1) Cardiovascular Examination

Greet patient, introduce yourself, shake hands with patient.

Expose entire upper half of body (topless)
! de"rees
#nspection at foot of bed$
(%r xxx appears well and comfortable & rest, he's alert and breathin" normally..)
1. General appearance general well-being, catheters, drips, scars, breathing
2. Apex beat, thrills
(eripheral )i"ns
Eyes$ Jaundice and anaemia
*on"ue$ shine torch high arch palate : marfans
-- dentition
canosis, hdration
+ands$ !allor, "Jaundice#, clubbing, $pooning, nicotine stains, splinter haemorrhages, Janewa lesions, %sler nodes,
palmar erthema
(ulse$
&adial: - rate, chx, rhthm
- collapsing "waterhammer pulse#
'elas: - &-&, &-(
(emoral
!ost tibial
'orsalis !edis
,e"$ pedal edema
-eck$ J)! "measure distance from sternal angle#, *arotid
(raecordium
(alpate
1# Apex +eat : ,
th
-*$, medial to mid-cla. line, lower and outermost where beat is distinctl felt
: /eft lateral position
: -f not there chec0 other side for dextrocardia
2# !arasternal hea.e and thrills
1# +ase of heart
.uscultate
1# Aortic "bell#
2# /eft axillar region - radiate "bell#
1# Aortic "diaphragm#
2# /eft axillar region ratiate "diaphragm#
,# /eft axillar region in left lateral position
3# 4ricuspid "d#
5# !ulmonar "d#
6# *arotid "bell#
%isc
$it patient up
1# as0 patient to expire and stop breathing, ausc for A&
2# ausc base of lung
1# chec0 for sacral edema, bac0 deformities
$urface mar0ings:
7itral: 2
th
-*$, 7* line
4ricuspid: ,
th
-*$, /$8
!ulmonar: 2
nd
-*$, /$8
Aortic: 2
nd
-*$, &$8
/) 0espiratory Examination
Greet patient, introduce yourself, shake hands with patient.
Expose entire upper half of body (topless)
#nspection at foot of bed$
(%r xxx appears well and comfortable & rest, he's alert and breathin" normally..)
1. General appearance general well-being, catheters, drips, scars, breathing
2. $hape of chest: pigeon, funnel, barrel
,. smmetr
3. using accessor muscles of respiration: scalene, serratus anterior, pect ma9or
5. rate of respiration
6. stridor:
;. cough: 'r or wet:
1<. sputum:
#nspection at ri"ht of bed$
Eyes$ Jaundice and anaemia
*on"ue$ central canosis, hdration status
+orners )yndrome$ sweating abo.e the brow as well as ptosis
+ands$ clubbing, pallor, palmar erthema, nicotine stains, canosis, flap"*%2 retention#, 41 wea0ness, =!%A
1ront
(alpate
1# 4rachea : de.iation:
tug:
2# Apex +eat
1# *hest 8xpansion
2# )ocal fremitus
(ercuss
1# apex
2# cla.icles
1# -*$ going lateral
.uscultate
;# +reathing sounds: >pper and /ower lobes
Axillar area
1<# )ocal resonance
1 0inds of sounds:
1# ?ormal: .esicular
2# Abnormal: bronchial "da. .ader#
1# Added: whee@es
crepitations
rubs
2ack
$it patient up. %pen up the scapula b folding patientAs arms on pillow on lap in front of patient
&epeat palpation"except apex beat and trachea#, percussion, auscultation
3) Gastrointestinal )ystem Examination
(atient position$ (lat on bed with 1 pillow under head
Greet patient, introduce yourself, shake hands with patient. Expose ade4uately (nipple to mid5thi"h).
