30 NOT FOR COMMERCIAL USE OR SALE

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moist protruding mass. * Polyps in rectum are fairly common variable in size and number can be pedunculated or sessile and usually soft (do biopsy). * Prolapse of rectum appear as doughnut or a rosette of soft tissue. It may shows circular fold on it when prolapse is large. * Firm nodular rolled edge mass in rectum suggest carcinoma. * Rectal shelf is a wide spread metastasis from any source to ant to the rectum in the area of peritoneal reflection in male and rectouterine pouch in female. * BPH starts at 5th decade of life. Affected gland usually feel symmetrically enlarged, smooth, firm & slightly elastic. The median sulcus may be obliterated. * Cancer of prostate is hard nodular, which may or may not be palpable due to altered counter of gland. Hardness may also results from prostatic stone, chronic inflamation. * Acute prostitis and acute febrile inflammatory condition usually bacterial. The gland is very tender, swollen, firm and warm. * Chronic prostitis does not produce consistent physical finding. ---------------------------------------------------------------------------------------------------PERIPHERAL VASCULAR SYSTEM * Radial & ulnar arteries are interconnected by two vascular arches with in the hand therefore doubly protected against possible arterial occlusion. * Femoral artery travel down deep into the thigh passes medially behind the femur &becomes a popliteal artery behind the knee. * Poplitial artery divides into two branches, ant branch continuous to the foot called dorsalis pedis artery and post branch passes behind the medial malleolus of the ankle called post tibial artery. * Like hand the foot is also interconnected by these two branches the dorsal pedis artery & post tibial artery therefore protected. * The deep vein of leg carry about 90 % of venous return from the lower extremity and are well supported by surrounded tissue. * Superficial vein are located subcutaneously and supported relatively poor. Superficial vein includes great saphenous vein and small saphenous vein. * Great saphenous vein originate from the dorsum of the foot and continuous anteriorly up till inguinal ligament medially. vs. Where as small saphenous veins originate from the side of the foot and passes upward posterior and drain into deep venous vein in the popliteal space. * Great saphenous vein and small saphenous vein communicate with deep venous vein (femoral vein) via communicating vein. * Inguinal lymph node are often 1 cm in diameter and occasionally 2 cm in adults. * Axillary lymph node drain most of the arm where as epitrochlear node drain ulnar forearm and hand. vs. where as little and ring finger and adjacent surface of the middle finger and few area of arm go directly to intraclavicular lymph node. * Superficial inguinal lymph node include two groups. 1. Horizontal group :- lie high below the inguinal ligament. 2. Vertical group :- lie near the upper part of saphenous vein. * Horizontal group of nodes drain the superficial portion of upper abdomen & buttock and external genitalia (but not testes), perinea area, lower vagina, canal. * Vertical groups of node drain the upper part of saphenous vein where as small saphenous vein is drained by nodes present in the same area. it is not associated with inguinal lymph node. * Children and young adolescent normally have longer lymph node relative to body size than do adult. * Lymph edema of arm and hand may follow axillary dissection and radiation therapy. * Prominent vien in the ademous arm may suggest venous obstruction. * Palpate the artery if it is widely dilated it is aneurysm. * In Reynaud dis wrist pulses are typically normal but spasm of more distal arteries cause episode of sharply demarcated pallor of finger. * If you feel arterial insufficiency at point x try to feel and compare the pulse from early ( proximal of the body ) segment of artery. For eg if radial pulse is diminish compare the brachial pulse and also with other hand pulse. * Feel for one or more epitrocheal lymph node with the pts elbow flexed to 90 degree. About the 3 cm above the medial epicondyle. Enlarge node may suggest lesion in the drainage area or may be the part of generalized lymphadenopathy. * Try to distinguish b/w generalized or localized lymphadenopathy by finding causative lesion in the damaged area or enlarge lymph node in at least two other contiguous lymph node region (generalized lymphadenopathy) . * Press deeply below the inguinal ligament in the middle to palpate femoral pulse. A decrease or absent pulse indicate dis of aortic or iliac level. All pulses distal to occlusion should be affected. * Chronic arterial occlusion causes intermittent claudication, postural color changes, and trophic changes in the skin, it is common due to atheroma. * Popliteal pulse is often difficult to find and feel --- exaggerated and wide pulse suggest aneurysm. It is not common but in case is due to atherosclerosis. * Flex the pts knee about 90 degree while he is supine facing downward press the thumb of the both hand deep into popliteal fossa to fell popliteal pulse. * Arteriosclerosis oblitrans most commonly obstruct arterial circulation in the thigh, the femoral pulse is normal but popliteal pulse is decreased or absent. * The dorsalis pedis pulse (at the dorsum of the foot) lateral to the extensor tendon of the great toe, it may be present higher in the ankle congenitally. Decreased or absent foot pulse with normal femoral and popliteal pulse suggest occlusive dis of the lower branch of popliteal artery for eg as in DM. * Look for post tibial pulse slightly below the medial malleolus of the ankle ( hard to feel ). Absent pulse may due to thrombus, emboli, result in pain 31 NOT FOR COMMERCIAL USE OR SALE

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numbness, tingling, pale and cold. If collateral circulation is good than only numbness & cold may results. * Feel the temp of feet and leg with back of your finger bilateral coldness is often due to cold environment or anxiety. vs. where as unilateral coldness with other signs suggest arterial insufficiency. * To check edema press your finger against skin for at least 5 sec. * In deep venous thrombosis the extent of edema suggest the location of occlusion. Eg when iliofemoral vein is occluded the entire leg is swollen. * In leg edema always discard CHF, drugs, lymphadema, deep venous thrombosis, incompetent venous valve, prolong standing. * Venos distention suggest a venous cause of edema. * Palpable femoral vein just medial to femoral pulse (below inguinal ligament). Its tenderness with painful pale and swollen leg suggest deep iliofemoral thrombosis. * Compress the calf against tibia with knee flexed. Look for tenderness and cords suggest deep thrombosis there ; Dx always depend on the kind of tests. Some time tenderness may not be present. * Local swelling, redness, warmth, and subcutaneous cord suggest superficial thrombophlebitis. * A brownish color or ulcer above the ankle suggest chronic venous insufficiency. * Thicker browny skin occur in lymph edema and advanced venous insufficiency. * Feel varicosities with pt in standing position. It seems dilated, tortous, with thickened wall. * Feel two different part of same varicose vein for pressure wave. If palpable pressure vein is some its mean that the two part of vein is connected. * Trendelenburg Test :- Elevate the leg to 90 degree to empty the venous blood while pt is supine than occlude the great saphenous vein by manual compression make sure that you are not occluding the deeper vessels. Now ask pt to stand while you keep the vein occluded, look for venous filling Normally it fills from below and take 35 sec. After pt has stood for 20 sec release compression and look for any additional filling. Normally there is non these both tests term negative - negative in normal condition. It could be neg - pos, or pos - pos, or pos - neg, in dis condition. * Rapid filling of superficial vein while saphenous vein is occluded indicate incompetent valves in the communicating veins. * Sudden additional filling superficial vein after release of compression indicate incompetent valve in the saphenous vein. * Pressure sores results when sustained compression oblitrate arteriolar and capillary blood flow to skin usually occur in those who are confined to bed. * Local redness of the skin warn of impeding necrosis. some deep pressure sores develop without antecedent redness. * Dependent edema may occur in back of the bed pt and do not appear in legs. * Look for sacral edema in bed pt ( press firm for 5 sec). * Pulse of the normal ulnar artery however may not be palpable. * Allen Test :- is useful to assure the patency of ulnar artery before puncturing the radial artery for blood sample. ask the pt to make tight fist compress both radial and ulnar firmly than ask pt to open the hand in relaxed position, now release your pressure over the ulnar artery. if ulnar artery is patent the palm flushes in 3 - 5 sec. Similarly the patency of the radial artery may be tested by releasing the pressure from radial artery while compressing ulnar. * Persistent pallor hand with allen test suggest occluded artery. * Diminished or absent pulse at wrist may suggest arterial occlusion due to buergers dis (thromboangitis oblitrans). * Raised the both legs at about 60 degrees until max pallor of the feet develop, usually occur with in a min, marked pallor on elevation suggest arterial insufficiency. After that ask pt to sit with legs dangling down normally, 15 sec delay pinkness and venous filling suggest arterial insufficiency. Normal response accompanied by diminished arterial pulses suggest good collateral circulation develop around arterial occlusion. In blacks observe the feet for signs. * Persistent rubor of foot (sp if unilateral) on standing and pale on elevation suggest chronic arterial insufficiency. Look for thin shiny atrophic skin, loss of hair on foot, nail thickened and ridged, ulcers (gangrene may develop). **Chronic arterial insufficiency * Intermittent claudication pain at rest, Decrease Or absent pulse. * Pale color cool temp. vs. **Chronic venous insufficiency (advanced) * None to aching pain on dependency (on standing), normal Pulse but difficult to hear due to edema. * Color normal or cyanotic on dependency. Normal temp with Brown pigment with chronicity. * No or mild edema , pt dangle the leg to relieve pain * Edema often marked * Ulceration if present involve toe or points trauma on feet. * Ulceration if present develop at side of ankle often medially. * Hair loss, thickened & ridged nail, shiny skin. * show dermatitis thickening of skin with brown pigmentation. Gangrene may develop Gangrene not present

* In neuropathic ulcer pain is absent gangrene may or may not be present. Shows decreased sensation and absent ankle jerk. * Edema due to CHF first appear in the dependent area of the body where hydrostatic pressure is high (ie feet and leg), other signs are increase jugular venous pressure, tender liver and enlarged S3 sound. * Edema due to hypoalbuminemia may first appear in the loose subcutaneous tissue of the eye lids especially after night but may also shows in feet and legs. In advanced cirrhosis edema become generalized.(Anasarca) 32 NOT FOR COMMERCIAL USE OR SALE

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* Edema due to renal retention of salt and water usually start In the dependent area (legs) or may become generalized. * Edema due to venous stasis is limited to area of blockade (local), but blockade of superior vena cava may cause edema of entire upper part of the body causes include thrombophlebitis , incompetent valve, tumor, fibrosis etc. * Edema due to lymphatic stasis (lymphedema) is characteristically non pitting usually limited to the local area cases include tumor, fibrosis, inflammation. * Orthostatic edema cause by prolong sitting or standing, usually occur in dependent area (legs). Also occur in those who get up after prolong bed rest. * Edema due to increase capillary permeability is typically local (inflammatory). It may be generalized due to bee sting or drug related allergic reaction. * Fatty legs are not edema. * Lymphedema is soft earlier but becomes hard later. ----------------------------------------------------------------------------------MUSCULO SKELETAL SYSTEM * Synovial mem cover the articular cartilage and secret synovial fluid in synovial cavity. * At the center of each disc is a nucleous pulpous (fibrogelatinous material) form a cushion or shock absorber . * Bursae are disc shape, fluid filled synovial sac which is present at point of friction around joint to facilitate movement. * Prepatellar bursae lie b/w skin and convex surface of joint. * Subacromial bursae lie in area where tendon and muscle rub against bone, ligament and other tendon and muscles. * Sequence of hand joints :- Distal phalanx - Distal interphalangeal joints (DIP) - Middle phalanx - Proximal interphalangeal joints (PIP) - Proximal phalanx Metacarpophalangeal joint (MCP) - Metacarpal - Carpal - Wrist joints (Radio carpal) - Radius. * Thumb lacks the middle phalanxs. * Tendon travel in tunnel like synovial sheath which may become inflamed. * Bursae of elbow lie b/w Olecranone and skin. * Sensitive ulnar nerve can be felt posteriorly b/w olecranone and medial epicondyle. * Elbow produce flexion, extention, pronation, and supination of arm. * The Gleno humeral joint (not palpable) covered by 4 muscles called Rotator cuff, 1. Supraspinatous muscle 2. Infrasupinatous Muscle 3. Teres minor 4. Subscapularis muscle. * Deltoid muscle lie at subacromion bursae and subacromion bursae lies over supraspinatous tendon. * Movement of the shoulder are adduction, abduction, external and internal rotation. * Sequence of foot joints :- Distal phalanx - Proximal phalanx - Metatarsophalangeal joint - 1st metatarsal - Transversetarsal joint - Tibia. ****** posteriorly calcaneus (Heel) - Subtalar joint - Talas - Tibiotalar joint (Ankle). * Strong Achilles tendon insert on heel posterior (calcaneus). * Tibiotalar joint (ankle joint) cause dorsiflexion and planter flexion. * Inversion and Eversion of foot by subtar (talocalcarneal joint) and transverse tarsal joint. * An imaginary line along the foot bones extending from the head of the metatarsalto the calcaneus is called longitudinal arch. * Ankle (tibiotalar joint) consist of lateral and medial malleolus. * Knee joint consist of patella, femer and tibia. It contain 3 compartments 1. Medial & lateral compartment of tibiofemoral joint. 2. Patellofemoral compartment (b/w patellar & femur) * Patella rest on articulating surface of femur above tendon of quadriceps muscle from femur and insert on tibial tuberosity. * Two cruciate ligament cross obliquely with in the knee give anterioposterior stability. * One can palpate tibiofemoral jointby press the thumb downward in the joint while the knee is flexed about 90 degree. * The soft tissue in front of tibiofemoral joint is fat tissue. * The prepatellar bursae lies b/w the patella and overlying skin. vs. superficial infrapatellar bursae lie ant to the patellar tendon. * Femoral head contain greater trichinae & lesser trochanter. * Ant to the hip joint there is iliopectineal bursae (iliopsoas). Where as lateral to the greater trochanter is trochanteric bursae. * Ischeal (ischeogluteal) Bursae not always present, it lies under the ischeal tuberosity on which person sits (schiatia nerve lies close to it). * When foot swing medially femur rotates externally & when foot swings laterally femur rotates internally at hip joint. * A line drawn b/w the iliocrest crosses the spinous process of L4. * Posteriorly superior illiac spine crosses the sacral area. * Most mobile portion of spine is the neck. Flexion and extention occur b/w head and C1 vertebrae. * Rotation occur b/w C1 and C2 vertebrae. Where as lateral bending occur b/w C2 and C7 vertebrae. * The alteration of disc and vertebrae in old age contribute to KYPHOSIS and increase the anterioposterior diameter of chest in women. * Range of motion varies among individual and it decreases with old age . * Tenderness in or around the joint need mention specification like arthritis, tendonitis, bursitis, osteomyelitis, etc. * Use back of your finger to feel and compare heat in symmetrical joints if both are involved than compare with tissue near them. 33 NOT FOR COMMERCIAL USE OR SALE

