1.

Schöber Test:

• Patient is standing, examiner marks the L5 spinous process by drawing a horizontal line across
the patients back.
• A second line is marked 10 cm above the first line.
• Patient is then instructed to flex forward as if attempting to touch his/her toes, examiner
remeasures distance between two lines with patient fully flexed.

The difference between the measurements in erect and flexion positions indicates the outcome of the
lumbar flexion.

[Link] Schober Test

This test eliminates the errors in identification of lumbosacral junction and makes sure that the entire
lumbar spine was included,

• Patient is standing, examiner marks both posterior superior iliac spine (PSIS) and then draws a
horizontal line at the centre of both marks
• A second line Is marked 5 cm below the first line.
• A third line is marked 10 cm above the first line.
• Patient is then instructed to flex forward as if attempting to touch his/her toes, examiner
remeasures distance between the top and bottom line.
[Link] point:

McBurney’s point refers to the point on the lower right quadrant of the abdomen at which
tenderness is maximal in cases of acute appendicitis. Acute appendicitis is characterized by the
inflammation, infection, or swelling of the appendix. The sign is seen in a vast majority (approximately
91%) of individuals with appendicitis. McBurney point is defined as a point that lies one-third of the
distance laterally on a line drawn from the umbilicus to the right anterior superior iliac spine. Classically,
it corresponds to the location of the base of the appendix

McBurney's point may be a useful site for insertion of a peritoneal dialysis catheter.

[Link] medusae:

Caput medusae, sometimes called a palm tree sign, refers to the appearance of a network
of painless, swollen veins around your bellybutton. Caput medusae is a network of large, visible
veins around the abdomen. From a distance, it might look like a black or blue bruise.
 Caput medusae is almost always caused by portal hypertension. This refers to high pressure
in portal vein. Caput medusae and palmar erythema are the cardinal signs for liver cirrhosis.

[Link] Gravidarum:

Striae gravidarum (SG) are atrophic linear scars that represent one of the most common
connective tissue changes during pregnancy. It is a type of stretch marks that present in
pregnancy, weight gain and during under some medication.

It is formed by the separation of underlying connective tissue with uterus due to enlargement
of uterus especially in last trimester. It also seen in arm, breast, buttocks region during
pregnancy.

It is reddish/pruple coloured lesion stretch marks which is enhanced by a hormone

oestrogen, relaxin and adernocortical hormones.

[Link] albicans or straie alba:

Striae albae is classified as the more chronic (or mature) stage of stretch mark
formation. Here stretch marks become more scar-like, irregularly shaped and hypopigmented
(faded / white – losing vascular alterations). Some may even develop a fine wrinkly texture.
7. Rovsings sign:

Rovsing’s sign is the finding of right lower quadrant pain during palpation of the left side of the
abdomen or when left-sided rebound tenderness is elicited. These findings are valuable when present,
but their absence does not exclude [Link] acute appendicitis, palpation in the left iliac fossa
may produce pain in the right iliac fossa.
 [Link] monitoring:

A Holter monitor is a small, wearable device that records the heart’s rhythm. It’s used to
detect or determine the risk of irregular heartbeats (arrhythmias).

A Holter monitor test may be done if a traditional electrocardiogram (ECG or EKG) doesn’t
provide enough details about the heart’s condition. If the irregular heartbeats are infrequent, a longer
term monitor called an event recorder may be needed.

A health care provider may recommend a Holter monitor if you have:

• Signs and symptoms of an irregular heart rhythm (arrhythmia)

• Unexplained fainting

• A heart condition that increases the risk of arrhythmias

[Link] sign:

In gastroenterology, the puddle sign is a physical examination maneuver that can be used to
detect the presence of [Link] is useful for detecting small amounts of ascites – as small as 120 mL;
shifting dullness and bulging flanks typically require 500 mL.

In relation to auscultatory percussion, the puddle sign is more specific, but less sensitive.

Procedure,

The steps are outlined as follows:

• Patient lies prone for 5 minutes

 • Patient then rises onto elbows and knees
• Apply stethoscope diaphragm to most dependent part of the abdomen
• Examiner repeatedly flicks near flank with finger. Continue to flick at same spot on abdomen
• Move stethoscope across abdomen away from examiner
• Sound loudness increases at farther edge of puddle
• Sound transmission does not change when patient sits

[Link] test / Coin percussion test:

 A coin test (or a bell metal resonance) is a medical diagnostic test used to test for a punctured lung. A
punctured lung can cause air or fluid to leak into the pleural cavity, leading to, for example,
pneumothorax or hydrothorax.

Procedure: In a coin test, a coin held against the chest is tapped by another coin on the side where
the puncture is suspected. A stethoscope is placed on the back to listen to breath sounds and the sound
of the coins. If a tinkling sound is heard, it is likely that air or fluid has found its way into the pleural
cavity.