#-)(EC*#6-
.t foot of bed$
11. General appearance general well-being, catheters, drips, abdomen shape "scaphoid, flat, distended#
12. Abdominal mo.ement with respiration, pulsations, .isible peristalsis
11. 7asses, scars, 9aundice, cachexia, hernia "as0 patient to cough#, pigmentation
%ove to ri"ht of bed
1. =ands
'uputrenAs contracture, finger clubbing, palmar erthema, leuconchia, 7uehrc0eAsB trans.erse white
lines "all indicati.e of chronice li.er disease#
=old out arm, extend wrists and abduct finger for 1, seconds to chec0 for hepatic flap "asterixis#
*hec0 for brusisingB spider nae.i
2. 8es
*hec0 for 9aundice "upper sclera# and pallor "lower con9uncti.a#
1. !arotids
*lench masseters, feel for enlargement "suggesti.e of alcoholism#
2. 7outh
*hec0 for fetor and ulceration
$tic0 out tongue to chec0 hdration status
,. ?ec0B *hest
!alpate supracla.icular nodes "suggesti.e of gastric patholog#
Gnaecomastia
$pider nae.i "more than 2#
3. Abdomen
!resence of prominent .eins, chec0 direction of flow "below umbilicus# if present
*arput merdusea "portal hpertension#: flow awa from umbilicus towards legs
-)* obstruction: flow towards head
!resence of pulsations, .isible peristalsis
$ister JosephAs nodules suggesti.e of abdominal malignanc
$traiae
(.,(.*#6- .-7 (E0C8))#6-
$CuatB 0neel beside bed ees le.el with abdomen
1. /ight palpation
-nform patient, as0 if tenderness present
(eel o.er ; regions "tender region last#, chec0 for tenderness and masses
2. 'eep palpation
-nform patient to warn of discomfort
(eel o.er ; regions, feel and define masses felt "site, si@e, shape, surface, edge, consistenc, tenderness,
7obilit, pulsatilit, abilit to get o.er#
1. /i.er
(eel from right iliac fossa, palpate up to right hperchondrium
=and 0eep still during inspiration to feel for li.er, inch up during expiration
!ercuss for lower edge
!ercuss for upper edge from second intercostal space
7easure span "normal: D11cm#
2. Gall bladder
7a be palpable below right costal margin along linea semilunaris
8licit 7urphAs sign if cholecstitis suspected
,. $pleen "-#
!alpate from right iliac fossa to left hpochondrium
!ercuss for dullness at lowest intercostal space, left anterior axillar line
3. Ascites "shifting dullness#
!ercuss for dullness towards left flan0
Eeep hand on dull spot, turn patient to right lateral position and wait for 1< seconds to 1 minute
!ercuss for resonance
5. $pleen "--#
As0 patient to flex hips while in the right lateral position, compress left thoracic wall with left hand and
palpate for spleen again with right hand "from right iliac fossa to left hperchondrium#
*hec0 for scars on patientAs bac0 while at patient is at right lateral position
6. Eidnes
Guide patient bac0 to ling position with left hand, 0eep left hand below patientAs left flan0
+allot the left 0idne bimanuall with right hand on top
&epeat bimanual balloting of the right 0idne
;. =ernias
*ompress deep inguinal ring "mid-inguinal point# and as0 patient to cough
(eel for cough impulse
/oo0 for umbilicalB paraumbilical hernia
.8)C8,*.*#6-
1. !lace stethoscope below umbilicus for bowel sounds "o.er 1 minutes without bowel sounds: paraltic ileus#
2. +ruits
>mbilicus: *hec0 for aneursm at bifurcation of aorta
Abo.e umbilicus at both sides: chec0 for renal stenosis

End examination with examination of external "enitalia and per rectal examination
a) -eurolo"ical Examination (Cranial -erves)
Greet patient, introduce yourself, shake hands with patient.