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* Tenderness and warm over a thickened synovium suggest RA. * Palpable bogginess or doughiness of the synovial mem suggset synovitis. * Redness of the overlying skin of the joints with tenderness suggest septic or gouty arthritis, or rheumatic fever. * Crepitus palpable or audible crunching or grating produce over the joint suggest roughened articular cartilage of inflamed joint or osteoarthritis (OA). * Subcutaneuos nodule with joint sign suggest RA or Rheumatic fever. * Involvement of only one joint increase the likelihood of bacterial arthritis, RA typically involve several joints symmetrically . * Swelling, tender and decrease range of motion in temporomendibular joint suggest arthritis. * Ask pt to touch chin to chest and each shoulder than touch ear to corresponding shoulder, than finally extend the neck to evaluate mobility. * Immobile neck with head and neck thrust forward, contrasting with the Kyphotic thorax suggest ankylosing spondilitis . * Making fist or extending finger when is impair or painful suggest arthritis, inflamation of tendon sheath (tenosynovitis) and fibrosis in the palmar fascia ( Dupuytrens Contractures ). * Osteoarthritis of DIP appear as hard dorsolateral nodule called Heberdens Nodule. * Palpable PIP joint are involve more commonly in RA than in osteoarthritis. * Squeeze the metacarpophalangeal joint (MCP) on both side from both thumb of your hand, pain suggest synovitis, RA, Remember OA rarely involve MCP joints. * Bilateral swelling of wrist from several weeks suggset RA. * Gonococcal inf may involve the wrist or tendon sheath of the wrist (Gonococcal tenosynovitis). * Look for Olecranon process (at elbow) ,pain suggest bursitis. * Plapate the groove b/w epicondyle and colcannon for any sign. * Palpate sternoclavicular joint, acromioclavicular joint, subacromial area and bicepital groove for pain and look range of motion. * The most common cause cause of shoulder pain is rotator cuff tendonitis ( Impingement $ ). * Palpate ant aspect of ankle with your thumb, pain suggest local arthritis. * Pain along Achilles tendon suggest Achillis tendonitis or bursitis. * Nodule suggest rheumatoid arthritis. * Tenderness on compression of the metatarsophalangeal joint is the early sing of RA. vs. Where as acute inflamation of first metatarsophalangeal joint suggest gout. * Compress the feet b/w your finger and thumb look for tenderness exert pressure just proximal to the head of 1st and 5th metatarsal (foot palpation). * Palpate metatarsophalangeal joint individually to locate the origin of pain. * Stabalize the ankle (tibitalar joint) with one hand , grasp the heel with other hand and invert and evert the foot. In sprain ankle inversion and planter flexion cause pain where as eversion and dorsiflexion is relatively pain free. * Stabalize the heel than invert & evert the forefoot to localize the pain. * Inspect Bowlegs ( Qenu Varum ), knock knee ( Qenu Valgum ), Inability to extend fully ( flexion contractures ). * Feel supra patellar pouch, 10 cm above superior border of the patella. Swelling suggest synovial thickening or fluid eg in OA. vs. where as Pateller bursitis cause a more localize swelling ant to patella. * Bulge Sign :- Displace any fluid with the bulge of your hand. A bulge of returning fluid indicate the effusion of knee joint. * Balloon Sign :- press the right thumb and index finger on each side of patella and with your left hand press the suprapatellar pouch. Now with your right thumb and finger feel the fluid entering the space next to patella and note when fluid returns back. * Compress patella against underlying femur, ask pt to tighten the knee against table any cripitant or pain suggest patellofemur disorder. * Palpate tibiofemoral joint by flexing the pt knee to about 90 degrees, palpate ligament note point of tenderness or any irregular bony ridge. Bony ridge may suggest OA. * A tender swollen tibial tuberosity in an adolescent suggest OSGOOD - SCHLATTER DIS. * Posterior of the knee can be best palpate when pt is standing. * Ask pt to bent each knee against against the chest firmly observe the range of motion, flexion of opposite thigh at the same time suggest flexion deformity of the hip or lumbar lordosis. ( normally opposite thigh dont flex ). * Bending of knee against chest and internal rotation should be done. Ristriction of internal rotation indicates hip dis in arthritis. External rotation is also restricted. * Ristricted abduction is also common in hip disease. * Tenderness below the inguinal ligament and lateral to the femoral pulse suggest Iliopecteneal bursitis or Iliopsoas abscess. * Tender below and on the trichinae suggest trochantic bursitis. * Tenderness on ischial bursae and ischial tuberosity suggest ischial bursitis because of adjacent sciatic nerve pain from this bursitis may mimic sciatica. *Look for swelling in the popliteal space suggest bow leg, knock knees, bakers cyst (swollen bursae). * Unequal hight of the iliac crest cause pelvic tilt, Scoliosis. Adduction or abduction deformity of the hip also cause pelvic tilt. * Paravertebral muscle spasm and ankylosing spondylitis may prevent flattening (lumbar concavity persist while flexion). 34 NOT FOR COMMERCIAL USE OR SALE

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* As person flex the lumbar concavity should flattened out normally. * Sit behind the pt stable the pelvic ask pt to bend laterally, forward and backward and than twist the shoulder one away from than other. Decreased mobility suggest osteoarthritis or ankylosing sodalities. * A spinous process of L5 or L4 that feel unusually prominent in relation to the one above it suggest Spondulolisthesis of prominent vertebrae. * Thumping of spine with ulnar surface of your fist when produce pain suggest OA, malignancy or infection. * Remember tenderness of costovertebral angle ,may suggest kidney infection rather than musculo skeletal. * Herniated intervertebral disc (commonly b/w L4 -L5 or L5 - S1)may produce tenderness of the spinous process, intervertebral joint, paravertebral muscle, sciatica notch or sciatica nerve. * Rheumatoid arthritis may also cause tenderness of intervertebral joints. * Ankylosing sodalities may cause sacroiliac tenderness. * For lower back pain with radiation into leg, ask pt to lie down and raise the leg straight up until pain occurs, than dorsiflex the foot. Sharp pain radiating from back down to leg in L5 - S1 distribution (radicular pain) suggest tension or compression of the nerve root often cause by herniated lumbar disc. Dorsiflexion of foot increases the pain in the effected leg. Increase pain in effected leg when opposite leg is raised strongly confirm radicular pain and constitute + ve crossed straight leg raising sign. * Pain & numbness in the hand specially at night suggest compression of median nerve in carpel tunnel. Through the tunnel run flexor tendon & median nerve. * Hold the pts wrist in acute flexion for 60 secs. If numbness and tingling develop over the distribution of median nerve which is palmar surface of the thumb, index, middle and part of ring finger. This suggest +ve Phalen Test and so Carpal Tunnel $. * Tinels Sign :- Percuss lightly over the course of median nerve with your finger. In the Carpal Tunnel $ tingling or electric sensation over median nerve distribution suggest +ve Tinel,s sign and so suggest Carpal Tunnel $. * Measures pts legs is done by measuring the distance b/w anterosuperior spine and medial malleolus. Tape should cross the knee on its medial side. Unequal length may explain scoliosis. * Explain the range of movement by degrees . For eg * Elbow flex from 45 - 90 degrees or elbow has flexion deformity of 45 degree and can be flex further to 90 degree. * Supination of elbow 30 degree ( 0 - 30 degrees). * Pronation of elbow is 45 degree ( 0 - 45 degree). * Nodules on distal interphalangeal joints (Heberden Node) and the proximal interphalangeal joint nodes (Bouchards Node) are usually present OA , it also shows ulnar deviation of distal phalanx. Metacarpopahlangeal joint are spared . vs. Radial deviation when finger deviate toward thumb and ulnar deviation when finger deviate toward little finger. * Tender painful stiff joints are characteristics of RA symmetrical involvement of both joints are typical. Proximal interphalanges, Metatarsophalangeal, and wrist are frequently involved. Look for spindle shape swelling of proximal interphalanges. * Chronic RA shows thickening of proximal interphalanges and metacarpophalangeal joints. Finger may be deviate to ulnar side . Finger may show Swan Neck Deformity (hyperextention of proximal interphalangeal joint and fixed flexion of distal interphalangeal joint), and Boutonniere Deformity (persistent flexion of proximal interphalangeal joint hyperextension of distal interphalangeal joint). * Rheumatoid nodules may appear in chronic and acute stage. * Chronic tophaceous gout some time mimic OA and RA. Knobby swelling around the joint some time ulcerate and discharge white chalk like water (uric crystal). * Ganglion are Cystic round usually nontender swelling around the tendon sheath in hand and joint capsule it may develop else where at ankle and feet. * Acute tenosynovitis is infection of flexion tendon sheath may follow local injury even of apparently trivial nature. Ext is painful. * Acute tenosynovitis may progresses to Thenar space or else where in the palm early Dx and Tx is important. * Injury to the finger tip may case infection of finger pad result into painful swelling wih dusky redness. This dis called Felon. * Dupuytrens Contractures (flexion contractures) caused by thickened plaque overlying the flexor tendon of the ring finger; thickened fibrotic cord develop b/w palm and finger, flexion contracture ensues. * Trigger Finger cause by painless nodule in the flexor tendon in the palm near the head of metacarpal feel for nodule on snap. * Thenar Atrophy suggest disorder of median nerve and its component eg Carpal Tunnel $ or Median Nerve Disorder. * Hypothenar Atrophy ulnar nerve disorder. * Olecranon Bursitis may develop from trauma, RA, Gouty arthritis. * Lateral Epicondylitis (tennis elbow) follows repetitive extention of wrist or pronation or supination of the arm. Pain on lateral epicondyle, extension of wrist against resistance cause increase in pain. * Medial epicondylitis (pitchers ,golfers, or little league elbow) Follows repetitive wrist flexion as in throwing. Wrist flexion against resistance increases pain in medial epicondyle. * Arthritis of elbow cause bysynovial inflammation or fluid is felt best in the groove b/w Olecranon and epicondyle. Palpate boggy soft, Fluctuant swelling for tenderness. * Impingement or Rotator cuff tendonitis occur when rotator cuff (arm) impinge against the acromian and coracoacromial ligament. Repeated event cause edema, hemorrhage, inflammation and fibrosis. Tenderness is max just below the tip of acromian, arm elevate over the head cause sharp pain. 35 NOT FOR COMMERCIAL USE OR SALE

Prepared by Dr. IRFAN MIR

ONLY FOR EDUCATIONAL PURPOSE

* Rotator Cuff Tear repeated impingement cause partial or complete tear of acromian and coracoacromial ligament usually after 40 yrs of age. It cause Supraspinatus & Infraspinatus muscle pain and tenderness in partial tear where as complete tear cause characteristic shoulder shrugging. * Calcific tendonitis refer to degenerative process in tendon it is associated with deposition of Ca++ salt. It involve suprasspinatous tendon, usually in pt over 30 yrs of age. Tenderness is max below the tip of the acromian, more often in women. It mimics impingement $. * Bicipital Tendonitis is inflammation of the bicep tendon. It cause ant shoulder pain resembles rotator cuff tendonitis. Tenderness is max in bicipital groove. Ask the pt to supinate the forearm against resistance with pt elbow flexed 90 degrees. Increase pain confirm disorder. * Acromioclavicular Arthritis is uncommon cause of direct injury to shoulder girdle with resulting degenerative changes. Tenderness over acromioclavicular joint, where as motion of the Glenohumeral joint is not painful unlike other shoulder condition. * Adhesive capsulitis (Frozen shoulder) is refer to mysterious fibrosis of the of the glen humeral joint capsule . Diffuse dull aching pain with restricted motion ensues. Usually unilateral b/w age 50 - 70 yrs with often antecedent painful disorder of shoulder or possible Myocardial Infarction. Course is chronic resolve spontaneously at least partially. * Metatarsophalangeal joint of the great toe may be the first joint involve in the acute gouty arthritis shows pain with hot dusky red swelling. Acute gout may also involve the dorsum of the foot do not mistaken with cellulites. * Hallux Valgus is the great toe abnormally abducted in relationship to the 1st metatarsal which is self deviated medially. Area may become inflamed and painful. * Flat feet may cause tenderness from medial malleolus down along the medial planter surface of foot. * Ingrown toe nail may dig and injure the lateral nail fold resulting in inflammation and infection. It may present granulation tissue with purulent discharge. It commonly involve great toe. * Hammer Toe commonly involve the 2nd toe characterize by hyperextension of metatarsophalangeal joint and flexion of proximal interphalangeal joint. Corn frequently develop over pressure point which is proximal interphalangeal joint. * Corn develop due to pressure over the skin (dorsum of foot) cause pain. It may develop on moist area called Soft Corn. * Callus like Corn occur on thick skin due to pressure such as sole (planter surface) it is usually painless but if produce pain suspect underlying planter wart. * Planter Wart (Verruca Vulgaris) located on thick skin of sole, look like callus but look for small dark spot that gives a stippled appearance of Wart. Normal skin line stop at the Warts edge unlike callus. Usually it is painful. * Neuropathic Ulcer develop at sole on pressure points usually infected, indolent(painless), suspect central or peripheral neuropathy like DM etc. * When there is flattening of lumbar curvature, look for muscle spasm in lumbar area and decrease spinal mobility these combination of signs suggest possibility of herniated lumbar disc or ankylosing spondylitis sp in men. * Lordosis (lumbar lordosis) is accentuation of normal lumbar curve develop to compensate protuberant abdomen of pregnancy or obesity, Kyphosis (compensation effect). * Kyphosis is a rounded thorax convexity common in aging sp in women. If the pt is adolescent consider Scheuermanns dis. * Gibbus is an angular deformity of collapsed vertebrae caused by metastatic cancer, tuberculosis of the spine. * Scoliosis is the lateral curvature of the spine may cause thoraxic convexity of one side of the thorax. When deformity can be seen with pt flex forward, that is one side of the thorax bulge posterior and other side bulge or displaces interiorly called Structural Scoliosis. (Plumb line from spinous T1 fall in gluteal cleft but some time not). vs. where as when scoliosis compensate for another abnormality such as unequal leg length called Functional Scoliosis. It neither involve vertebral rotation nor thoracic abnormality and scoliosis disappear with forward flexion. * List is lateral tilt of spine when a line drop from T1 (plumb line) it falls to one side of the gluteal cleft, causes are herniated disc, muscle spasm, scoliosis. NERVOUS SYSTEM * Myelin sheath create the white color of brain contain tracts called Axons. * Basal ganglia (Straite nuc) is additional cluster of Gray matter (neuron) in the brain which initiate and execute movement. * Thalamus & Hypothalamus ( In Diencephalons ) is another cluster of Gray mater. Thalamus process sensory impulse and relay them to cerebral cortex. vs. where as Hypothalamus maintain endocrine sys. * Internal Capsule is a White matter. Myelin fibers converage from all part of the cerebral cortex into it and descend it to the brain stem. * Consciousness depends on higher center and reticular activating (arousal) sys in Diencephalon and upper brain stem. * Cerebellum coordinate the movement that maintain body up right in space. * Spinal cord also maintain reflex activity. * CN II to CN XII arise from Diencephalon and brain stem nuclei. * CN I and CN II are fiber tract emerging directly from brain. * CN I -------- Olfactory nerve (S) -------- Sense smell. * CN II -------- Optic nerve (S) ----------- vision. * CN III -------- Occulomotor nerve (M) ---------- Pupillary constriction, opening of eye, and eye movement. * CN IV -------- Trochlear nerve (M) ----------- Downward Inward movement of eye. 36 NOT FOR COMMERCIAL USE OR SALE

Prepared by Dr. IRFAN MIR * CN V

ONLY FOR EDUCATIONAL PURPOSE

* CN VI * CN VII * CN VIII * CN IX * CN X

-------- Trigeminal nerve (S,M) ----------- 1. Motor Mastication, lateral movement of jaw. ----------- 2.Sensory Ophthalmic sensation by V 1 Maxillary sensation by V 2 Mendibular sensation by V 3 -------- Abducen nerve (M) ----------- Lateral deviation of eye. -------- Facial nerve (S,M) ----------- Taste of ant 2/3 of tongue, Facial expression, Closing eye & mouth, Control Submendibular, lingual & lacrimal gland. -------- Acoustic or Vestibular nerve (S) ----------- Hearing and balance. -------- Glossopharangeal nerve (S,M) ----------- Taste post 1/3 of tongue, Sensation from soft palate or pharynx, Sensory part of gag reflex, Carotid sinus reflex, parotid gland.