[Link] and chronic ascites

Ascites is the build-up of fluid in the space between the lining of the abdomen and abdominal organs.

Causes , Ascites results from high pressure in certain veins of the liver (portal hypertension) and low
blood levels of a protein called albumin.

• Chronic hepatitis C or B infection

• Alcohol overuse over many years
• Fatty liver disease (non-alcoholic steatohepatitis or NASH)
• Cirrhosis caused by genetic diseases
• Cancer of the appendix, colon, ovaries, uterus, pancreas, and liver.
• Clots in the veins of the liver (portal vein thrombosis)
• Congestive heart failure
• Pancreatitis
• Thickening and scarring of the sac-like covering of the heart (pericarditis)
Types,

• Acute (peritoneal fluid is about 125ml)

• Chronic ( peritoneal fluid is about 125ml to 500ml)

[Link]’s sign.

One of the physically demonstrable symptoms of meningitis is Kernig’s sign. Severe stiffness of the
hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.

A positive test is the elicitation of pain or resistance with passive extension of the patient’s knees past
135 degrees in the setting of meningeal irritation.

[Link] sign

Brudzinski signs, which are caused by irritation of motor nerve roots passing through inflamed meninges
as they are under tension. The Brudzinski’s sign is positive when passive forward flexion of the neck
causes the patient to involuntarily raise his knees or hips in flexion.
[Link] reflex

The palatal reflex is activated by touching the left and right palatal arch with a spatula or brush.
Physiologically, there is a slight lifting of the relevant arch.

[Link] reflex.

To test the gag reflex, you gently touch one and then the other palatal arch with a cotton swab or
tongue blade, waiting each time for gagging. If the glossopharyngeal (IX) nerve is damaged on one side,
there will be no response when touched.
[Link]’s sign

Murphy’s sign is elicited in patients with acute cholecystitis by asking the patient to take in and hold a
deep breath while palpating the right subcostal area. If pain occurs when the inflamed gallbladder
comes into contact with the examiner’s hand, Murphy’s sign is positive.

[Link]’s sign/ reflex

Sign run a pointed object from the heel. Along the lateral aspect of the foot. Forwards. Towards the
great toe in a normal human being it will result in the flexor reflex or grasping of the toes
 • The Babinski reflex occurs after the sole of the foot has been firmly stroked. The big toe then
moves upward or toward the top surface of the foot. The other toes fan out.
• This reflex is normal in children up to 2 years old. It disappears as the child gets older. It may
disappear as early as 12 months.

[Link] of tenderness

Tenderness is pain or discomfort when an affected area is touched. It should not be confused with the
pain that a patient perceives without touching.

[Link].

• Inflammation of the foreskin and head of the penis.

• Balanitis is most common in uncircumcised men.
• Causes include skin disorders, infection, poor hygiene, uncontrolled diabetes and harsh soaps.

How balanitis look like?

Balanitis looks like redness, discoloration (red, purple, gray or white) or discolored patches on the head
of your penis. It may also have shiny, swollen areas of skin.
20. Obturator sign

• Obturator sign is a clinical sign of acute appendicitis, it is defined as discomfort felt by the
subject/patient on the slow internal movement of the hip joint, while the right knee is flexed. It
indicates an inflamed pelvic appendix that is in contact with the obturator internus muscle .
• The obturator sign, also called Cope’s obturator test, is an indicator of irritation to the obturator
internus muscle.

[Link] sign

• Psoas sign is elicited by having the patient lie on his or her left side while the right thigh is flexed
backward. Pain may indicate an inflamed appendix overlying the psoas muscle.
• The psoas sign, also known as Cope’s sign or Cope’s psoas test
[Link] angle

• An area located on either side of the human back between the lateral borders of the erector
spinae muscles and inferior borders of the twelfth rib, so called because the kidney can be felt at
this location.
• Position of patient: Sitting or Prone : It is performed by striking the fist of one hand against the
dorsal surface of the other hand, which is placed flat along the posterior CVA margin. Normally,
percussion in CVA should not elicit tenderness.

• Causes of costovertebral angle( CVA) tenderness ,

1. Acute pyelonephritis
2. Calculi
3. Renal artery occlusion
4. Perinephric abscess

[Link] spondylitis.

• Ankylosing spondylitis, also known as axial spondyloarthritis, is an inflammatory disease

that, over time, can cause some of the bones in the spine, called vertebrae, to fuse.
• This fusing makes the spine less flexible and can result in a hunched posture. If ribs are
affected, it can be difficult to breathe deeply.
• Clinical examination done by schober and modified schober test.
• Axial spondyloarthritis has two types. When the condition is found on X-ray, it is called
ankylosing spondylitis, also known as axial spondyloarthritis. When the condition can’t be
seen on X-ray but is found based on symptoms, blood tests and other imaging tests, it is
called nonradiographic axial spondyloarthritis.
[Link].