(osition$ $itting up
6lfactory (#)
As0 patient an loss of sense of smell
6ptic (##)
1. )isual Acuit
!atient to remo.e spectacles
*hec0 using fingers "use 1, 1 and ,#
2. )isual fields "'one at the end of the examination#
$it opposite patient, as0 patient to co.er 1 ee and loo0 straight into our ee
>se a red pin, bring it in from 9ust outside the peripheral .isual field
1. (undoscop
6cculomotor (###), *rochlear (#9), .bducens (9#)
1. !upillar reflex "smpathetic component from --, parasmpathetic from ---#
$hine light indirectl and obser.e patientAs pupil si@es "chec0 gross differences in si@e, shape,
regularit#
Assess reaction of pupil to light
$wing torch from ee to ee, chec0 for paradoxical papillar dilation "7arcus Gunn pupil#
*hec0 accommodation b first as0ing patient to focus on farawa ob9ect before focusing on pin 1<cm
in front of nose, chec0 for papillar constriction "failure to constrict: eg Argll &obertson pupil#
2. 8e mo.ements
7o.e pin in F=A manner and as0 patient to follow with his ees
*hec0 for abnormal ee mo.ement
As0 if diplopia present
1. ?stagmus
As0 patient to loo0 to the side and chec0 for saccadic ee mo.ements bac0
*ri"eminal (9)
1. $ensor component
>se a piece of tissue paper and test for sensation on the 1 sensor di.isions
4est for corneal reflex b touching the cornea of patient while he loo0s awa "chec0 blin0ing of both
ees#
2. 7otor component
*hec0 for wasting of temporalis and masseters
As0 patient to clench teeth and feel for masseters
Jaw 9er0
1acial (9##)
As0 patient to loo0 up, chec0 for furrowing of forehead
As0 patient to smile
As0 patient to shut ees and chec0 for asmmetr
9estibulococchlear (9###)
Ghisper into ears of patient while distracting him at the other ear b rubbing the finger
>sing a tuning for0 "2,3 h@#, chec0 for hearing at both ears. -f hearing absent, place for0 at mastoid
process to determine conduction or sensor deafness
Glossopharyn"eal (#:), 9a"us (:)
!atient to sa FahA with mouth open, chec0 for de.iation of the u.ula or asmmetrical lifting of the
soft palate with a torch
/isten for hoarseness of .oice
8licit a gag reflex "not recommended#
.ccessory (:#)
As0 patient to shrug shoulder and chec0 for asmmetr
As0 patient to turn head against a force and chec0 for wea0ness of the sternocleidomastoids
+ypo"lossal (:##)
*hec0 for tongue wasting, fasciculations and tongue de.iation
b) -eurolo"ical Examination ((eripheral)
(atient position$ (lat on bed with 1 pillow under head
Greet patient, introduce yourself, shake hands with patient, check for dystrophia myotonica (unable to relax
muscles after contraction). Expose arms by rollin" up sleeves.
#nspection at foot of bed$
12. General appearance general well-being, catheters, drips, scars, breathing
1,. !osture eg decorticate ">/ flexed, adducted and pronated, // extended#
13. 7uscle atroph
15. Abnormal mo.ements fasciculations "large muscles, especiall abdomens#, tremor
16. $0in signs eg neurofibromatosis
%6*60 );)*E%
(ronator dirft
!atient straightens arms, palms face upwards and close ees. *hec0 for drifting of arms
- 'ownwards: upper motor neuron "pramidal# wea0ness
- >pwards: cerebellar disease
- $earching mo.ement of fingers: loss of proprioception
%uscle tone$
1. 4a0e patientAs hand, inform patient of intention. $upinate and pronate wrist. *hec0 for flaccidit or spasticit
2. &epeated passi.e flexion and extension of elbow
1. =old patientAs 0nee, inform patient and abruptl lift 0nee upwards to chec0 for flexion of the leg "flaccidB
normalB spastic#
2. /og-roll legs of patients and assess mo.ement of feet
,. 8licit clonus b sharpl dorsiflexing the foot with 0nee slightl flexed and hip externall rotated. *hec0 for
recurrent plantar flexion
0eflexes$
1. +iceps 9er0 *,, *3
2. $upinator 9er0 *,, *3
1. 4riceps 9er0 *5, *6
2. Enee 9er0 /1, /2
,. An0le 9er0 $1, $2
3. !lantar reflx /,, $1, $2 "chec0 for +abins0iB extensor response: extension of big toe, fanning of remaining
digits#
Coordination (Cerebellar si"ns)
1. (inger-nose test - intention tremor, past-pointing
2. &apidl alternating mo.ements "pronate and supinate hand# chec0 for dsdiadocho0inesis
1. =eel-shin test run heel of leg along opposite shin
(ower (,ower limbs)
1. =ip
(lexion "/2, /1# patient straighten leg, flex hips and resist downward force applied abo.e 0nee
8xtension "/,, $1, $2# patient 0eeps leg down and not let ou pull it up from underneath calfB an0le
Abduction "/2, /,, $1# patient abduct leg and not let ou push it in
Adduction "/2, /1, /2# patient 0eep leg adducted and not let ou pull it out
2. Enee
(lexion "/,, $1# patient bend 0nee and not let ou straighten leg
8xtension "/2, /,# patient bends 0nees slightl and tries to straighten 0nee against force
1. An0le
'orsiflexion and plantaflexion "$1, $2# patient attempt to dorsiflex and plantaflex an0le against force
(ower (8pper limbs)$ As0 patient to sit at edge of bed
1. $houlder
Abduction "*,, *3# patient abducts arms and flex elbows, resist downward force
Adduction "*3, *5, *6# - patient abducts arms and flex elbows, resist upward force
2. 8lbow
(lexion "*,, *3# patient flexes elbow against force
8xtension "*5, *6# patient extends elbow against force
1. Grist
(lexion "*3, *5# patient flexes wrist against force
8xtension "*5, *6# patient extends wrist against force
2. (ingers
(lexion, extension "*5, *6#
Abduction, adduction "*6, 41#
c) Examination of the Cerebellar )ystem
/ocali@ing signs: H'A$=-?GI
7sdiadocho0inesisJ ataxiaJ slurred speechJ hpotoniaJ intention tremorJ nstagmusJ "ait abnormalit
Head
1. =ori@ontal ee mo.ement
Jer0 hori@ontal nstagmus
2. $peech:
H+ritish constitutionI or HGest &egister $treetI
H/alalalalaI: -rregularl irregular in .olume and rhthm
*erebellar speech is 9er0, explosi.e and loud with an irregular separation of sllabus
Hand
1. (inger-nose test
8lbow must be up
(ind out patientAs reachable target and place finger about 1 inch before
'o not shift finger as patient reaches for it.