-------- Vagus nerve (S,M) ----------- Sense soft palate & pharynx, External auditory meatus, Motor part of gag Reflex Sense larynx, control swallowing, abdominal and thoraxic viscera Autonomically. * CN XI -------- Accessory nerve (M) ----------- Neck movement (trapazius and sternocloid). * CN XII -------- Hypoglossal nerve (M) ----------- Muscle of tongue and Hyoid bone. * Each peripheral nerve has ant (ventral) root containing motor fiber and post (dorsal) root containing sensory fiber these both merge to form spinal nerve fiber than Spinal nerve fiber comingle with similar fiber to form peripheral nerve. * Triggering spinal reflexes known as muscle stretch or deep tendon reflex. Because a selected segmental level sensory neuron fire the ant horn cell directly producing the reflex. Thus reflex relay over central and peripheral nervus sys. **Reflexes :* Ankle reflex :- correspond S1 primarily * Knee reflex :- correspond L2, L3, L4. * Supinator or Brachiodorsalis Reflex :- correspond C5, C6. * Bicep reflex :- correspond C5, C6. * Tricep reflex :- correspond C6, C7. * Upper abdominal reflex :- correspond T8, T9, T10. * Lower abdominal reflex :- correspond T10, T11, T12. * Planter reflex :- correspond L5, S1. * Three kind of motor pathway impinge on the ant horn cell. 1. Corticospinal tract (Pyramidal tract) Control motor activity of muscle (skilled movement). Its fiber from CNS when enter Spinal cord (lower motor neuron) called Corticobulbar tract. 2. Extrapyramidal system is complexed include motor pathway b/w cerebral cortex, basal ganglia, brain stem, spinal cord out side the corticospinal tract. It maintain muscle tone, control body movement, sp automatic stereotype movement. (eg walking). 3. Cerebellar system received both sensory and motor input, coordinate muscle activity, maintain equillibrium & control posture. * All three higher motor pathway effect movement only through LMN called final pathway. * Damage to LMN cause Ipsilateral defecit result in decrease muscle tone and reflexes. * Neither extra pyramidal nor cerebella dis cause paralysis but each can be disabling. Extrapyramidal damage specially basal ganglia produce change in muscle tone, most often increase in tone, slow or lack of spontaneous or automatic movement (bradykinesia), disturb posture o gait. vs. where as cerebella damage impair coordinaton, gait, equillibrium and decrease muscle tone . * Pain and temp sensation cross the spinal cord and pass upward in spin thalamic tract of the cord. * position and vibration pass directly to the post column ascend upward and cross midline at medullary level and continues to thalamus (MLS. Medial leminiscal sys). * Light touch takes one or two pathways. It enter into post column has accurate localizarion & finely discriminating (MLS). * Crude touch sensation precieved as light touch without accurate localization, it uses spinothalamic tract. * Light and Crude touch fiber synapse at post horn ascend into spinothalamic tract of opposite side of thalamus. Touch sensation often preserved despite partial damage to cord because touch sensation of one side of the body ascend by both side of cord.* A lesion in sensory cortex may not impair the preception of pain, touch, and position but does impair fine descrimination. * Loss of position and vibration sense with preservation of other senses suggest dis of post column. * Loss of sensation of the waist down together with paralysis and hyper active reflexes in leg indicate transection of spinal cord. * Imp Dermatomes :37 NOT FOR COMMERCIAL USE OR SALE

Prepared by Dr. IRFAN MIR * C3 --- innervate front of neck * C6 --- innervate thumb and radial arm * C8 --- innervate ring and little finger

ONLY FOR EDUCATIONAL PURPOSE

* T4 --- Innervate the nipple * T10 --- umbilicus * L5 --- ant anle and foot (great and two other toes) * L3 --- knee and distal thigh * L1 --- Innervate inguinal area * S1 --- heel * S5 --- perianal area * Aged person develop benign essential tremor, the tremor is usually slightly faster with no muscular rigidity. vs. where as Jaw, lip, head hands may tremble at rate and amplitude with muscle rigidity suggest Parkinson * Age may also decreases the reflexes and senses (like vibration and position) symmetrically, if it is asymmetrical look for neurologic abnormality. * For neurologic examination organize yoyr thinking into 5 categories. 1. Mental status and speech. 2. Cranial nerve function. 3. Motor system. 4. Sensory system. 5. Reflexes. * The join function of CN V, VII, X, XII produce speech and sound. * CN I (Olfactory n) :- Test the sense of smell by presenting fimiliar odor like coffee, vanilla, cloves, first with open eyes than with close eyes, one nostril at a time. Loss of smell may include trauma, smooking, cocaine use, congenital. * CN II (Optic n) :- Screen the visual field by confrontation. Any defect suggest visual extincton due to lesion in the parietal cortex, or occipital cortex (eg stroke , tumor etc) called Anopsia. * CN II & III (Optic & Occulomotor n) :- Examin the papillary reaction to light examin the near response. * CN III, IV & VI (Occulomotor, Trochlear & abducen n) :- Test extraoccular movement in 6 cardinal direction of gaze. Look for loss conjugate movement in any of 6 direction. Look for nystagmus and its direction (quick and slow component) and plane (horizontal, vertical, rotatory, mixed). Ptosis for ptosis (dropping of upper eyelid) which is Occulomotor nerve III palsy may also suggest Horner $ and myasthenia gravis. * CN V (Trigeminal n) :- Sensory test -- Take sharp and dull object to test all three trigeminal fields. Forehead, cheek, and jaw for pain with eye closed. Ask pt to report whether it is dull or sharp if finding are abnormal confirm it by temp sensation test with hot and cold water or tunning fork. Light touch test can be done by fine wisp of cotton. Ask pt to respond when you touch the skin. Unilateral loss of sensation suggest lesion of Trigeminal nerve V or interconnecting higher sensory pathway, such sensory loss may also be associated by conversion reaction. * CN V (Trigeminal n) :- Motor test -- Ask pt to clench teeth note the strenght weakness on one side suggest lesion of Trigeminal nerve V. Bilateral weakness suggest periphera or central involvement. The test is difficult to interpretate when pt has no teeth. palpate both muscles temporal and massetter. * Corneal reflex test :- Ask pt to look upward touch the cornea not just the conjunctiva with fine wisp of cotton. Look for blinking sensory part of the reflex carry by Trigeminal nerve V. vs. where as motor part of reflex carry by Facial nerve VII. Absence of sensory part of reflex suggset Trigeminal nerve V lesion where as absence of motor part reflex suggest facial nerve VII lesion. Contact lens may abolish this reflex. * CN VII (Facial n) :- Inspect face at rest and also during conversation look for asymmetry tics or other abnormal movement, flattening of nasolabial fold and drooping of lower eyelid suggest facial nerve weakness. Ask pt raise both eye brows, frown, close both eye against the force of your hand. Show both lower and upper teeth, smile puff out both cheeks, note any weakness or asymmetry, if there is any suggest Bells palsy, stroke, paralysis or tumor. * CN VIII (Vestibulochoclear n) :- (Acoustic n) Assess hearing than test for lateralization and compare air and bone conduction. Nystagmus may indicate vestibular dysfunction. * CN IX, X (Glossopharyngeal & Vagus n) :- Listen to the pt voice does it have nasal quality or hoarseness if yes hoarseness suggest vocal cord paralysis vs. where as nasal sound suggest paralysis of palate or congenital partial palate. Ask pt to yawn or say Aah watch movement of the soft palate and pharynx, soft palate normally raised symmetrically and uvula remains in middle and port pharynx move medially. If palate fail to rise suggest bilateral lesion of vagus nerve X. * Lost of Gag reflex by stimulating the back of throat each side (it may be decrease or absent in some normal people) sugget lesion of Glossopharyngeal nerve IX or Vagus nerve X. * CN XI (Accessory n) :- Look for atrophy or fasciculation the trapazius muscle compare both sides. Ask pt to shrug both shoulder upward against your hand, note strength and and contraction of trapazius. Weaknes with atrophy and fasciculation indicate peripheral nerve disorder. When trapazius is paralyzed the shoulder droop and scapula displaced downward & laterally. Ask pt to turn head on each side (laterally) against your hand force observe the contraction of stern mastoid, note the strenght. Bilateral weakness cause difficulty raising the head of the pillow. * CN XII (Hypoglossal n) :- Listen to the articulation of the pts words it depend upon CN V, VII, X, XII. Look for pts tongue lie on the floor of the mouth any atrophy or fasiculation suggest peripheral nerve dis. Look for pt tongue protrude out note symmetry and atrophy or deviation unilateral lesion of weak side is suggested. Ask pt to move tongue side to side and push the tongue against the cheek and palpate strenght externally and note symmetry. * Increase in muscle bulk with diminish strength is called pseudohypertrophy seen in Duchenne muscular dystrophy. * Flatening on Thenar and Hypothenar aminence and furrowing b/w the metacarpel suggest atrophy. Localized atrophy of Thenar and Hypothenar eminence suggest damage to medial and ulnar nerve respectively. * Fasiculation suggest peripheral nerve damage as a cause of atrophy. If u see none tap on the muscle with a reflex hammer you may stimulate them. * Muscle tone is a slight muscle tension during relaxation in normal muscle. This can be assessed by flexing and extending a muscle on both side. Tense pt shows increase resistense. 38 NOT FOR COMMERCIAL USE OR SALE

Prepared by Dr. IRFAN MIR

ONLY FOR EDUCATIONAL PURPOSE

* If you suspect decrease resistence (muscle tone) hold forearm and hand loosly back and forth normally the hand move freely but never completely floppy. Floppiness indicate flaccid muscle. * Increase resistance that varies commonly worsen at extereme of the range called Spasticity. vs. where as resistance that persist through out the range and in both direction is called lead pipe rigidity. * To assess muscle tone in leg support the pt thigh with one hand and grasp the foot with other hand than flex and extend the knee and ankle on each side to note the resistance. * Impair muscle strenght is called Paresis (weakness). absence of strength is called Plegia (paralysis). weakness of one half of the body is Hemiparesis. paralysis of one half of the body is called Hemiplegia. paralysis of leg is Paraplegia. paralysis of all 4 extremities called Quadriplegia. * Measure strength is graded from 0 - 5 scale. * 0 --- no muscle contraction detected. * 1 --- barely detectable flicker or trace of contraction. * 2 --- active movement with gravity eliminated. * 3 --- active movement against gravity. * 4 --- active movement against gravity and some resistence. * 5 --- active movement against full resistance without fatigue. * If muscle is too weak to overcome resistance test then against gravity alone or with gravity eliminated. For eg Dorsiflexion of the wrist can be tested against gravity alone and when forearm is midway b/w pronation and supination extention of the wrist can be tested with gravity eliminated. * Flexion test --- C5, C6 --- bicep strength. Extention test --- C6, C7, C8 --- tricep strenght. Both can be done by pusing and pulling against your hand at elbow. * Extention of wrist test --- C6, C7, C8, radial nerve --- can be done by asking pt to make fist and resist while your pulling it. Weakness suggest peripheral nerve disorder or radial nerve damage. * Grip test --- C6, C8, T1 --- ask pt to squees two of your finger hard and not to let them go while you pull them. Weakness suggest central or peripheral nervous system disorder or painful disorder of hand. * Finger abduction test --- C8, T1, ulnar nerve --- spread the pts finger ask him not to adduct against you are forcing on them weakness suggest ulnar nerve disorder. * Opposition of thumb test --- C8, T1, median nerve --- ask pt to touch the tip of the little finger with the thumb against your resistance . Weakness suggest median nerve disorder or Carpal tunnel $. * Hip flexion test --- L2, L3, L4, iliopsoas --- ask the pt to raise the leg against resistance on his thigh by your hand. * Hip adduction test --- L2, L3, L4, adductors --- ask pt to bring both leg together while you maintain resistance to keep them open. Pt should be in supine position. * Hip abduction test --- L4, L5, S1, gluteus medial & minimus --- place your hand firmly on the bed out side the pt knee and ask pt to spread both leg against the resistance. * Hip extension test --- S1, gluteus maximus --- ask pt to push posterior thigh down against your hand resistance. * Symmetrical weakness of the proximal muscle suggest myopathy, vs. where as symmetrical weakness of distal muscles suggest polyneuropathy. * Knee extension test --- L2, L3, L4, quadriceps --- support the knee in posteriorly in flexed position and ask pt to straighten his leg against your hand. * Knee flexion test --- L4, L5, S1, S2, hamstring --- pull the flexed leg with one hand on the knee and other hand under the ankle and ask the pt not straighten the leg while you push the knee to straighten it. * Dorsi fexion test --- L4, L5 --- ask the pt to pull up and push down the feet against hand resistance. Planter flexion test --- S1 --- same as dorsiflexion test * Rapid alternating movement :- ask the pt to strike one hand on his thigh raise the hand turn it over and than strike the back of the hand on the same place again & repeat this alternating movement. Failure to do so suggest cerebellar dis, upper motor neuron weakness, of extra pyramidal dis. * If one movement cannot follow quickly by its opposite movement (rapid alternating movement) or it is slow, irregular or clumsy than it is called Dysdiadochokinesia. it suggest cerebellar dis, upper motor neuron dis, extra pyramidal dis. * Ask the pt to tap distal joint of thumb with the tip of index finger rapidly failure to do so or slow clumsy movement suggest dysdiadochokinesia. * ask the pt to tap your hand as quickly as possible with the ball of each foot in turn note slowness awkwardness if present suggest dysdiadochokinesia of cerebellar dis. * Ask the pt to touch his nose with the tip of his finger. In cerebella dis movement are clumsy, unsteady or inappropriate. When finger over shoot its mark and than reach it fairly well such movement are called Dysmetria. * Position sense test :- Ask the pt to touch your steady finger with the tip of his index finger and ask him to so with closed eyes. Normal people perform it well. Failure to perform suggest failure of position test cause by Labyrinth or cerebellar disorder. * Cerebellar disorder cause incoordination that may get worst with eye closed. Inaccuracy with eye closed suggest loss of position sense. Repetitive and consistent deviated to one side movement which worst with eye closed suggest cerebellar or vestibular dis. * Ask the pt to place one heel on opposite knee and than run it down to ward big toe, note accuracy and smoothness. Repeat it with eye closed for position 39 NOT FOR COMMERCIAL USE OR SALE