Proctitis is inflammation of the lining of the rectum. Proctitis may be acute or chronic.

Common symptoms include:

• Anorectal pain.
• Pain in your abdominal left quadrant.
• Blood or mucus in your poop.
• Swelling or fullness in your rectum.
• Continuous feeling like you need to have a bowel movement (tenesmus).
• Difficult or painful bowel movements (dyschezia).
• Constipation.
• Diarrhea.
[Link]/ Proctoscopy:

• A proctoscopy, also known as a proctosigmoidoscopy or rigid sigmoidoscopy, is a procedure that

uses a proctoscope to view the inside of the rectum and anus. Measuring about 6 inches long,
the rectum is the lowest part of the colon (large intestine), which holds waste, or stool, and ends
at the anus.
• A proctoscope is a hollow, tube-like speculum that is used for visual inspection of the rectum.
Both disposable and non-disposable proctoscopes are available for use.
• The proctoscope is used in the diagnosis of hemorrhoids, carcinoma of anal canal or rectum
and rectal polyp. It is used therapeutically for polypectomy and rectal biopsy.

[Link] and Bulbar Palsy;

Pseudobulbar palsy (UMN lesion): Pseudobulbar palsy is due to an upper motor lesion caused by
bilateral disturbance of the corticobulbar tracts. Pseudobulbar palsy is characterized by dysarthria,
dysphagia, facial and tongue weakness, and emotional lability.
Bulbar palsy ( LMN lesion) : Bulbar weakness (or bulbar palsy) refers to bilateral impairment of
function of the lower cranial nerves IX, X, XI and XII, which occurs due to lower motor neuron lesion
either at nuclear or fascicular level in the medulla or from bilateral lesions of the lower cranial nerves
outside the brain-stem.

[Link] motor neurons.

• The upper motor neurons originate in the cerebral cortex and travel down to the brain
stem or spinal cord, while the lower motor neurons begin in the spinal cord and go on to
innervate muscles and glands throughout the body.
• They are found in the cerebral cortex and brainstem and carry information down to
activate interneurons and lower motor neurons, which in turn directly
signal muscles to contract or relax. UMNs in the cerebral cortex are the main source of voluntary
movement.

[Link] motor neurons.

• The lower motor neuron is responsible for transmitting the signal from the upper motor neuron
to the effector muscle to perform a movement.
• There are three broad types of lower motor neurons: somatic motor neurons, special visceral
efferent (branchial) motor neurons, and general visceral motor neurons.
• Damage to the lower motor neurons can lead to flaccid paralysis, absent deep tendon reflexes
and muscle atrophy.
29. Madelung’s deformity.

• Madelung’s Deformity is a congenital dyschondrosis of the distal radial physis that leads to
partial deficiency of growth of the distal radial physis.
• Diagnosis is made radiographically with disruption of the ulnar volar physis of the distal radius,
excessive radial inclination, excessive volar tilt, and ulnar carpal impaction.

[Link]’s sign.

• Trousseau’s sign for latent tetany is most commonly positive in the setting of hypocalcemia.
• A positive sign is characterized by the appearance of a carpopedal spasm which involves flexion
of the wrist, thumb, and MCP joints along with hyperextension of the IP joints.
• This spasm results from the ischemia that is induced by compression through the inflated cuff to
20 mmHg over their systolic blood pressure for 3 minutes.
[Link]’s sign.

• Chvostek’s sign is described as the twitching of facial muscles in response to tapping over the
area of the facial nerve.
• The Chvostek sign—a contraction of ipsilateral facial muscles subsequent to percussion over the
facial nerve( infront of your ear)—is considered a clinical indicator of hypocalcemia.
• It is otherwise called as Facial nerve tapping test.
[Link]’s shoulder.

• Sprengel deformity is a rare congenital disorder in which the shoulder blade (scapula) is too high
on one side of the body. The affected abnormal shoulder blade is also abnormally connected to
the spine, often restricting movement of the shoulder.
• It is caused by an interruption of normal development and movement of the scapula during
early fetal growth (probably between the 9th and 12th weeks of gestation).
[Link] palsy and Bell’s palsy
Features of Bell’s palsy (LMN lesion) and Facial palsy ( UMN lesion)

[Link] beat.

• The apex beat or apical impulse is the palpable cardiac impulse farthest away from the sternum
and farthest down on the chest wall, usually caused by the LV and located near the midclavicular
line (MCL) in the fifth intercostal space.
• Identification. The normal apex beat can be palpated in the precordium left 5 th intercostal space,
half-inch medial to the left midclavicular line and 3–4 inches left of left border of sternum. In
children the apex beat occurs in the fourth rib interspace medial to the nipple.
 • The apex beat may also be displaced by conditions:
1. Pleural or pulmonary diseases
2. Deformities of the chest wall or the thoracic vertebrae
3. Lateral and/or inferior displacement of the apex beat usually indicates enlargement of the heart,
called cardiomegaly.
4. Sometimes, the apex beat may not be palpable, either due to a thick chest wall, or conditions
where the stroke volume is reduced; such as during ventricular tachycardia or shock.