/oo0 at patientAs ee. !atient not blin0ing implies that he 0nows he wonAt hit his own ee
?ote intention tremors and past-pointing
2. 'isdiadocho0inesis
=and must be lifted up
Legs
,. =eel-shin test
Gi.e commands: 1#/ift leg 2#4ouch 0nee 1# $lide down shin
3. 4oe-finger test
$et a realistic target
/oo0 for intention tremor and past-pointing
Others
5. $it
/oo0 for truncal ataxia
6. !endular 9er0
!erform 0nee 9er0 the lower leg continues to swing a number of times before coming to rest, an e.idence of
hpotonia
;. $tand
As0 patient to ta0e one step forward, awa from bed. /oo0 at stance. "+road based K wider than shoulder#
!ut legs together. 'onAt close ees.
1<. Gal0ing
Get patient to stand in tandem then wal0 in tandem
Causes
Rostral vermis lesion (only lower limbs affected)
>suall due to alcohol
Unilateral
8xamine the cranial ner.es for e.idence of cerebellopontine angle tumour "*? ,, 5, 6 affected# or the lateral
medullar sndrome and auscultate o.er the cerebellum. /oo0 in the fundi for papilloedema. ?ext examine
peripheral signs of malignant disease and .ascular disease
*auses
- $pace-occuping lesion
- -schaemia
- 7ultiple sclerosis
- 4rauma
Bilateral
/oo0 for signs of multiple sclerosis, (riedreichAs ataxia "pes ca.us is the most helpful clue# and hpothroidism.
*auses
- 'rugs, e.g. phentoin
- Alcohol
- (riedreichAs ataxia
- =pothroidism
- !araneoplastic sndrome
- 7ultiple sclerosis
- 4rauma
Midline
8.idence of midline lesion: truncal ataxia, abnormal heel-toe wal0ing or abnormal speech
*auses
- 7idline tumour
- !araneoplastic sndrome
------------------------------------------------------- the end ----------------------------------------------------------------------------
Extra %isc stuff$
1) .pproach to the 0espiratory )i"ns
'isorder 7ediastinal
displacement
*hest wall
mo.ement
!ercussion
note
+reath
sounds
Added
sounds
)ocal
&esonance
*auses
*ollapse -psilateral
shift
'ecreased 'ull Absent or
reduced
Absent -ntraluminal: 7ucus,
foreign bod,
aspiration
7ural: +ronchial
*A
8xtramural:
lmphadenopath,
aortic aneursm
!leural
effusion
'isplaced
awa
&educed $ton dull Absent,
bronchial
o.er
upper
border
Absent &educed 4ransudate, 8xudate,
=aemothorax,
*hlothorax,
8mpema
*onsolidation ?one &educed 'ull +ronchial *rac0les -ncreased /obar:
pneumococcal
+ronchopneumonia:
bacterial
(ibrosis ?one 'ecreased
smmetricall
?ormal ?ormal (ine
crepitations
$*=A&4
&A$*%
!neumothorax 4o opposite
side
'ecreased =per
&esonant
Absent or
greatl
reduced
Absent &educedB
Absent
$pontaneous,
4raumatic
Asthma ?one 'ecreased
smmetricall
?ormal or
decreased
?ormal or
reduced
Ghee@e
(hysical Examination < 7etermine (leural Effusion, Collapse or Consolidation
Collapse
1. -ntraluminal
- 7ucus "e.g. postoperati.e, asthma, cstic fibrosis#
- (oreign bod