Prepared by Dr. IRFAN MIR

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sense failure to do so or over shooting target suggest cerebellar dis or vestibular dis. * Note gait, ask pt to walk across the room. If gait lack coordination with reeling and instability is called Ataxia. Ataxia may suggest cerebellar dis, loss of position sense or intoxication. * Heel to toe walk (Tandem walk) it may reveal ataxia that was not previously obvious. * Walk on the toe and than on to heel are sensitive test respectively for planter flexion and dorsiflexion of ankle as well as balance. Failure suggest distal muscular weakness, or upper motor neuron weakness (UMN). * Hop in place on each foot require good position sense and normal cerebella function. * Shallow knee bend first on one leg and than on other on standing position. Difficulty suggest proximal weakness (extensor of the hip) or weakness of the quadriceps (extensor of the knee) or both. * Rising from the sitting position with out support and stepping up on a sturdy stool are more suitable test than hoping or knee bend when pt is old. People with proximal muscle weakness involving pelvic girdle & leg have difficulty in rising up & stepping up. * Romberg test (position sense test) :- pt should stand with feet together with open eyes and than close both for 20 - 30 sec with out support. In atexia due to loss of position sense vision compensate for sensory loss. Pt stand well with open eyes and loss balance with eye closed (+ve Romberg test). In cerebella atexia the pt has difficulty standing with feet together whether eyes are closed or open. * Pronator drift test :- Pt should stand 20 - 30 secs with both arm straight forward palm up and eye closed. A person who can not stand may tested for pronator drift in sitting position. The pronator of one arm suggest contra lateral lesion of corticospinal tract. (Downward drift of the arm with finger flexed or elbow flexed during test called pronator drift). After that ask pt to keep arm up and eyes shut, tap the arm briskly downward, arm usually return to normal horizontal position. This response when weak in one arm suggest lack of position sense. In cerebellar incoordination arm return to its original position but overshoot and bounce. When pronator drift test shows side or upward drift with searching writhing movement of the hand suggest loss of position sense. * Evaluate sensory system test :- Pain & temp -------- Spinothalamic tract Position & vibration ------ Post column (medialleminiscal sys) Light touch ------- Spinothalamic tract and post column Discriminative sensation -------- post column and cortex * Sensory testing may quickly fatigue pt and than produce unreliable results. Conduct examination as efficiently as possible. * Meticulous sensory mapping help to establish the level of spinal cord lesion or peripheral nerve or its branches. * Hemisesory loss occur due to lesion in the spinal cord or higher pathway. * Compare pain temp touch from distal area to proximal area of extremities. Symmetrical distal sensory loss suggest polyneuropathy ** Suggested sensory examination pattern include. * Both shoulder --- C4. * Inner & outer aspect of both arm ---- C6, T1. * Thumb & little finger --- C6, C8. * Front of both thigh --- L2. * Medial & lateral aspect of both Calves --- L4, L5. * Little toe --- S1. * Medial aspect of each buttock --- S3. * When testing vibration and position sense first test the finger and toes. If these are normal safely assume proximal area will be normal. * Map out the boundaries of sensory loss or hypersensitivity in repetitive fashion from distal to proximal direction. * Bilateral sensory loss of poly neuropathy in gloves and stocking pattern often seen in alcoholism and DM. * The pts eye should stay closed during sensory testing. * Pain can be tested with pin by asking it is dull or sharp. Analgesia refer to absence of pain. Hypogesia refer to decrease sensitivity to pain. Hypergesia refer to increase sensitivity to pain. * Temp sensation is often omitted if pain sensation is normal but include it if is there any question of hot and cold. * Test light touch with fine wisp of cotton. Touch the skin lightly avoid pressure calloused skin is insensitive should be avoided. * Anesthesia is absence of touch sensation. Hypoesthesia or Hyperesthesia is decrease or increase sensitivity to touch sensation. * Vibration sense :- use tunning fork tap it on your heel place it firmly over the distal interphalangeal joint of pt and than interphalangeal joint of big toe. Ask what pt feels. If pt is uncertain ask pt to tell when vibration stops, and than touch the fork to stop it. If vibration sense is impaired proceed more prominent bony prominence (wrist, elbow, medial malleolus, spinous process, clavicle, etc) * Vibration sensation is often a first sensation to be lost in peripheral neuropathy common causes include DM, alcoholism. * Vibration sensation also lost in posterior column dis as in tertiary syphilis , Vit B12 deficiency. * Testing vibration sense in the trunk may be useful in estimating the level of cord lesion. Aging also decreases the vibration sensation. * Position sense :- hold the big toe by your index finger and thumb and pull it away laterally than upward and downard ask pt to tell position each time with eye closed. If position sense is impaired move the test proximally to detect spinal or peripheral lesion. * Loss of position like loss of vibration suggest posterior column dis (mediallaminiscal sys) or lesion of preipheral nerve or root. * Discrimination Sensation :- This test depend on touch and position sense. Pts eye should closed all the time. Start with, * Steriogenesis test -- abiliy to identify objects by feeling it eg coins, key, pen, cotton ball, ask pt to distinguish head From tail. On coin its a sensitive test. 40 NOT FOR COMMERCIAL USE OR SALE

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* Number identification test (Graphesthesia) :- Draw a number with blunt edge of pencil or pen on pts palm and ask. * Two point discrimination test :- use the side of two pins or clip touch a finger pad on two places alternate a double stimulus, Irregularly with one point t touch (not too hard), distance b/w the two points is < 5 mm on finger pad. * Point localization test :- Touch a point on pts skin than ask apt to open a eye and point the placed touched. Test is Specially useful on the trunk & legs. * Extinction test :- Simultaneously touch corresponding area on both side of the body ask pt whether he feel it or not. * When discrimination sensation is impaired pt can not respond appropriately to discrimination test it suggest sensory cortex dis. * Steriogenesis , number identification, and two point discrimination also impaired by post column dis (MLS). * Lesion of the sensory cortex Increases the distance b/w two recognizable point. * During extinction test only one stimulus may be recognized suggest lesion of the opposite sensory cortex. * Asteriogenesis is inability to identify the object with eye closed. Suggest post column dis (MLS). * Reflexes are graded on 0 - 4 scale. * 4 + very brisk hyperactive with clonus (rhythmic oscillation b/w flexion and extension) . * 3 + Brisker than average (possible but not indicative of dis). * 2 + average normal * 1 + some what diminished - low normal. * 0 + no response. * Hyperactive reflexes suggest CNS dis sustained clonus confirmed it. * Reflex may be diminished or absent when sensation is lost or spinal segment is damaged, or peripheral nerve is damaged. Dis of muscle or neuromuscular junction may also decreased reflexes. * Reflexes response depends partially on your force use no more force than you need to provoke a definitive response. * Symmetrical diminish or even absent reflex may found in normal people. * When reflex is symmetrically diminished or absent use reinforcement technique ( it involve isometric contraction of other muscle that may increase reflex activity ) for eg ask pt to clench his teeth or squeeze one side thigh with opposite hand while you check the arm reflex of other hand or ask pt to pull both hand against each other while u check the leg reflexes. * Bicep reflex ( C5, C6 ) :- pts arm should be partially flexed 45 degrees place your thumb firmly on bicep tendon strike the reflex hammer on thumb toward bicep tendon (ant to elbow), observe flexion of elbow. Watch and feel contraction of bicep muscle. * Tricep reflex ( C6, C7 ) :- flex pt arm at 90 degree with palm toward the body and pull it slightly across the chest strike the tricep tendon above the elbow posteriorly watch contraction of the trice and extention at elbow (ask pt to let the arm go before you strike). * Supinator and brachioradialis reflex (C5, C6 ) :- pts hand should rest on abdomen or thigh (lap) with forearm partially pronated strike the radius about 1 2 inches above the wrist watch for flexion and supination of the arm. * Abdominal reflex :- test the abdominal reflex by lightly but briskly stroke on each side on abdomin above (T8, T9, T10) and below (T10, T11, T12) the umbilicus. Use woodened end of the cotton tipped applicator or tongue blade (splitted) fro stimulus note contraction. Obesity may mask abdominal reflex. * Abdominal reflex may be absent in central or peripheral nervous system. * Knee reflex ( L2, L3, L4 ) :- Tap briskly the patellar tendon just below the patella with knee in flexed position note contraction of the quadriceps with extension at the knee. * Ankle reflex ( S1 ) :- Dorsiflexion of the foot at ankle with pt sitting strike the Achilles tendon watch and feel for planter flexion, note speed pf relaxation after muscle contraction. Slowed relaxation phase of reflex in hypothyroidism is often seen and felt in ankle reflex. * Planter response ( L5, S1 ) :- Stroke the lateral aspect of the sole curving medially toward the toe with sharp dull object. Note movement of the toe which flex normally. Dorsiflesion of the big toe accompanied by fanning of the other toe constitute Bibinski Response often indicate the CNS lesion in corticospinal tract. Alcohol intoxication, and epilepsy also cause Bibinski Response. * A marked Bibinski response is occasionally accompanied by reflex flexion of hip and knee. * Clonus :- If the Bibinski reflex seems hyperactive test for ankle clonus, support the knee in partially flexed position with your other hand Dorsiflex and Planter flex the foot few time which encourage the pt to relax and than sharply Dorsiflex the foot and maintain it in Dorsiflexion . Look and feel for rhythmic osscillation b/w Dorsiflexion and Planter flexion. Normally ankle does not react to the stimulus in most people but may be seen in tense and exercised pt. Sustained clonus may indicate CNS dis. * Clonus can also be illicit in other joint eg sharp downward displacement of patella may illicit patellar clonus. * Asterixis :- Ask pt to stop traffic by holding both arm forward with hand locked up and finger spread watched for one or two minutes. Sudden brief non rhythmic flexion of the hand and finger indicates Asterixis causes include metabolic encephalopathy in pt whose mental function are impaired. * Winging of scapula :- Ask the pt to extend his arm against your hand or wall (resistance). Observe the scapula normally scapula lies close to thorax. In winging scapula juts (lift) backward suggest serratus ant muscle weakness or muscular dystrophy or thoracic nerve injury. Scapula may appear winged in very thin people too. * Meningeal sign :- Flex and extend the neck, pain and resistance suggest meningeal inflammation, arthritis or neck injury. * Brudzinskis sign :- When flex the neck note flexion of the hip and knee (brudzinski,s sign). Usually hip and knee remain relax, if hip and knee flex suggest meningeal inflammation. 41 NOT FOR COMMERCIAL USE OR SALE

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* Kernings sign :- Flex the pts leg at both hip and knee and than straighten the knee discomfort behind the knee during full extension occur in may normal people but this maneuver should not produce pain, +ve kernings sign when pain and resistance occur on extending the knee when it is bilateral suggest meningeal irritation. * Compression of lumbosacral root may also cause resistance and pain in low in lower back and post thigh, but usually in one leg. Where as in both leg (+ve kernings sign) suggest meningeal irritation. * Anal reflex ( S2, S3, S4 ) :- Using dull object stroke outward in the 4th quadrant from the anus watch for reflex contraction of anal musculatures. Loss of anal reflex suggest lesion in S2, S3, S4 as in cauda equina lesion. * Coma signals potential life threatening event effecting the two hemisphere, the brain stem or both. One should first assess ABC (airway, breathing, and circulation) than establish the pts level of conciousness and than examin the pt neurologically try to find out metabolic and structural reason. * Remember Cardinal DONTs :* Do not dilate pupil very imp clue in structural vs. metabolic coma (reaction to light often remain intact in metabolic coma). * Do not flex the neck if there is any trauma to neck or head immobilize cervical spine. Get chest x-ray first rule out the vertebral fracture that could compress spinal cord. * To assess the consciousness there is 5 clinical level of consciousness (arousal). Increase your stimuli in step wise manner. * I Alertness : speak to pt in normal tone an alert pt open the eye looked at you and respond fully (Arousal intact). * II Lethargy : speak with pt in loud voice ask name etc. Lethargic pt appear drowsy but open the eye & looked at you respond to question & than fall a sleep. * III Ostentation :- shake the pt gently as if awakening a sleep. An obtunded pt open eyes looked at you but respond slowly and confused. Alertness and interest in environment is decreased. * IV Stupor :- apply a painful stimulus to tendon, sternum, or nail bed (no strong stimuli needed). A stuporous pt arise from sleep on after painful stimuli, verbal response are slow or even absent, pt lapses into unresponsive state when stimuli is ceases. There is minimal awareness of self or the environment. * V Coma :- apply repeated painful stimuli, a comatose pt remain unarousable with eye closed. There is no evident response to Inner need or external stimuli. * Reaction to light often remain intact in metabolic coma where as structural lesion like stroke may lead to asymmetrical pupil and loss of light reaction. * When occulomotor pathway is intact eye look straight where as in structural hemispheric lesion the eye look at the lesion. vs. On other hand in irritative lesion due to epilepsy or early cerebral hemorrhage the look away from the lesion. * Deviation of eye to one side is term Gaze preference eg right or left. * Occulocephalic reflex (Dolls eye movement) :- Holding open the eye lid, turn the head quickly first one side than other. In comatose pt with an intact brain stem the pt eye move in opposite direction as if still gazing ahead in initial position (doll eye movement). Dolls eye movement suggest lesion of mid brain, pons, or very deep coma. Make sure there is no neck injury before doing this maneuver. * Occulovestibular reflex ( with calorie stimulation ) :- If occulocephalic reflex (dolls eye movement) is absent seek further assessment of brain stem. (never do this maneuver in awake pt) first make sure ear drums are intact and canal is clear. Elevate the pts head to 30 degree, place kidney basin under ear to catch any over flow. With large syringe inject a ice water in the ear canal watch for direction of deviation of eye in horizontal plane (maneuver may need 120 ml of ice water to illicit the response). In comatose pt with this maneuver eye drift toward the irritated ear. Repeat on opposite side after 3 minutes no response to stimuli suggest brain stem injury. * Posture and Muscle tone :- apply painful stimuli and note. * Normal --- Avoidant :- Pt pushes the stimulus away. * Stereotype :- Stimulus evoke abnormal posture response of trunk & extremities, suggest decorticate or decerebrate Rigidity. * Flaccid Paralysis or no response :- Grasping each arm near wrist and raising it to vertical position. In hemiplegia the limp Hand drop to form a right angle 90 degree with the wrist. It suggest corticospinal tract Lesion. Flaccid arm drop like a flial. - Compare a fall of each leg while u support pts knee in flexed position. In hemiplegia flaccid leg fall rapidly. - Flexed a pts knee in a manner that heel rest on the bed & than with draw the support. In hemiplegia the flaccid leg fall rapidly into extension with external rotation at the hip. * Check facial symmetry, Eye reflexes ( CN V, CN VII ), Papiledema ( HTN ), Blood CSF in ear or nose ( Suggest skull fracture ), Tongue injury ( seizures ), Jaundice, Cyanosis, CO poisoning, Alcoholism, Uremia, Bruises, Laceration. * Nystagmus is the Rhythmic Oscillation of eye analogous to tremor in the body. Nystagmus has both slow and fast phase but it is defined by fast phase eg when pt has left nystagmus eye move slowly to right and than fast to left. * Occasionally nystagmus has no quick or slow phase rather have coarse oscillation it is said to be a pendular nystagmus, other are horizontal, vertical or rotatory nystagmus. The movement of nystagmus occur in plane of the movement not in direction of gaze. * Facial paralysis (Bells palsy) occur due to lesion in the facial nerve VII , where as facial paralysis due to CNS lesion occur due to CVA affect motor neuron. In facial paralysis pt cannot close the eye & eye ball rolls up, pt cannot wrinkle forehead & raise eye brows. vs. Facial paralysis due to CNS lesion 42 NOT FOR COMMERCIAL USE OR SALE