[Link] sign.

• A third sign used to diagnose meningitis is called nuchal rigidity. ( After kernig ‘s and brudzinski
sign)
• Nuchal rigidity is an inability to flex the neck forward due to rigidity of the neck muscles.
• To test for nuchal rigidity, the examiner flexes the patient’s neck and the test is positive if there
is palpable resistance to passive flexion.
36. Chronic ascites.

Ascites results from high pressure in certain veins of the liver (portal hypertension) and low blood
levels of a protein called albumin. Diseases that can cause severe liver damage can lead to ascites.

How to examine;

• Palpation and percussion are used to evaluate ascites.

• A rounded, symmetrical contour of the abdomen with bulging flanks is often the first clue.
• Palpation of the abdomen in the patient with ascites will often demonstrate a doughy, almost
fluctuant sensation.

Examination methods:

1. Fluid thrill test/Fluid wave test

2. Shifting dullness
3. Succession splash

FLUID THRILL TEST/ FLUID WAVE TEST

The fluid wave test or fluid thrill test is a test for ascites (free fluid in the peritoneal cavity).

Procedure

• It is performed by having the patient (or a colleague) push their hands down on the midline
of the abdomen.
 • The examiner then taps one flank, while feeling on the other flank for the tap. The pressure
on the midline prevents vibrations through the abdominal wall while the fluid allows the tap
to be felt on the other side.
• The result is considered positive if tap can be felt on the other side. However, even with the
midline pressure, transmission through the skin must be excluded.
• A positive fluid wave test indicates that there is a free fluid (ascites) in the abdomen. When
one side of the abdomen is pressed, the other side may also be painful due to the transfer of
the fluid in it.

SHIFTING DULLNESS

Shifting dullness refers to a sign elicited on physical examination for ascites (fluid in the peritoneal
cavity).

Procedure

• Lie down the patient on supine position with thighs flexed.

• Percussion across the abdomen as far as of flank dullness , with the point where tympany
and dullness is noted.
• Then the patient his/ her rolled onto their side , now make percussion from umbilicus to
flank region.
• Positive signs means the area of dullness will shifted to dependent site, The area of tympany
will shift towards the top .
 Succession splash

A succussion splash, also known as a gastric splash, is a sloshing sound heard through
a stethoscope during sudden movement of the patient on abdominal auscultation. It reflects
the presence of gas and fluid in an obstructed organ, as in gastric outlet obstruction.
Procedure

• A physical examination can show an abdominal succussion splash, which is

elicited by placing the stethoscope over the upper abdomen and rocking the
patient back and forth at the hips.

• Retained gastric material greater than three hours after a meal will generate a
splash sound and indicate the presence of a hollow viscus filled with both fluid
and gas.

• An example would be a gastric outlet obstruction (GOO) due to pyloric stenosis,

with abdominal succussion splash.

37. Edema and it’s types.

Swelling and puffiness in different parts of the body is called edema

Nature of edema:

1. Pitting edema

2. Non pitting edema

Types of edema:

• Peripheral edema - It affects the feet, ankles, legs , hands and arms.
• Pulmonary edema- Excess fluid collects in lungs which cause difficulty in breathing.
• Cerebral edema- Occurs in brain
• Macular edema- Occurs in part of retina called macula in which the blood vessels are leaks.
Mostly seen in diabetic retinopathy.
• Periorbital edema- Around the eyes, mainly seen in early morning. It is sign of renal disease.

[Link] neck deformity.

Hyperextension of Proximal interphalangeal joint( PIP) and flexion of Distal interphalangeal joint (DIP)

Causes;

• Weakness or tearing of ligament in palm.

• Tear of tendon that flexes the middle joint.
[Link] deformity

It is a medical condition in which the finger is flexed at the proximal interphalangeal joint (PIP) and
hyperextended at the distal interphalangeal joint (DIP). It is also referred to as a “buttonhole deformity.

[Link] diagnosis of Hematuria

Presence of blood especially RBC in urine is called as Hematuria.

Differential diagnosis are,

• Urinary tract infection (UTI) such as cystitis ( infection in urinary bladder), pyelonephritis (
infection in kidneys)
• Systemic lupous erythematous
• Sickle cell anemia
• Urolithiasis ( Stones)
• Prostatic hyperplasia and tumour.

41. Radial nerve palsy.

Radial nerve palsy is a condition that affects the radial nerve and if damage to this nerve occurs,
weakness, numbness and an inability to control the muscles served by this nerve may result.