- Aspiration
2. 7ural
- +ronchial *A
1. 8xtraluminal
- !eribronchial lmphadenopath
- Aortic aneursm
le!ral "ff!sion
8xamination
/oo0 for aspiration mar0
At least ,<<ml of pleural fluid for clinical detection
Aetiolog
2. 4ransudati.e effusion
- -s the patient edematous:
- **( J)! ele.ated. Apex displaced
- ?ephrotic $ndrome !eriorbital edema. &enal biops scar
- *hronic /i.er 'isease !eripheral stigmata. Ascites
1. 8xudati.e 8ffusion
- 7alignanc *er.ical and axillar lmphadenopath. &eCuest for breast examination
- -nfection 4+, pneumonia. /oo0 at temperature chart
- Autoimmune $/8: &A:
2. %thers:
- !ulmonar embolism secondar to ')4
- =pothroidism
- 7eigAs sndrome
,. ?.+.
- *ommonest cause of pleural effusion **(
- 7assi.e pleural effusion is almost alwas malignant
/ightAs *riteria "for exudates#
1. &atio of pleural fluid to serum protein L<.,
2. &atio of pleural fluid to serum /'= L<.3
1. !leural fluid /'= greater than two thirds the upper normal limit for blood /'= le.els
Consolidation (Conditions presenting with a consolidative pict!re)
1. !neumonia
- *ommunit-acCuired
a# $treptococcus pneumoniae "3<-5<M#
b# Atpical "7coplsma, /egionella, *hlamdia# ",-16M#
c# =aemophilus influen@ae ",M#
d# $taphlococcus aureus
e# 7oraxella catarrhalis
f# )iruses "influen@a, parainfluen@a, .aricella, &$)#
- =ospital acCuired
a# $. aureus
b# Gram-negati.e organisms "Elebsiella, !roteus, 8.coli, !seudomonas#
2. +ronchiectasis
- -nfection
a# *hildhood: !ertussis
b# !ost 4+ infection
c# %bstruction *A, foreign bod
- *ongenital
a# -gA =pogammaglobulinaemia
b# *stic (ibrosis
c# EartagenerAs sndrome
#ibrosis
- +asal "!osteriorl#
0 &A
. Asbestosis
) $/8, $cleroderma
# -diopathic
6 %thers 'rugs: *totoxics, Amiodarone, ?itrofurantoin, Antirheumatics
- >pper @ones "Anteriorl#
) $ilicosis, $arcoid
C *G!
+ =istoctosis
. An0losing spondlitis
0 &adiation
* 4+
- +oth
- ?eurofibromatosis
E 8xtrinsic allergic al.eolitis
( !ulmonar haemorrhage sndrome
. Al.eolar proteinosis
, /mphangiomomatosis
Chest :5ray
$hite%o!ts
1. !leural 8ffusion
- +lunting of the costo-phrenic angle
- 7eniscus
2. *ollapse
- /oss of .olume.
- 4racheal de.iation
- Ghite-out
1. *onsolidation
- ?on-uniform shadowing, border not well demarcated
- Air bronchogram
2. *oin lesion
- 8dgeN speculated, irregular or lobulated edge suggests malignanc
- *alcification
- *a.itation
,. +ronchiectasis
- &ing shadows gi.ing honecombed appearance
- &are: 4ramline shadows, 4ubular shadows, Glo.e shadows
3. (ibrosis
- (ine reticulonodular shadows extending into the axillar aspect of the hemithorax. (ine ground-glass
appearanceJ *oarse =onecomb
- (ibrosis ma causes shrin0age of the lung which will not be caused b consolidation or edema
- +lurred heart and diaphragm borders
Blac& l!ng fields
1. *%!'