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pt can close the eyes perhaps with slight weakness & can wrinkle forehead & raise eye brows. Flat nasolabial fold and paralysis of lower face occur in both types. * Three Types of Tremors :1. Resting tremor :- Most prominent at rest may decrease or disappear with voluntary movement (Pill roll tremor) it occur in Parkinsons dis (about 5 per second). 2. Postural tremor :- Occur when affecting part is actively maintaining a posture for eg fine rapid tremor of hyperthyroidism, Anxiety, fatigue, benign (familial). These type worsen with intention. 3. Intentional tremor :- Intentional tremor is absent at rest appear with activity and often get worst as target get neared causes include cerebella pathway dis or multiple sclerosis. * Oral Facial Dyskinesia :- Are rhythmic repetitive bizarre movement chiefly involve the face, mouth, jaw and tongue (grimacing, Pursing of the lips, protrusion of the tongue, opening and closing of mouth, deviation of jaw). Limb and trunk involve less often. Causes include Psychosis, elderly, edentulous, drugs (antipsychotic like phenothhiazine cause tardive duskiness). * Tics are brief repetitive, stereotyped coordinated movement occuring at irregular level on face, trunk, and shoulder. * Chorea ( Choriform ) are brief, rapid, jerky, irregular and unpredictable movement. Unlike tics they seldom repeat them selves normally involve face, head, lower arm and hand causes include Sydenhams chorea (with rheumatic fever) & Huntingtun dis. * Athetosis movement are slow more twisting and writhing than choriform movement and have larger amplitude. Commonly involve face and distal extremities. Athetosis is often associated with plasticity causes include cerebral palsy. * Dystonia are some what similar to athetotic movement but involve longer portion of the body including trunk, Grotesque twisted posture may result causes include primary torsion dystonia, spasmodic tort colitis, drugs (phenothiazine). * Spasticity is an increase muscle tone (hypertonia). During rapid passive movement, initial hypertonia may give way suddenly as the limb relaxes. This spastic catch and relaxation id known as Clasp - knife resistance cause by upper motor neuron lesion of the corticospinal tract at any point from cortex to spinal cord, causes include stroke specially late or chronic stage. * Rigidity is increased resistance that persistent through out the movement ( unlike plasticity ) and are independent of rate of movement is called the lead pipe rigidity. when you flex or extend the wrist or forearm a superimposed ratchet like jerkiness is called Cogwheel Rigidity. It is usually caused by lesion in extra pyramidal system specially the basal ganglia.(eg Parkinsonism). * Flaccidity (hypotonia) cause limb to be floppy due to lesion in LMN or ant root at any point from ant to peripheral nerve. Causes include Guillian - barre $, also in intial phase of spinal cord injury (spinal shock) or stroke. * Paratonia is sudden change in tone with passive range of motion. That is sudden loss of tone that increase the ease of motion is called Mitgenen (moving with); Or sudden increase in tone that makes motion more difficult is called Gegenhalten (holding against) due to lesion in both hemisphere of frontal lobe usually cause by dementia. * Stroke in cerebral cortex results into increase deep tendon reflexes, contra lateral UMN weakness or spasticity. Flexion is stronger than extension in arm, planter flexion is stronger than dorsiflexion in foot, leg is externally rotated at hip. Further more it cause contra lateral sensory loss on limb and trunk. * Stroke or acoustic neuronal in brain stem results into weakness and spasticity (as above), plus CN deficit such as diplopia (from weakness of extra occular muscle) and dysarthria, also manifest deep tendon reflex with no sensory finding. * Trauma of the spinal cord causing compression result into weakness spasticity but often effect both side (when damage is bilateral) causing paraplegia or quadroplegia, dermotomal sensory deficit on trunk and increase deep tendon reflex. * Subcortical Gray matter :- Basal ganglia lesion as in Parkinsonism result into bradykinesia (slow movement), Rigidity and tremor with normal to decreased deep tendon reflexes. The sensation is not effected. * Cerebellar lesion due to stroke or tumor results in hypotonia, ataxia, abnormal movement including nystagmus, dysdiadocho - kinesia and dysmetria with normal to decreased deep tendon reflexes. Sensation not effected. * LMN lesion due to polio, amyotrophic lateral sclerosis results into decrease deep tendon reflexes, motor weakness and atrophy in segmental and focal pattern, fasciculation. Sensation stay intact. * Spinal nerve and root lesion due to herniated disc results into decreased deep tendon reflexes, motor weakness and atrophy in root innervated pattern some time with fasciculation, also show sensory loss in nerve pattern. * Peripheral nerve polyneuropathy is due to alcohlism, DM, result into motor weakness and atrophy more distal than proximal some time with fasciculation. Also show sensory deficit in stocking - glove distribution. * Peripheral nerve Mononeuropathy due to trauma results into motor weakness and atrophy in nerve distribution some time with fasciculation. Also show sensory loss in nerve pattern. * Lesion in neuromuscular junction due to Myesthenia gravis results into fatigue more than weakness sensation stay intact and reflexes normal. * Muscle dis due to Muscular dystrophy results into normal to decreased reflexes, motor weakness, usually more proximal than distal. Fasciculation rare, sensation stays intact. * In spastic hemiparesis one arm is held immobile and close to the side with elbow, wrist, and interphalangeal joints flexed. Leg is extended in the planter flexion of the foot often scraping the toe or circle it stiffly outward and forward (circumduction). Underlying defect unilateral hemisphere dis as with stroke. * Scissors Gait is stiff. Each leg is advanced slowly, thigh tend to cross forward on each other at each step and step is short. Pt appear to be walking 43 NOT FOR COMMERCIAL USE OR SALE

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through water. It is associated with bilateral spastic paresis of the leg. * Steppage Gait is when pt drag their feet and lift them high with knee flexed and bring them down with a slap on the floor thus appear walking upstairs. They are unable to on their heel. Steppage gait may involve one or both sides it is associated with foot drop. Usually secondary to LMN dis. * Sensory Ataxia is unsteady and wide base (feet wide apart) gait. These pt through their feet forward and outward and bring them down first on the heel than toe with double tapping sound. Pt watch the ground for guidance while walking. With eye closed they cannot stand steadily with feet together (+ Romberg sign) and staggering gait worsen. It is associated with loss of position sense in leg from polyneuropathy or post column damage. * Cerebellar Ataxia is staggering, unsteady, wide base gait with exaggerated difficulty on turning. These pt cannot stand steady with feet together whether their eyes are open or closed. It is associated with cerebellar or their tract dis. * Parkinson Gait is stooped posture with head and neck forward and hip and knee slightly flexed. Arm are flexed at elbow and wrist. The pt is slow in getting started, steps are short and often shuffling. Arm swing is decreased, pt turn around stiffly all in one piece. it is associated with basal ganglia defect of Parkinson dis. * Metabolic coma caused by arousal center poisoned or critical substrate depleted it result into normal to hyperventilation with regularity pupil is normal and equal to light. If ventilation is irregular is usually cheynes stroke. If pupil is pinpoint its from opiate or cholinergics. It may be unrelated with fixed or dilated from cholinergic or hyperthermia. Level of consciousness changes after pupil changes. metabolic coma is typically results from uremia, hyperglycemia, alcohol, drugs, liver failure, hypothyroidism, anorexia, ischemia, meningitis, encephalitis hypo or hyperthermia. * Structural coma caused by lesion damaging brain stem arousal area either directly or secondary to more distal mass. In structural coma respiration is irregular specially cheynes stroke or ataxic breathing pupil are fixed and uncreative. Mid position fixed suggest mid brain compression where as dilated fixed pupil suggest compression of Occulomotor nerve III from herniation. Level of consciousness change before pupil changes. structural coma usually suggest Epidural, Subdural, or intracerebral hemorrhage, cerebral infarct or emboli, tumor abscess, Brainstem infarct or cerebral infarct. * Psychiatric disorder may mimic coma. * Abnormal pupil interpretation :* Small pupil ( 1 - 2.5 mm ) suggest damage to sympathetic pathway in hypothalamus, metabolic encephalopathy, drugs. Reaction to light is normal. * Pin point pupil ( < 1 mm ) suggest hemorrhage in the pons or drugs (like morphine, heroin). Reaction to light may be seen with magnifying glass. * Mid position fixed pupil ( 4- 6 mm ) are fixed to light reaction and suggest structural damage to mid brain. * Large Pupil :- bilaterally fixed and dilated pupil is may be due to severe anoxia and its sympathetic effect as seen after cardiac arrest. Atropine like agent, phenothiazine, and tricyclic antidepressant may cause dilated fixed pupil. vs. where as bilaterally large reactive pupil may be due to cocain, amphetamine, LSD, or other sympathomimetic nervous system agonist. * One large pupil that is fixed and dilated warn herniation of the temporal lobe causing compression of coulometer nerve III and mid brain. * Abnormal posture in comatose pt :* Decorticate rigidity ( abnormal flexor response ) :- In decorticate rigidity upper arm are held tightly with elbow, wrist, and finger flexed, the legs are extended and internally rotated. Feet are planter flexed, this posture suggest destructive lesion in corticospinal tract or very near to cerebral hemisphere. \ When this posture is unilateral suggest chronic spastic hemiplegia. * Hemiplegia ( early ) :- One side paralysis results into slack ( fall loosely ) arm and leg. Leg may externally rotated, one side face may paralyzed, both eye may looked toward the lesion. Hemiplegia suggest unilateral corticospinal tract lesion. * Decerebrate rigidity ( abnormal extensor response ) :- In decerebrate rigidity jaws are clenched and neck is extended. Arms are adducted and stiffly extended at elbow, with forearm pronated, wrist and finger flexed. Legs are stiffly extended at knee with feet planter flexed. This posture may occur spontaneously or only in response to external stimuli such as light, noise, pain. It is caused by lesion in diencephalons, mid brain, or pons although severe metabolic disorder such as hypoxia, hypoglycemia, may also produce it. ----------------------------------------------------------------------------------------------------------------------PEDIATRICS * Bibinski response in child is normal beyond the age of two years. * The developmental mile stone in children is measured by DDST ( Denver Developmental Screening Test ). * Neonatal time 1st 28 days, * Infancy time 1st year of life, * Early childhood 1 - 4 yrs, * Late childhood 5 - 12 yrs, Adolescent 13 - 20 yrs. * In children looking the ear, mouth, or palpating abdomen should done near the end of examination. * APGAR score should be done in 1 minute and 5 minute after birth. * 1 min APGAR score of 7 or less usually indicate nervous system depression, Score of 4 or less indicate severe depression require immediate resuscitation. * 5 min APGAR score of < 7 place the infant at high risk for subsequent CNS and other organ dysfunction.

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Prepared by Dr. IRFAN MIR ** APGAR SCORE SYSTEM :1. Heart rate 2. Respiratory effort 3. Muscle tone 4. Reflex irritability 5. Color Score 0 Absent Absent Flaccid No response Blue, Pale Score 1 < 100 Slow, Irregular Some flexion Crying Pink body, blue extremities.

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Score 2 > 100 Good crying Active movement Crying vigorously, sneeze, cough All pink

* Normal birth wt is 2500 gms or more, Low birth wt is 1500 - 2499 gms, Very Low birth wt is 1000 - 1499 gms, Extremely Low birth wt is < 1000 gm. * Ballard Scoring system enables estimates of gestational age. Preterm ----------- gestation < 37 weeks Term ----------- gestation 37 - 42 weeks Post term -------- gestation > 42 weeks. * Birth wt and gestational age . * Wt small for gestational age ( SGA ) - birth wt < 10th % of intrauterine growth curve. * Wt appropriate for gestational age (AGA ) - Birth wt with in 10th and 90th % of intrauterine growth curve. * Wt large for gestational age ( LGA ) - Birth wt > 90th % of intrauterine growth curve. * explain like this for eg, Preterm SGA or AGA or LGA. Or Post term LGA or SGA or AGA . * Failure to pass tube in nasopharynx suggest Post Nasal Atresia also called CHOANAL. where as failure to pass the tube in stomach suggest Esophgeal Atresia usually with an association of Tracheoesophageal fistula. * Pump the 10 cc gas in the stomach while intubation and ascultate in epigastria area to confirm patency. * Always examin when baby is not too satiated ( therefore less responsive ) nor too hungry ( therefore more agitated ). * Normal full term new born lie in symmetrical position with the limb semi flexed and leg partially abducted at hip with head in the mid line or turn to one side. * In normal baby forearm supinate with flexion at elbow and pronate with extention. * Examining the hip abduction should be perform at last because baby to cry. * In Breech baby, leg and head are extended, and the leg of the frank breech baby are abducted and externally rotated. * Low amplitude high frequency tremor in extremities and body are seen with vigorous crying and even at rest during first 48 hrs. by day 4 after birth if tremors occur at rest signals CNS dis. Asymmetrical movement of arm & leg at any time alarm the possibility of CNS or PNS deficit, birth injury or congenital problem. * DDST is design to reveal developmental attainment from birth to 6 yrs of age. Remember its not a measure of intelligence. Many children with mild developmental delay also score normal. * Dialogue with child will indicate the child level of receptive and expressive function. * Abused child usually demonstrate no separation anxiety when physically environmentally remove from parents. Both child and parent may appear over affectionate to one another in an attempt to hide the abuse. * When two or more siblings are to be examined start with older one. * When examining the heart place your left hand on pts left shoulder for distraction and use right hand to ausculatate. * Use command like roll over on the belly rather than will you roll over on your belly for me. * Rarely for the childs sake or the parent it is necessary to discontinuous the exam and return to it another time as in extreme crying or resistance. * If resistance is inappropriate for childs age, the examiner should consider the possibility of underlying developmental, emotional, parent - child interactional difficulties. * Regardless of age every sexual active female should have periodic pelvic examination and pap smear. * The average rectal temp in infancy and childhood is usually 99 degree F* (37.2* C) until 3rd year. At 18 month 15% of children have mean rectal temp of 100* F ( 37.8* C ). rectal temp may approach 101* F ( 38.3* C ) in normal children. * Anxiety ( eg elective hospital admission ) may elevate body temp. Infant bundling may elevate skin temp but not core body temp. * During childhood temp elevation from 103* F - 105* F (39.5* C - 40.5* C) is common even in mild temp. * Beyond the one month of age a pulse greater than 180 usually indicates paroxysmal atrial tachycardia.

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* Average heart rate in children. Average Range * Birth 140 B/min 90 - 190 * 1 - 6 month 130 B/min 80 - 180 * 6 - 12 month 115 B/min 75 - 155 * 1 - 2 yrs 110 B/min 70 - 150 * 2 - 6 yrs 103 B/min 68 - 138 * 6 - 10 yrs 95 B/min 65 - 125 * 10 - 14 yrs 85 B/min 55 - 115 * Respiratory rate. * New born 30 - 60 R/min * Early childhood 20 - 40 R/min * Late childhood 15 - 25 R/min * Age Reach to adult rate * In children respiration rate > 100/min is associated with lower respiratory tract obstruction eg Bronchiolitis, pneumonia, asthma . * In children unlike adult the point at which the sound first muffled (not the disappearance point) is recorded as diastolic pressure; because in early childhood Korotkoff sound are not audible due to a narrow or deep placed brachial artery. * In Infant BP reading from the thigh are approx 10 mmHg higher than those in upper arm. If they are same or lower coarctation of aorta should be suspected. * Normal systolic BP in male is in vicinity of 70 mmHg at birth. 85 mmHg at 1 month. 90 mmHg at 6 month. 95 mmHg at 5 yrs. 100 mmHg at 8 yrs. 110 mmHg at 13 yrs. 120 mmHg at 18 yrs. * The diastolic pressure reaches 55 mmHg at 1 yr and 70 mmHg at 18 yrs. * In female child Normal Systolic Diastolic Pressure is 5 mmHg lower than male except in 1st yr of life. * The most common cause of HTN in infancy and childhood are; * Renal dis ----------------------------- 78% * Renal arterial dis ------------------- 12% * Coarctation of aorta --------------- 2% * Pheochromocytoma -------------* Primary HTN become increasingly prevalent beyond age 6 * In adolescent HTN frequently accompanies obesity. * Measurement of height and wt above 97th and below 3rd percentile on standerd growth chart may indicate growth disturbance and require investigation. * The head circumference (growth) should be measured at every physical exam during first two yr of life. Place the tape over occipital, parietal and frontal prominence to obtain the greatest circumference. * If head circumference is delayed consider premature closure of suture or microcephaly ( may be Familial or chromosomal abnormality, congenital disorder, maternal metabolic disorder, or neurologic insult ). When growth is too rapid consider hydrocephalus, subdural hematoma or tumor. * In normal new born color change is often seen, one side of the body is red other side is pale and abrupt border separates the two sides at the mid line this phenomenon is called Harlequin Dyschromia it is transient with unknown etiology. * If striking color change occur in premature infant and those with congenital hypothyroidism and Down $ shows marbled or dappled reticular pattern on skin. * Generalized paler in new born may indicate either anoxia, in which the pulse will be slowed vs. in sever anemia in which the pulse will be very rapid. * In new born hand and feet may be blue ( Acrocyanosis ) after 4 - 5 hr cyanosis become less marked. If it does not disappear with in 8 hr or warming consider cyanotic congenital heart dis. * Acrocyanosis may recur through out early infancy when baby is cold. * ILL defined blackish bluish area located over the buttock and lower lumbar region often seen in blacks, native american, Asians are called Mongolian spot. it usually disappear in childhood (occur due to pigmentation of deeper layer of skin). * Fine downy growth of hair called Lanugo over entire body shed with in two weaks. * Superficial desquamation of skin and also cheesy white material composed of Sebum and desquamation epithelial cell called Vernix Caseosa usually disappear by 2nd or 3rd day after birth. * Skin desquamation at birth occur in babies born after 40 weeks of gestation in those with placental circulation insufficiency and various form of congenital Ichthyosis. * Physiologic jaundice which is peak at 4th and 5th day usually disappear with in week but it may persist for month. * If jaundice other than physiologic appear with in 24 hr of birth suggest possible hemolytic dis , biliary obstruction, or infection. * Use natural day light rather than artificial light to evaluate jaundice at any age. In border line cases press a glass slide against a cheek to help you detect the pressure of jaundice. * Children who are fed yellow vegetable (carrot, sweet potato, squash) may develop yellow color of skin this condition is called Carotenemia. sclera is spared In this. 46 NOT FOR COMMERCIAL USE OR SALE

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* Milia is a pin head size smooth, white raised area with out surrounding erythema often on nose, chin, forehead are caused by retention of sebum in the opening of sebaceous gland. It disappears spontaneously vs. where as Miliaria Rubra consist of scattered vesicle on erythematous base usually on face and on trunk usually caused by sweat gland obstruction. It is also disappears in 1 - 2 weeks. * Erythema Toxicum usually appear 2nd or 3rd day of life cosist of erythematous macules with central multiracial wheals or vesicle scattered over body appear like a flea bite. This unknown lesion disappear with in week. * Irregular pink area found in neck, eyelid, upper lip, face, or forehead is due to proliferation of capillaries bed called Capillary Hemangioma, the lesion disappear at about 1 yr of age. Although they may reappear in adulthood when skin is flush from anger or embarrassment. vs. where as such lesion on larger area are not likely to be disappear or fade called Port - wine stain. * Port wine stain innervated by ophthalmic portion of trigeminal nerve V or on vascular bed of the meninges and or orbit result in seizures, hemi paresis, mental retardation and glaucoma - Strugg Weber $. * Degree of hydration (turgor) can be evaluate by compressing the skin b/w thumb and finger. The delay return of skin to its original position is called Tenting suggest dehydration. * The area where major suture intersect called Fontanelles are soft concavities (ant & post). Ant close b/w 4 - 26 months of age where as post fontanelle close by 2 month of age. * Normal fontanels are soft concavities. Increase Intracranial Pressure produce bulging. It can also be seen when baby cry, cough, and vomit. Pulsation of fontanelle reflect the peripheral pulse. * Increased Intracranial (IC) Pressure is found in infection and neoplastic dis of CNS and with obstruction of CSF pathway. Ant fontanelle is imp indicator of IC pressure. * Decreased IC pressure reflect in a depress fontanelle sign of dehydration. * A large post fontanelle may be present in congenital hypothyoidism. * Inspect scalp of dilated veins it suggest long standing Increased IC pressure. * Normal new born infants cranial bones may over lap the suture called Molding results from the passage of head through birth canal it disappear with in two days. * Caput Succedaneum is newborns scalp with edema & bruising over the occipitoparietal region caused by drawing the scalp into cervical os when Amniotic fluid sac ruptures. A negative pressure (vacuum) produces distended capillaries. It subside with 24 hr of life. * Asymmetry of the cranial vault ( Plagiocephaly ) occur when infant lies constantly on one side. It usually disappears later in life when body is more active. Same way when the head is flexed on sternum in utero the microganthia may result. * Plagiocephaly is apt to be more prominent in infant with torticollis secondary to injury to stern mastoid muscle at birth in the mentally and physically handicapped and under stimulated infant. * At birth most new born has relatively long occipital frontal diameter and narrow bitemporal diameter called Dolichocephaly it disappear by the end of year and in some it last indefinitely. * The shape of the head may altered by premature closure of one or more of the cranial suture called Craniosynostosis for eg Saggital suture hypostasis produce long narrow head. Dx is made by Roentgenogram. * If you press temporoparital or paritooccipital too firmly you can feel underlying bone momentarily ( feel like ping pong ball ). This condition is known as Craniotabes it is due to osteoprosis. This may be found in some normal infant. Purposeful elicitation of this finding is not recommended. * Craniotabes may be results from increase IC pressure as in hydrocephaly, Rickets or congenital syphilis. * Percuss the parietal bone on each side by tapping your index finger directly. It will produce crack pot sound (Macewens sign). It is normal in infant before closure of cranial suture. * Macewens sign can be illicit in older infant and children who have Increase IC pressure which cause cranial suture is separation, eg in lead encephalopathy and brain tumor. * Chvosteks sign :- Percuss at the top of the cheek just below the zygomatic bone in front of ear with index finger. It produce one or two contraction of the facial muscle. It present in many new born and persist till early childhood. * Chvosteks sign when produce by many contraction and repeated contraction suggest hypocalcaemia (tetany), tetanus, or tetany due to hypoventilation in children and adolescents. * Transilluminate the skull in infant suspecting to have CNS dis in complete dark room. * During transillumination in normal infant a 2 cm halo of light present around circumference of flash light when it is placed over the frontal area. 1 cm halo is present when it is over occipital area. When halo is uniform over the entire head it suggest partially absence or thinning of cerebral cortex. Localized bright spot may be seen with subdural effusion or Porencephlic cyst. * Auscultate head until late childhood. Systolic and continuous bruit may be heard over temporal area in normal child until age 5. Similar finding may be found in older children who are significantly anemic. * Bruit heard in non anemic older children suggest increase IC pressure, IC arteriovenous shunt or an aneurysm. * In infant hypoglossal duct, fistula or cyst may be seen or felt in mid line just above the thyroid cartilage. * Remanant of the three lower brachial cleft may be seen as a tag, cyst or fistula, along with the ant border of the sternomastoid muscle. * HIV infection is the most common cause of and associated with generalized lymphadenopathy. 47 NOT FOR COMMERCIAL USE OR SALE

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* Fracture of the clavicle may occur in vertex or breech delivery. * Move the neck in all direction it is usually supple injury or bleed In sternomastoid muscle during birth process result in WRY Neck ( Torticollis ) . it cause head tilted toward and twisted away from the injury side. In 2 - 3 weeks the firm fibrous mass is felt with in the muscle which usually disappear in 3 - 4 months. * Cephal hematoma :- not present at birth may appear with in 24 hr after birth, due to subperiosteal hemorrhage involving the outer table of one of the cranial bone. Unlike Caput Seccedaneum swelling, hematomas swelling is associated with fracture that does not extend across the suture. It may be small or even entire bone results from difficult delivery. Swelling develop a raised body margin with in 2 - 3 days due to rapid Ca++ deposition. It disappear with in few week leaving a residual osteoms which disappears in year or two. * In hydrocephaly ant fontanelle is bulging and eye may be deviated downward creating Setting Sun Sign. Setting Sun sign also seen briefly in some normal newborns. * Baby with fetal alcohol $ are at increase risk of growth deficiency, microcephaly, and mental retardation. Shows short palpebral fissure, wide and flattened Philtrum ( a vertical groove in the mid line of upper lip and thin lips). * Congenital Syphilis occur after 16 week of gestation and effect virtually all fetal organ. If no treated 25 % of babies will die before birth and 30 % shortly after birth. * Survivors of congenital syphilis show flaccid stigmata include bulging of the frontal bones, nasal bridge depression (saddle nose) a circumoral rash, mucocutaneous inflammation, fissuring of mouth and lips (Rhagades) and tibial periostitis (saber shin) dental dysphasia ( Hutchinsons teeth ). * Cretinism ( congenital hypothyroidism ) has coarse facial features, low set hair line, sparse eye brows, enlarge tongue, associated features include cry, umbilical hernia, Dry and cold extremities, my edema, mottled skin, and mental retardation. It is imp to note that the babies with congenital hypothyroidism have no physical stigmata, this has led to screening all new born in USA for depress thyroxin or increase TSH. * Facial nerve palsy ( VII ) can occur during difficult delivery or due to inflammation of middle ear branch of nerve due to ostitis media. usually recovers. * Battered child $ occur in those who physically abused, child may look sad and forlorn with physical sing of abuse. * Child with perennial allergic rhinitis has open mouth (cannot breath with nose) and edema and discoloration of the lower Orbitopalpabral groove ( allergic shiners ). Child often push the nose upward and backward ( allergic salute ) with hand to relieve nasal itch. * Grave dis ( thyrotoxicosis and hyperthyroidism ) occur in 2/1000 kids under age 10. Accelerated linear growth with staring eyes and hyper metabolism often suggest hyperthyroidism. * Parotid swelling and tenderness suggest mumps, a bacterial infection or a stone. * Inspect the orifice of parotid duct ( Stensons duct ) for redness and swelling suggest infection of parotid gland. * Swelling of parotid gland due to any reason usually extend above and below the mendible at the angle of jaw where as swelling due to cervical adenitis occur only below those land marks. * Cervical lymphadenopathy may occur due to viral respiratory infection in which enlarge lymph node is usually nontender. In infectious mononucleosis (EBV) lymphadenopathy is generalized and tender. In leukemia, hodgkins dis, non Hodgkin lymphoma, and metastatic cancer may cause enlarge lymph node. Acute tonsillitis may cause enlarged ant cervical lymphadenitis which is very swollen and tender. Acute otitis externa, acute and chronic mastoiditis, scalp lesion (Pediculosis, tinea captis) cause acute posterior cervical lymphadenopathy. * Other reason for cervical lymphadenopathy are Kawasaki dis, TB, Cat scratch dis, and atypical mycobacterium infection. * If lymph node is < 2 cm in diameter and not so hard or fixed to skin or underlying tissue and the chest X - ray finding are normal, it is mostly due to infectious origin rather than malignancy. * Concern of malignancy raised when supra clavicular node is enlarged or fever lasting more than a week with lymphadenopathy and wt loss in last 6 month. * Kawasaki dis ( mucocutaneous lymph node $ ) :- characterize by fever, conjunctivitis, oral mucosal lesion, rash, cervical lymphadenopathy, carditis, coronary artery vasculitis. * Occipital lymphadenopathy may occur with scalp lesion and usually presents with rubella. * Nuchal rigidity suggest CNS infection, bleeding and tumor. * When Meningeal irritation is present the child can not sit with legs fully extended, arms in legs and chin touching chest. Rather child assume the tripod position. Fig Here (leg extended and hand supporting upper body posterior and head look little up, and cannot perform chin to chest maneuver) * Hold the baby in your arms, fixing the head with your thumb, rotate your self in one side this cause the bay eyes to open since eye looks in the direction, you move you can inspect the eyes. * Nystagmus in one or many direction is common immediately after birth. During first 10 days of life if eye remain fixed (doll eye test) . Intermittent alternating convergent strabismus (crossed eyes) is frequently seen during first 6 months. * Nystagmus which persist after few days may indicate blindness. * Alternating convergent strabismus persisting beyond 6 month become unilateral sooner or divergent strabismus ( laterally deviated eyes) occurring at any time indicate occular muscle movement or diminish visual acuity. * Small subconjunctival or sclera hemorrahge in new born are common. * Observe the papillary reaction by covering each eye with your hand and than uncovering it. Papillary reactivity is poor to light during first 4 - 5 months. * The corneal reflex is normally present but is not tested for unless neurologic deficit is suspected. * In iris brushfields spot appear as a white specks around the entire iris and may be present in normal infant. 48 NOT FOR COMMERCIAL USE OR SALE

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* Brush field spot with apicanthal fold strongly suggest Down $. * Application of silver nitrate (prophylaxis for gonococcal conjunctivitis) may cause chemical conjunctivitis later it characterized by edema of the lid, inflammation of conjunctiva and purulent discharge. Therefore erythromycin is recommended rather than silver nitrate for ophthalmic neonatrum. * Dacryocystitis and nasolacrimal duct obstruct with occular discharge and tearing may follow chemical conjunctivitis due to silver nitrate instillation. * Vision assessment of the new born is based on the presence of visual reflex - papillary constriction to light, blinking and extension of head in response to light (Optical blink response) and blinking by moving quick movement of an object toward eye. * At 2 - 4 weeks fixation of object occur; At 5 - 6 weeks coordination of eye movement occur; At the age of 1 yr normal visual acuity is in the range of 20/200. Failure to progress along these ages may indicate developmental delay or diminish or absent vision. * Retina (fundus) reflect red or orange by setting Opthalmoscope at 0 diopters and viewing it by the distance of inches normally in infancy . * Retinal anomalies, opacities of cornea or ant chamber or lens interrupt the light pathway give partial red or complete dark reflex. * In infant cataract, persistent posterior lenticular fibro vascular sheath, retinopathy of prematurely may cause dark light reflex. * When white retinal reflex is encountered called Leukokoria if occur during or beyond infancy suspect retinal detachment, chorioretinitis , retinoblastoma. * Perform retinal exam in all children specially before 2 month and after 6 month of age. * During fundal exam cornea may be seen at + 20 diopters, lens at +15 diopters and fundus at 0 diopters. * Small retinal hemorrhage are often present. If they are extensive, severe anoxia, subdural hematoma or subarachinoid hemorrhage should be suspected. * Papilledema rarely develop in children even with markedly increase IC pressure, because fontanelle and open sutures absorb the Pressure. And after age of 3 yrs the sutures will separate sufficiently to prevent papilledema. * Retinal hemorrhage is associated with IC bleeding are accompanied by dilated, congested, tortuous retinal vein. * Pigmentary changes occur in new born with congenital toxoplasmosis, CMV, Rubella infection. * In early childhood Amblyopia Exanopia is more prevalent and offer best prognosis with early intervention. Improvement is unlikely if Tx is initiated after 6 yr of life. * Amblyopia is reduced vision in other wise normal eye and is caused by disuse; Because disconjugate fixation of one of the two images suppressed optic cortex. Which cause one eye to become lazy and stop functioning to its full capacity. * Common causes of Amblyopia Exanopia are Strabismus and Anisometropia where as obstructive Ambylopia is secondary to cataract, corneal opacity or severe ptosis. * Paralytic and non Paralytic Strabismus are due to ocular muscle weakness and unequal visual acuity in the two eyes. * To detect Ambylopia one eye must be covered by patch. Child may preferred it on bad eye on asking. * Opticokinetic testing is the most accurate method of testing visual acuity in early childhood ( sp < age 3) and children of more than 3 yrs of age Snellen e - Chart is adequate. * The normal visual acuity at age 3 + 20/40 and at age 4 - 5 yrs 20/30 and at age 6 - 7 yrs 20/20 any difference in visual acuity b/w the two eye (eg 20/20 R, 20/30 L) may lead to Amblyopic. * Vision testing in other wise normal child is recommended at the beginning of age of 4. * Distinguish a simple refractive error from an organic cause of diminish vision by asking the child to look through a pin hole punched in a card. Vision improve by this if refractive error is present. But not with organic occular dis. * Normally the upper portion of the auricle (Pinna) join the scalp on or above extension of the line drawn across of inner and outer acanthi of eye. Where as small deformed or low set auricle may indicate associated congenital defect specially Renal Agenesis ( Potters $ ). * A small skin tab, cleft or pit just forward to the tragus represent the remnant of first brachial cleft. * In infancy light reflex on the tympanic mem is diffuse and does not become cone shape for several month. * Acoustic Blink Reflex is a blinking in response to sudden sharp sound produce at the distance of about 12 inches from the ear during infancy. * The Acoustic blink reflex is difficult to illicit ding the first 2 - 3 days of life. At to week of age infant may jump in response of sudden noise; Between 3 - 4 month eye and head will turn toward the sound. * Perinatal problem that the risk for hearing defect include birth wt < 1500gms, anoxia, ototoxic medication (aminoglycoside) , exchange transfusion, congenital infection, hyperbilirubinemia ( 20mg/dL ) and meningitis. * Acute Otitis Media in children is characterized by tympanic mem that is red bulging and has a dull or absent light reflex . Purulent material some time can be seen behind the tympanic mem. * When air is introduced or removed from normal ear canal, tympanic mem moves in and out, if this movement is absent chronic middle ear infection or acute Otitis media is suspected. * Washing ear canal is contraindicated in perforated tympanic mem in the first instance. * Moving Pinna can cause pain in Otitis Externa and Otitis Media but produce no discomfort in purulent Otitis media. * Acute Mastoiditis may cause pain on pulling the auricle of ear, it may accompany Otitis. * Acute Otitis Media or Serous Otitis media may cause significant temporary hearing loss for several months. * The nasal passage in new born may be Obstructed in Choanal Atresia and by displacement of the nasal cartilage during delivery. * Rarely in new born super numerary teeth are found these are soft have no enamel and shed with in few days. They should be removed however to prevent 49 NOT FOR COMMERCIAL USE OR SALE