- *%!' aBw large lungs due to air trapping and de.elopment of bullae
- 'iaphragm flat or scallop shaped
- =ear elongated and narrowed
- !eripheral prunning
2. !neumothorax
- /ung edge
- 7ediastinal shift awa from blac0 line tension pneumothorax de.elopingN
1. !ulmonar embolism
- Gestermar0As sign of reduced perfusion: area blac0er than lung on opposite side
/) .pproach to Cushin"'s )yndrome
Examination$
Comment on moon%li&e facies and tr!ncal distrib!tion of adipose tiss!e appearing to spare limbs'
Hands
1. &heumatoid hands:
2. =pocount mar0s
1. *lubbing and tar stains
2. 4hin s0in "do double-pinch test#
,. +ruising of s0in
3. Gasting of s0in
5. !roximal mopath
#ace
1. -nspect: 7oon-li0e facies, !lethora, Acne, =irsutism
2. 7outh for thrush
1. 8es for cataracts "long term steroid use#
(r!n&
1. 'orsal fat pads "+uffalo hump#
2. (eel spine for e.idence of osteoporoisis "Gibbus#, collapse of .ertebrae and 0phoscoliosis
1. &espirator Auscultate for whee@ing
)bdomen
1. 4hinning of s0in and purple striae
!urple striae suggests acti.e disease
2. 4ransplanted 0idne
Re*!est
1. 4o ta0e blood pressure
2. 4o test urine for glucose
1. *hec0 .isual fields "for pituitar tumour#
2. 8xamine the fundus for optic atroph, papilloedema, signs of hpertensi.e or diabetic retinopath
Clinical *opics
C!shing+s syndrome is ca!sed by e,cess steroid from any ca!se while C!shing+s disease is increased
prod!ction by the adrenals secondary to e,cess pit!itary )C(H'
)etiology of C!shing+s -yndrome (R!le of .s)
)etiology
;<M exogenous steroid use 1<M endogenous steroid production
;<M A*4=-dependent 1<M A*4=-independent
"adrenal adenoma, *A#
;<M !ituitar 1<M 8ctopic
"bronchial carcinoid, small cell *A lung#
;<Mmicroadenoma 1<M macroadenoma
/nvestigations
1. $creening tests to confirm diagnosis
%.ernight dexamethasone suppression test
1mg !% at midnight. *hec0 serum cortisol before and at 6am.
-f le.el suppresses to D,<nmolBl probabl not *us0ingAs
22 hr urinar free cortisol
?: D26<nmolB22hr
2. 4ests to determine site of hormone production
=igh dose dexamethasone suppression test
2mgB3h !% for 2 das
/ow-dose dexamethasone fails to suppress urinar steroid secretion in *ushingAs disease whereas
high dose dexamethasone suppresses it slightl
?ormal (ull suppression
!ituitar-dependent *ushingAs $ome suppression
8ctopic A*4=Badrenal tumour ?o suppression
*&=
*ortisol rises with pituitar disease but not with ectopic A*4= production
*4B7&- pituitar
!lasma sampling from inferior petrosal sinus
Management
1. *ushingAs 'isease 4rans-sphenoidal microadenomectom, pituitar irradiation, total bilateral
adrenalectom
2. Adrenal 4umour $urgical resection, mitotane therap, resection of recurrent tumour
1. 8ctopic A*4= surgical resection of tumour
2. 4aper corticosteroid therap
3) .pproach to (arkinson's 7isease
+istory$
1. 4remors
>suall unilateral at onset, starting in the upper limb.
2. &igidit
(alls: !oor balance: !ain: $tiffness:
1. !o.ert of mo.ement
'rooling of sali.a, difficult in writing, change in .oice
2. (amil histor
,. =istor of encephalitis
3. =istor of exposure to manganeses dust, *%, or carbon disulphide
5. >se of 74!