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their aspiration into lower respiratory tract. * Petechiae are commonly found on soft palate after birth. * Epsteins pearls are pin head size or yellow rounded elevation that are located along the mid line of the hard palate near the post border these are caused by retained secretion and disappear with in few weeks or after month. * Thrush in infancy is difficult to distinguish from milk curd which wipes away easily where as thrush cannot. * Little saliva produce during first three month of life the presence of large amount of saliva may be a sign of esophageal atresia since saliva cannot be swallowed. * A shrill or high pitched cry in infancy may indicate IC pressure. Such cries also occur in new born infant born to narcotic addicted mother. * Hoarse cry should make one suspect Hypocalcemia, Tetany, or Hypothyroidism. * Absence of cry suggest serious illness, vocal cord paralysis, or profound mental retardation. * A continuous expiratory or inspiratory stridor is caused by upper airway obstruction, due to polyps, hemangioma, small larynx (infantile laryngeal stridor), or delay in the development of the cartilage in tracheal ring (Tracheomalacia). * Pale, boggy nasal mucous mem with or without presence of gelatinous, peeled, pink - grape appearing polyps in the post nasal passage which is found in chronic allergic rhinitis. * Normal infant glow observed during transillumination of frontal sinus (frontal sinus is not well developed for the procedure until 10 yrs). If transilluminate is absent or diminished sinusitis is present. Sinus tenderness and Hx suggest the Dx. * Maxillary sinus can be seen by inserting the transilluminator light in pts mouth against the hard palate on both side while room is dark. Low or diminish glow suggest sinusitis. * The presence of Koplik,s spot on buccal mucosa opposite the 1st and 2nd molar in a child with fever coryza and cough suggest measles ( Rubeola ), with generalized maculo popular rash with in 24 hr is confirmatory. ( Koplik spot appear as a grain of salt on individual erythmatous bases ). * When child clamp their teeth push the tongue depressor through the lip and along the buccal mucosa and b/w the gums behind the molar. This produce a gag reflex with complete view of pharynx. * Irregular white specks or patches on tooth enamel result from exposure to Fluoride where as grayish mottling of enamel results from tetracycline Tx of child under age 8 years. * Malocclusion or misalignment of teeth due to thumb sucking are reversible if habit is substantially arrested by 6 - 7 yrs. * Malocclusion is most often is due to hereditary predisposition but may be due to premature loss of primary teeth. * Maxillary over growth is associated with chronic hemolytic anemia. * Mendibular overgrowth occur rarely in the initial stage of juvenile rheumatoid arthritis, affecting the temporomendibular joint, a shortened mandible (microganthia) eventually ensues however in chronic cases. * To examine the maxillary protrusion (overbite) or mendibular protrusion (underbite) do not ask the child to show teeth because the upper and lower teeth are align reflexly when presented for examination. Rather ask the child bite down than part the lips and observe the true bite. Normally the lower teeth with in the arch of upper teeth. * Black child tend to have earlier eruption of permanent teeth than do white child. At the age of 10 months most children have two upper and two lower teeth (central incision). From that point on 4 teeth are added every 4 months. * Normal shedding of primary teeth begin at age 6. Permanent teeth start erupt b/w the age of 6 - 7 yrs & ends by 17 - 22 yrs of age. * Smooth tongue is found in avitaminosis where as strawberry or raspberry tongue are seen at specific age of scarlet fever. * Tonsils usually have deep crypt on their surface which often have white concretion or food particles protruding from their depth this does no indicate dis. * The white exudates on tonsil suggest streptococcal tonsillitis particularly accompanied by a beefy red uvula and palate patechiae where as a tick gray adherent exudates on tonsillar tissue suggest Diptheritic tonsillitis. * A gray discoloration of tonsillar tissue it self due to necrosis suggest infectious mononucleosis. * When a tonsil is red and protrude forward and medially. A peritonsillar abscess is almost certainly present. * The Adenoids also called Pharyngeal tonsil consist of hyperplastic lympoid tissue located on both side of nasopharynx medially to the Eustachian tube orifice. Adenoid palpation should be carried out when there is Hx of recurrent fever, headache, cough, it suggest Chronic Adenoiditis or Adenoidal abscess. * Tape three tongue blade together with your left hand place your gloved right index finger into the mouth behind the soft palate, very rapidly give massage to adenoidal and surrounding lymphoid tissue 3 - 4 time this will make you palpate posterior nasopharynx (this procedure produce vomit). * In the case of chronic adenoiditis and adenoidal abscess, palpation reveal the enlarge boggy adenoid tissue massage produce copious amount of blood, mucous and pus. * Children with markedly enlarge adenoid will mouth breath and snore and may have recurrent bouts of otitis media and sinusitis. * Asymmetry and corresponding voice change are often observed from varying period often tonsillectomy. Note absence of asymmetrical movement of soft palate in response to gaging and phonation which indicate paralysis and weakness. * Donot examine the throat when acute epiglottitis is suspected because gag reflex could cause complete laryngeal obstruction and death. * Child with high fever, sore throat, croupy cough, hoarseness, drooling and difficulty in swallowing may have acute epiglottitis in such case epiglottis is swollen and cherry red. 50 NOT FOR COMMERCIAL USE OR SALE

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* Children with hyper nasal speech or no voice may have sub mucosal cleft palate. * Pectus Excavatum may manifest in early infancy by marked mid line sternal retraction with normal inspiration. vs. Pectus Carinatum (chicken breast) do not ordinarily become evident until early childhood. * The breast of new born in both sexes often enlarged and engorged a white liquid some time called witchs milk (due to maternal estrogen) last week or two. * Super numerary nipple occasionally found on thorax and abdomen along vertical line. They are of no significance. * When breathing is predominantly thoracic suspect intra abdominal or intra thoracic pathology that restrict the use of diaphragm Where as in abdominal breathing suggest pulmonary dis. * New born infants normal breathing is 30 - 40/min. Alternating with Periodic Breathing is during which respiratory rate slowed markedly and may even cease (Apnea) 3 or more time for 3 seconds. This alternating breathing pattern may have been observed in 30 - 95 % of premature babies and less often in full term infant. The short Apnic period is not accompanied by bradycardia. * Period of Apnea lasting longer than 20 secs and accompanied by bradycardia may indicate cardiopulmonary, CNS dis or high risk of sudden infant death $. * Feel for tactile fremitus in infant by placing the hand on chest when baby cries than percuss the chest directly. * The percussion is normally hyper resonant and the in hyper resonance has the same significant as dullness in adult may be due to consolidation of lung and intrathoracic mass or pleural fluid. * In infancy breath sounds are longer than in adult because stethoscope is closer to the origin of sound. * Breathing in new born normally is slow and shallow than rapid and deep. * Extension or other movement of head with inspiration indicate use of accessory muscle of respiration and usually accompanied severe respiratory dis. * Because of smallness of thoracic cage in infant and the ease of sound transmission, breath sound are rarely absent entirely even with atelectasis, effusion, emphysema, pneumothorax, consolidation of lung. * Palpable and audible wheeze frequently occur in infant because of small lumen of tracheobronchial tree and is easily narrowed by slightly swelling of mucous mem or by amount of mucous. * An inspiratory wheeze called stridor indicate narrowing high in tracheobronchial tree vs. where as expiratory wheeze suggest narrowing lower down in the lung field. * Breast development in girl may begin normally as early as 8 yrs of age. Asymmetrical growth of preadolescent is common. Completition of growth usually correct these inequalities. * Generate tactile fremitus by feeling the chest wall ask child to say 99 or 1,2,3 which generate deep breathing. If not ask child to blow out the breath. * Diminution of femoral pulse as compare to radial pulse or their absence may be the only finding to suggest forestation of aorta in infancy or early childhood. * In infant breath sound may be mistaken for murmur occlude the nares momentarily to clarify this issue. * Peripheral edema in children is more likely to be periorbital and cause by renal failure. * During first 48 hr of life the heart murmur is due to patent ductus arteriosus and foramen ovale. The murmur is systolic and less than grade 2 in intensity. It disappear spontaneously after closure of ductus arteriosus and foramen ovale. * The apical impulse (PMI) is often visible at the level of 4th interspace untill age 7 yrs. * Sinus arrythmia (heart rate faster on inspiration and slower on expiration) is almost always present in infancy & early childhood. Premature ventricular contraction are quite common too. * Normally S1 is Louder than S2 at the apex. Splitting of S2 at the apex is found in 25 - 33 % of infant and children but is of no significance. * S2 is louder than S1 in plutonic area but when S2 is equal or greater than S1 at apex pulmonary HTN should be suspected. * 50% of children develop innocent murmur at some time during childhood but examiner must therefore distinguished b/w innocent or organic murmur. * Innocent murmur are less than grade 3 in intensity and is of short duration and low pitch (musical groaning quality) . It heard best with the bell of the stethoscope with pt supine. * A venous hum with both systolic and diastolic component is common in childhood. * Hemic Murmur are caused by blood flow through the heart. This occur when body require more oxygen than usual or when there is anemia. The murmur are located at the base of the heart, soft during systole and accompanied by tachycardia. * Carotid bruit and pulmonary branch stenosis are other commonly heard murmur disappear after first few month as pulmonary branch arteries enlarge. * Murmur of grade 3 or high are organic murmur indicate heart dis eg Acute RF or congenital heart dis. * Congenital heart dis heard best at the base of the heart. In atrial septal defect a grade 1 - 3 coarse systolic murmur is heard at 2nd and 3rd left interspace. vs. where as murmur of ventricular septal defect is more coarse and accompanied by thrill and is widely distributed. * The murmur of coarctation of aorta adult type is also heard best at 2nd or 3rd left interspace. It is louder and transmitted to the back medial to the scapula it may show palpable thrill at suprasternal notch. It also present BP in lower and BP in upper extremities. * Tetralogy of Fallot, Tricuspid atresia, Transposition of great vessel, and Eisenmenger $, are associated with Systolic murmur of grade 3 - 5. It also heard best at 2nd and 3rd left interspace. They are not well transmitted, may or may not be accompanied by thrill. These murmur has no distinguishing characteristics and may be present in infancy. In addition palpable liver pulsation may be present with Tricuspid Atresia and pure Pulmonic stenosis. 51 NOT FOR COMMERCIAL USE OR SALE

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* Murmur due to Rheumatoid heart dis are same as adult. * Congenital hart dis with no cyanosis are due to small Septal defect, Patent Ductus Arteriosus, Mild Pulmonic stenosis, Coarctation of Aorta. * Heart dis in infancy with out murmur are called Anomelous Origin of left coronary artery, Subendocardial Fibroelastosis, Glycogen Storage. They present with cardiac enlargement, tachycardia, and tachypnea. * Anew born with concave abdomen should immediately be investigated for diaphragmatic hernia with displacement of some the abdominal organ into the thoracic cavity. * Check no of vessel in umbilical cord normally there is two thick walled arteries and one thin walled vein. Vein is located at 12 o clock position. If there is only one artery it suggest variety of congenital anomalies. * The cutaneous portion of the umbilicus (umbilicus Cutis) retract to become flush with in abdominal wall where as gelatinous substance the Amniotic portion (Umbilicus Amnioticus) dries up with in one week and fall of with in two weeks. * The navel often fail to heal and glaucomatous tissue form at its base. * Infant are prone to Umbilical hernia, Ventral hernia and Diastesis recti all are easily detected by infants cry. * Many Umbilical hernia disappear by one year of age and almost all by age 4 - 5 yrs. * Abdominal reflexes are usually absent until after one yr of life. * Dilated abdominal vein may indicate portal vein obstruction. The direction of venous flow in portal HTN is down ward in vein below umbilicus. * Metallic Tinkling every 10 - 30 sec is normally heard in abdominal auscultation. * An in pitch or frequency of bowel sound or a marked diminuition indicate intestinal obstruction or ileus respectively. A venous hum is the sign of portal HTN * Marked Abdominal distention with tenderness may indicate acute surgical abdomen. * Palpate the abdomen in infancy is easy. Relax the infant by holding the leg flexed at knee than palpate abdomen by other hand. * Bladder in infant often normally percuss at the level of umbilicus. * In Hirshsprung Dis (congenital mega colon) a mid line supra pubic mass representing a feces filled recto sigmoid is found. * Avoid spasm and rigidity in palpating abdomen of crying infant giving bottle or pacifier. * In Pyloric stenosis unclothe infant in supine position and stand at foot side of the table. Feed the infant a bottle of sugar water or milk and observe the abdomen closely. If there is Pyloric stenosis, the peristalsis wave goes across upper abdomen left right and than become increasingly enlarge and frequent as the feeding progress. Inevitably baby will vomit with projectile force, at this point palpate deeply in the right upper quadrant with your extended middle finger. This will reveal the pyloric mass roughly 2 cm in diameter. * When child is too ticklish place the child hand under your hand to increase the relaxation. * Flex the knee and hip also relax the abdomen. * The pathological enlarge liver is usually palpate at or more than 2 cm below the coastal margin and has round firm edge. ( 1- 2 cm below the coastal margin is normal ). ** Normal Liver Span By Percussion at Different Age :* 1 yr ---- 2.8 cm in male and 3.1 cm in female. * 3 yrs ---- 4.0 cm in male and 4.0 cm in female. * 6 yrs ---- 5.1 cm in male and 4.8 cm in female. * 12 yrs ---- 6.5 cm in male and 5.6 cm in female. * 20 yrs ---- 7.7 cm in male and 6.3 cm in female. * The lower border of the liver can be determined with the Scratch Test. place the Diaphragm of stethoscope just above the right coastal margin at mid clavicular line with your finger nail slightly scratch the skin of the abdomen along the mid clavicular line; moving from below the umbilicus toward the coastal margin when your scratching finger reaches the liver edge you will hear the scratching sound as it passes through the liver to your stethoscope. * You can palpate the spleen b/w the thumb and your forefinger of right hand . * Pulsation in epigastria cause by aorta can be seen normally. Where as pulsation of the enlarge right ventricle may also be transmitted to the diaphragm and be visible in epigastria. * Tenderness and spasm of abdominal musculature in childhood are usually diffuse when serious pathology occur in abdomen. It suggest generalized peritonitis. * Ask the child to sit up from the supine position while you push down against the forehead with your hand. This maneuver can illicit pain in RLQ in Acute Appendicitis when the appendix is lying anteriorly. Where as when appendix is lying retrocecally over the Psoas or Obturator Muscle, Psoas or Obturator signs are often present. * Locate the urethral orifice and the shaft of the penis observe any abnormality like Hypospadius, Epispadius etc. * Palpate the scrotal sac and inguinal canal, locate testes, if it found in the inguinal canal use steady gentle pressure to put them down into the scrotum. * In 3% of male neonates one or both cannot felt in the scrotum by age 1 yr 2/3 of these testes will descended into the scrotum. * Bilateral Cryptoorchidism strongly suggest Adrenogenital $, in which infant sex is female and Hyponatremia, dehydration and shock may ensues with in first two week of life. 52 NOT FOR COMMERCIAL USE OR SALE