6. 8licit drug histor, esp neuroleptics
Examination$
0eneral /nspection
1. An expressionless or Hmas0-li0eI face
2. &esting pill-rolling mo.ement
roceed with the following
6. +rad0inesia
As0 patient to tocuh thumb with each finger in turn
;. *og-wheel rigidit
1<. Glabellar tap
4ap forehead abo.e the bridge of the nose repeatedl
!ar0insonAs continues to blin0 K 7ersonAs sign
11. Gal0
!aucit of mo.ement, festinent gait
Re*!est to
2. As0 patient a few Cuestions to assess speech
,. Assess handwriting
3. *hec0 for postural hpotension "$h-'rager sndrome, /-dopa treatment#
5. -mpaired .ertical ga@e "$teele-&icharson-%l@ews0i sndrome#
Clinical *opics
Clinical #eat!res
1. 4remor
2. &igidit: 1-, =@J *og-wheel rigidit due to superimposed tremor
1. A0inesia: -nc difficult in initiating mo.ement, diminished amplitude of repetiti.e alternati.e mo.ement
2. !ostural instabilit
?.+.: 'ifferentiate rigidit from spasticit
&igidit -ncreased tone of both flexor and extensor muscle grps, present throughout range of
passi.e mo.ement. $mooth K leadpipe rigiditJ -ntermittent K cog-wheel rigidit. *ommon in
extraprimidal sndromes, GilsonAs disease, *J'
$pasticit "clasp-0nife# -ncreased tone maximal at the beginning of mo.ement and suddenl
decreases as passi.e mo.ement is continued. *hiefl occurs in antigra.it muscles.
)etiology
1. -diopathic, i.e. !ar0insonAs 'isease
2. 'rug-induced "chlorproma@ine, metaclopromide, prochlopera@ine#
,. Anoxic brain damage
3. !ostencephalitic
5. 1-7thl-2-phenl-1,2,1,3-tetrahdropridine toxicit "74!# in drug abusers
6. 7ulitple sstem atroph
;. !rogressi.e supranuclear atroph
1<. (amilial
athological changes
1. ?euronal loss with depigmentation of the substantia nigra
2. /ew bodies
Management
1. 4remor the main problem Anticholinergic drugs
2. +rad0inesia the main problem / dopa
Laboratory findings
1. +lood count: AnaemiaJ thromboctosisJ &aised 8$& O *&! "Acti.it of inflammator process#J &aised
ferritin B /ow iron concentration
2. $erolog: &heumatoid factor "Autoantibodies against (c of -gG# in 5<M of cases
Radiological findings
1. $oft-tissue swelling
2. Juxta-articular osteopenia "Ad9acent bone dar0er on P-ra due to inflammation and increased blood
flow#
1. 7arginal bone erosions
2. /oss of 9oint space due to erosion of articular cartilage
,. Joint deformities
1r!g (reatment
1. $mptom-modifing drugs
Analgesics "!anadol, 4ramadol, !enidine#
?$A-'
2. 'isease-modifing anti-rheumatic drugs "'7A&'s#
Gold &enal impairment test proteinuria
!enicillamine &enal impairment test proteinuria
Antimalarias =droxchloroCuine can cause retinal maculopath
$ulfasala@ine /i.er function derangement, neutropenia, thromboctopenia
*orticosteroids >sed during bridging period before effects of other drugs set in
7ethotrexate 1
st
choice for se.ere disease. 'o *P&, test for =ep +, *, /(4s
A@athioprine
*iclosporin
-nfliximab
) .pproach to 0heumatoid .rthritis
Examination$
0eneral /nspection
;. *ushingoid appearance:
'ue to steroid treatment
1<. Geight loss
-ndicate acti.e disease
Hands
!lace hands on a pillow
12. Joints
$mmetrical deforming small 9oint polarthritis
>lnar de.iation
)olar subluxation of the 7*! 9oints
Q-thumb, $wan nec0, +outonniere deformit of fingers
11. $0in
)asculitic changes esp of the fingernails
!alms palmar erthema
8.idence of psoriatic arthropath, e.g. nail changes, plaCues
12. 7uscles
Gasting of small muscles
!almar tendon crepitus
1,. $oft 4issue
$no.ial thic0ening especiall at wrist
$no.itis causing spindling of fingers
13. ?er.e
*arpel 4unnel $ndrome: perform !halenAs test
"lbows
6. &heumatoid nodules
$uggest seropositi.e disease
;. !soriatic s0in lesions
1<. +ursitis
11. (lexion contractures
-ystemic Review
&eCuest to examine other 9oint in.ol.ement, extra-articular features
2. 8es ", features#
$clera $cleritis "ele.ated white B purple-red lesion surrounded b intense redness#J $cleromalacia
*on9uncti.a !allor ", causes for anaemia below#J &edness and drness "$9ogrenAs#
/ens *ataracts from steroid use
8xtra-ocular muscles 7ononeuritis multiplexJ 7asthenia 2 to penicillamineJ 8xtra-ocular muscle
tendon sno.itis
(undi *hloroCuine B gold-retinopathJ )asculitis
,. =ead and ?ec0
!arotids enlargement in $9ogrenAs
7outh drness and dental caries in $9ogrenAsJ ulcers from drug "gold# treatment
47J crepitus as patient opens and shuts mouth
?ec0 cer.ical spine for tenderness, muscle spasm and reduction of rotational
mo.ement
3. &espirator $stem ", features# 8xamine for signs of pleural effusion or pulmonar fibrosis
>pper airwa *ricoartenitis
!leura 8ffusion, pleuris
+ronchioles +ronchiolitis obliterans and organi@ing pneumonia "+%%!#
!arenchma (ibrosis, pneumonitis
-nfiltration *aplanAs "&heumatoid lung nodules in combination with
!neumoconiosis in coal wor0ers#
5. *ardio.ascular $stem
!ericardial rub
7urmurs "esp A&# due to nodular in.ol.ement of a heart .al.e
6. Abdominal $stem
$plenomegal suggesti.e of (eltAs sndrome "&A with splenomegal and neutropenia#
=epatomegal drug induced b methotrexate
-nguinal lmph nodes
;. /ower /imb
=ip limitation of mo.ement
Enees- Cuadriceps wasting, sno.ial effusions, flexion contractures, .algus deformit, +a0erAs csts in
popliteal fossae
/ower leg ulceration as .asculitic complication of (eltAs sndrome
$toc0ing distribution peripheral neuropath and mononeuritis multiplex of ner.es of the //
An0le /imitation of mo.ementJ nodules on Achilles tendon
(eet (ootdrop "peroneal ner.e entrapment or .asculitis#J 74J "swelling, subluxation#
&eCuest to loo0 at temperature chart, offer to ta0e +! and perform urine dipstic0 test.
Clinical *opics
1iagnostic Criteria (23 o!t of 4)
,. 7orning stiffness "L 1 hr# for L 3 w0s
3. Arthritis of three or more 9oint areas for L 3 w0s R12 grps: 6>/, 3//S
5. Arthritis of the hand 9oints for L 3 w0s
6. $mmetrical arthritis
;. &heumatoid nodules "At pressure areas: occiput, elbows, sacral region, Achilles tendon#
1<. $erum rheumatoid factor
11. &adiographic changes
Complications
11. *omplications of the condition
&uptured tendons, 9oints
$eptic arthritis
$pinal cord compression
Amloidosis "deposition of serum amloid A protein in intercellular matrix of organs# causes
nephritic sndrome and renal failure
12. $ide-effects of therap
'spepsia "?$A-'#
G- bleed "?$A-'#
!erforation "?$A-'#
Anaemia "?$A-'#
&enal impairment "penicillamine#
+one marrow hpoplasia "'7A&'s#
5 reasons for anaemia in R)
11. -ron deficienc
7icroctic hpochromic
+G-4 due to ?$A-' use
12. !ernicious anaemia, folate deficienc
7acroctic
-ncreased cell turno.er
1,. =persplenism
2 to (eltAs sndrome
13. Aplastic
?ormoctic normochromic
2 to Gold, penicillamine
+one marrow suppression
15. Anaemia of chronic disease
?ormoctic, normochromic
Laboratory findings
1. +lood count: AnaemiaJ thromboctosisJ &aised 8$& O *&! "Acti.it of inflammator process#J &aised
ferritin B /ow iron concentration
2. $erolog: &heumatoid factor "Autoantibodies against (c of -gG# in 5<M of cases
Radiological findings
3. $oft-tissue swelling
5. Juxta-articular osteopenia "Ad9acent bone dar0er on P-ra due to inflammation and increased blood
flow#
6. 7arginal bone erosions
;. /oss of 9oint space due to erosion of articular cartilage
1<. Joint deformities
1r!g (reatment
1. $mptom-modifing drugs
Analgesics "!anadol, 4ramadol, !enidine#
?$A-'
2. 'isease-modifing anti-rheumatic drugs "'7A&'s#
Gold &enal impairment test proteinuria
!enicillamine &enal impairment test proteinuria
Antimalarias =droxchloroCuine can cause retinal maculopath
$ulfasala@ine /i.er function derangement, neutropenia, thromboctopenia
*orticosteroids >sed during bridging period before effects of other drugs set in
7ethotrexate 1
st
choice for se.ere disease. 'o *P&, test for =ep +, *, /(4s
A@athioprine
*iclosporin
-nfliximab