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* Generalized scrotal edema may be present for several days due to the effect of maternal estrogen and of breech delivery when bruising is also present. * Hydrocele overlying the testes and spermatic cord are common in infancy and often associated with potential inguinal hernia. Hydrocele may be differentiated easily with hernia in that, former Transilluminate and are not reducible. Most Hydrocele detect in infancy reabsorbed by 18 month of age. * Examine the female genitalia by separating the labia majora at their mid point with thumb of each hand apply traction laterally and posteriorly for full view. * In new born female the mon pubis, labia majora and minora are prominent due to the effect of maternal estrogen, this prominence decrease in 1 or 2 month. Some time there is bloody vaginal discharge during first week which may be replaced by serosanguineous discharge for several more week. * Enlargement of the Clitoris and posterior fusion of the labia majora are the sign of ambiguous genitalia due to inborn error of testosterone biosynthesis, a chromosomal defect, teratogenic agent, development abnormality, if ambiguous genetalia is present it is essential that the sex of the child should be determined before sex assignment is made. * The absence of central Hymen orifice (imperforate hymen) is rare and of no clinical significance. If it persist Hydrocolops may occur and than Hematocolops may occur in adolescent girls ( both conditions are rare ) . * Hold the feet together and flex the knee and hip on the abdomen with one hand and with other hand observe the rectum. (use index finger for rectal examination regardless of the size of your finger slight bleeding may occur on its removal). * Testes may move upward when medial aspect of each thigh is scratched lightly ( Cremasteric Reflex ). * Enlargement of penis may occur in precocious puberty, due to an excess circulating androgen of adrenal or testicular origin due to tumor of an organ or pituitary gland. Other signs are Virilization, pubic and axillary hair, testicular size, somatic growth and muscle mass, hirsutism, deepening voice usually accompany the penile enlargment. * Overcome the Cremasteric reflex by having the child sit crossed legged on table exanimate testicle in this position. * Cryptoorchidism or undecided testicals may persist uni or bilaterally with testes remain in abdomen or with in inguinal canal. * The examination of inguinal hernia is same as in adult. * Examine the female genitalia in supine frog leg position. * Use childs own hand to open the genitalia for more comfort for her and your self. * Fusion of labia minora is seen occasionally in girl under 4 yr of age. It may be partial or complete. A thin mem that join the labial edges is easily lysed with cotton swab or a probe. The labia will also separate if the estrogen containing crme is applied to labia once or twice daily for several days. * The appearance of pubic hair or breast enlargement before 8 yrs of age in girls may be due to precocious puberty and must be thoroughly evaluated. * Foreign body are often inserted by child into vagina and cause irritation and infection which lead to purulent vaginal discharge. * Examination of vagina and cervix is indicated when sexual abuse is suspected. * Physiologic Leucorrhea (a thin whitish vaginal discharge) is common in adolescents where as purulent discharge may be due to foreign body, irritant vulvovaginitis, bacterial infection, or STD. * For rectal examination assure the child with knee, hip flexed and leg abducted. Ask child to breath rapid to mouth like puppy. Ask child to push down to relax sphincter. * Perianal skin tab in childhood are of no significance. * Bimanual recto abdominal palpation in female reveal a small mid line mass which is cervix any other mass than that should be consider abnormal. In young boys prostate gland is not palpable. * In fore foot in infant adducted at metatarsal - tarsal line is called Metatarsus - Adductus Deformity. it is common and spontaneous correction occur with in 2 yrs. * When the fore foot is twisted inward on its longitudinal axis (inverted) it suggest Metatarsus Varus. * Bowlegged Growth Pattern (Genu Varum) usually disappear at 18 month of age. Where as Knock - Knee Pattern ( Genu Valgum) persist from 2 yrs until 6 - 10 yr. * When fore foot is adducted and the foot is inverted suggest Talipes varus. * When fore foot adduction and inversion with planter flexion of entire foot occur suggest Talipes Equinovarus (Club foot). * The longitudinal arch in infancy is obscured by adipose tissue giving foot a flat appearance, dont misdiagnosed as being flat footed. * Spastic flat foot is very rare in children and not exist during infancy. It is characterize by pronation of entire foot, eversion of the fore foot and pain on walking. * Hip of all infant should be examine for dislocation. Flex the leg to right angle at the hip and knee with baby supine, place your index finger over the greater trochanter of each femur and your thumb over the lesser trichinae , abduct both hip simultaneously until the lateral aspect of each knee touches the examining table. This maneuver is known as Ortolani Test. * When congenitally dislocated hip is present you will see and feel the Clunk or click at the femoral head, which in this condition lies posterior to the acetabulum and enters the acetabulum at same point in the 90 degree abduction arc. This finding is know as Ortalanic Sign. * Beyond the new born period as the muscle surrounding the hip increases strength, the clunk or click of the ortolanic sign is less obtainable, the Abduction of the flexed leg becomes a significant sign in congenital dislocation of the hip. * Detect a unstable hip (non dislocated hip but potentially dislocate able) by placing your thumb medially over the lesser Trochanter and your index finger laterally over the greater trichinae, press your thumb backward and out ward feel the movement of the head of femur laterally out of acetabulum (normally no 53 NOT FOR COMMERCIAL USE OR SALE

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movement is felt). Than with your index finger press greater trichinae forward and inward feel for sudden movement (normally there is non). If movement is present it constitutes Barlows sign. this sign is not diagnostic of congenital dislocated hip, but it indicate the need to observe baby for this possibility. * Palpate spine carefully specially lumbosacral area, skin, pigmented spot, hairy patches, or deep pit that might over lie the external opening of the sinus tract that extend to spinal canal. * Spinabifida Occulta (a vertebral defect) may be associated with underlying defect of spinal cord (Diastomatomyelia) that can cause mal function of the bladder and rectum also weakness and paralysis of lower extremities. * A sinus tract provide potential entry to organism into spinal cord cause meningitis. * In childhood the thoracic convexity is and lumbar concavity is . Lordosis is common and rarely cause symptom. * Test for severe hip dis with its associated weakness of gluteous medius muscle by observing the child from behind as the wt is shifted from one leg to another pelvis tilt toward the affected hip when wt is borne on affected side (+ Trendelenburg Sign). * Ask child to bend forward when you suspect scoliosis. From behind watch for asymmetry of scapula, rib cage, and hipmark spinous process with ink and look for curve. * The absence of infantile automatism (reflex activity) in neonate or persistence of some beyond there expected time of disappearance may indicate severe CNS dysfunction. * Assess mental status by observing the ease of transition b/w the state of alertness and drowsiness, ease of consolability, orientation to visual and auditory stimuli and habituation of various stimuli. * Postural indicator of severe Intracranial disease, include persistent asymmetries, predominant extension of extremities and constant turning of head to one side, marked extension of head, stiffness of neck, and extension of arm and legs (Opisthotones) Indicate severe meningeal or brain stem irritation seen in IC infection or hemorrhage. * Test for motor function by putting each major joint through its range of motion to determine muscle tone, plasticity, & flaccidity. * Use Denver Developmental screening Test for gross and fine motor coordination testing. * Test for pain sensation by flicking he infant palm or sole with your finger, observe for withdrawal or arousal and change in facial expression( do not use pin to test pain sensation). * Absence of withdrawal when a painful stimuli is applied to an extremity indicate anesthesia or paralysis. If a facial expression or a cry changes in the absence of withdrawal suggest paralysis. Where as with spinal cord lesion or dis, the extremities withdraw reflex with pain but babys facial expression or cry will not change. * CN are tested in infancy as in adult. * 12th CN is easily tested. Pinch the nostril of the infant this produce reflex opening of mouth and raising of the tip of tongue. In 12th CN paresis the tongue tip deviate toward the effected site. * Because the corticospinal tract is not fully developed in infant, the spinal reflex mechanism (deep tendon reflex and planter response) during infancy are variable. There exaggerated presence or absence has very little diagnostic significance. * The technique for eliciting these reflexes is similar to that in adult except you used semi flexed index finger can substitute for neurologic hammer. * Babinski Response to planter extension stimulation can be illicit in some normal infant until 2 yrs of age. How ever planter flexion response is illicit in 90% of normal infants. * Tricep reflex is usually not present until after 6 month of age where as rapid rhythmic planter flexion of foot in response to ankle reflex (ankle clonus) is common in new born as many as 8 - 10 such contraction occur normally (unsustained ankle clonus). When the contraction are continuous (sustained ankle clonus) severe CNS dis should be suspected. * One can also illicit ankle clonus by pressing your thumb over the ball of the infant foot and abruptly dorsiflexing the foot. * Abdominal reflex is absent in new born but appear in 6 months of life. * With baby supine raise the lower leg stroke the perianal area with a paper clip and observe the external anal sphincter contraction. Absence of reflex suggest loss of innervation due to spinal cord lesion at the level of lower sacral segment (or higher) Such as spin bifida, tumor or injury. * Infantile Automatism are reflex phenomenon have prognostic value for CNS integrity. * Blinking (Dazzle) reflex present at birth disappear after 1st year. It is a eye lid close in response of bright light absence of reflex may indicate Blindness. * Acoustic Blink reflex (Cochleopalpabral) present at birth both eyes blink in response to sharp loud noise. Absence may indicate noise or impaired or absent hearing. * Palmar Grasp Reflex disappear at three to four month this reflex enhance by offering a baby bottle since suckling facilitate grasping. Persistence of Grasp reflex beyond 4 months suggest cerebral Dysfunction. Note that baby normally clench their hand during the first month of life, persistence of the clench hand beyond 2 months suggest CNS damage particularly when finger overlap the thumb. * Rooting Reflex disappear at 3 - 4 months may be present longer during sleep. Absent reflex suggest generalized or CNS dis. * With baby head position in the mid line and the hand held against the ant chest stroke with your finger the perioral skin at the corner of the babys mouth and on upper and lower lip in response mouth will open and turn to the stimulated side. * Trunk Incurvation (Galants) Reflex disappear at 2 months. Hold the baby horizontally and prone in one of your hands. Stimulate one side of the babys back approx 1 cm from the midline along the paravertebral line extending from shoulder to buttock. This produce curving of the trunk toward the stimulated 54 NOT FOR COMMERCIAL USE OR SALE

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side with shoulder and pelvic moving in that direction. Absence of the reflex suggest transverse spinal cord injury or lesion. * Vertical Suspension Positioning disappears after 4 month. It illicit while you support the baby upright with your hand under the axila the head is normally maintained in the midline and the leg are flexed at the hip and knee. Fixed extension and adduction of the leg (scissoring) indicate spastic paraplegia, diplegia. * Placing response best illicit after first 4 days disappearing time is variable. Hold the baby upright from behind by placing your hand under the baby arms with your thumb supporting the back of the head. Now allow the dorsal surface of one foot to touch the under surface of table (take care not to planter flexed the foot). Note baby respond by flexing the hip and knee and placing the stimulated foot on the table the opposite leg step forward and a series of alternate stepping movement occur as you move the baby forward. These response are absent when paresis is present and in babies born by breech delivery. * Rotation Reflex present at birth hold the baby under the axillae, at arms length facing you and turn baby in one direction and than other, the head turn the direction you turn baby. If you restrain the head with your thumb the baby eyes will turn in the direction you turn baby. The head and eye do not move if there is vestibular dysfunction. Strabismus may be detected early in this maneuver. * Tonic Neck Reflex may be present at birth but usually appear at 2 months of age and disappears at 6 months. It can be illicit by turning the head of baby at supine position with holding a jaw over babys shoulder. The arm and leg on the side to which the head is turned extend while opposite arm and leg flexed. This fencing posture response does not occur normally when each time this maneuver is performed. Repeat this maneuver on other side too, when this fencing response occur at any age indicating major CNS damage. * Bilateral cerebral injury produce hypotonic with normal or brisk deep tendon reflex, delay in reaching motor milestone and persistence of the tonic neck reflex. * Perez Reflex and Moro Reflex (startle Reflex) :- They are present at birth and disappear by 3rd month. Absence of either reflex during first 3 months of life indicates severe cerebral insult, injury to upper cervical cord, advanced ant horn cell dis or severe myopathy. * Perez Reflex :- Suspend the baby prone in one of your hand, place the thumb of your other hand on babys sacrum and move it firmly toward the head and spine, Flexing of knee, cry and empty of bladder are the usual responses.(it may be useful to collect urine specimen from neonate). * Moro Reflex (Startle Reflex) :- Hold the baby in supine position, supporting the head back and leg. The sudden lower the entire body about two feet and stop abruptly, Other way is to produce loud noise (eg strike the table with palm of your hand). It produces a response in which arm briskly abduct and extend with hand open and finger extended, than arm return forward over the body and baby cries. * persistence of Moro reflex beyond 4 month may indicate neurologic dis and the persistence of response beyond 6 month is almost exclusively suggest neurologic dis. An asymmetrical response in upper exteremities suggest hemi paresis, injury to the brachial plexus, fracture of the clavicle or humerus, lower spinal cord injury, congenital dislocation of hip may produce absence of response in one or both legs. * Combination of finding in infancy with Hx of hemolytic anemia or hemolytic dis or neonatal jaundice are presence of the Setting of Sun Sign, Opisthotones, and absence of Moro Reflex suggest Kernicterus. * In congenital Hemiplegia, unilaterally absent or diminish movement of the extremity along with abnormal posturing is seen. Reflexes and muscle tone is normal. * The Spastic Diplegia Produce variable dystonic spasm, Followed by hypotonic early in infancy and persistent clenched fist coupled with scissoring after the first few month. * Asymmetric arm movement in walking and running may indicate hemi paresis may show unequal wear of sole of the shoes. It may also caused by orthopedic condition. * Observe the children rising from the floor , from a supine position. Normally sitting position is first assumed, the leg are than flexed at knees while the arm are extended to the side of the body to push off from the floor in smooth motion. * In certain form of muscular dystrophy with pelvic girdle weakness, rising from supine to standing position is different (Gowers Sign) because weakness of the hip extensor muscle, the child roll over to prone position and pushes of the floor with the arms, bringing the legs to flex position under the trunk the leg are extended with the help of hand and forearm. Which push up on the thigh until the upright position is gained. ----------------------------------------------------------------------------------------------------

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