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124 • THE GASTROINTESTINAL SYSTEM
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Fig. 6.17 Palpation of the spleen. A Initial palpation for the splenic edge moving diagonally from the umbilicus to the left hypochondrium. B If the spleen is
impalpable by the method shown in A, use your left hand to pull the ribcage forward and elevate the spleen, making it more likely to be palpable by your right
hand.
6.14 Causes of splenomegaly
Haematological disorders
• Lymphoma and lymphatic
leukaemias
• Myeloproliferative diseases,
polycythaemia rubra vera and
myelofibrosis
Portal hypertension
Infections
• Glandular fever
• Malaria, kala-azar
(leishmaniasis)
• Bacterial endocarditis
Rheumatological conditions
• Rheumatoid arthritis (Felty’s
syndrome)
Rarities
• Sarcoidosis
• Amyloidosis
• Haemolytic anaemia, congenital
spherocytosis
• Brucellosis, tuberculosis,
salmonellosis
• Systemic lupus erythematosus
• Glycogen storage disorders
Fluid thrill
• If the abdomen is tensely distended and you are uncertain
whether ascites is present, feel for a fluid thrill.
• Place the palm of your left hand flat against the left side of the
patient’s abdomen and flick a finger of your right hand against
the right side of the abdomen.
• If you feel a ripple against your left hand, ask an assistant or
the patient to place the edge of their hand on the midline of
the abdomen (Fig. 6.19). This prevents transmission of the
impulse via the skin rather than through the ascites. If you still
feel a ripple against your left hand, a fluid thrill is present
(detected only in gross ascites).
The causes of ascites are shown in Box 6.15.
Auscultation
Examination sequence (Video 6F)
• With the patient supine, place your stethoscope diaphragm
to the right of the umbilicus and do not move it.
Fig. 6.18 Percussing for ascites. A and B Percuss towards the flank from resonant to dull. C Then ask the patient to roll onto their other side. In ascites
the note then becomes resonant.
The physical examination • 125
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• Listen for up to 2 minutes before concluding that bowel
sounds are absent.
• Listen above the umbilicus over the aorta for arterial bruits.
• Now listen 2–3 cm above and lateral to the umbilicus for
bruits from renal artery stenosis.
• Listen over the liver for bruits.
• Test for a succussion splash; this sounds like a half-filled
water bottle being shaken. Explain the procedure to the patient, then shake their abdomen by rocking their pelvis using
both hands.
Normal bowel sounds are gurgling noises from the normal
peristaltic activity of the gut. They normally occur every 5–10
seconds but the frequency varies.
The absence of bowel sounds implies paralytic ileus or peritonitis. In intestinal obstruction, bowel sounds occur with
increased frequency and volume and have a high-pitched,
tinkling quality. Bruits suggest an atheromatous or aneurysmal
aorta or superior mesenteric artery stenosis. A friction rub, which
sounds like rubbing your dry fingers together, may be heard over
the liver (perihepatitis) or spleen (perisplenitis). An audible splash
more than 4 hours after the patient has eaten or drunk anything
indicates delayed gastric emptying, as in pyloric stenosis.
Hernias
The inguinal canal extends from the pubic tubercle to the anterior
superior iliac spine (Fig. 6.20). It has an internal ring at the midinguinal point (midway between the pubic symphysis and the
anterior superior iliac spine) and an external ring at the pubic
tubercle. The femoral canal lies below the inguinal ligament and
lateral to the pubic tubercle.
Hernias are common and typically occur at openings of the
abdominal wall, such as the inguinal, femoral and obturator canals, the umbilicus and the oesophageal hiatus. They may also
occur at sites of the weakness of the abdominal wall, as in
previous surgical incisions.
An external abdominal hernia is an abnormal protrusion of the
bowel and/or omentum from the abdominal cavity. External
hernias are more obvious when the pressure within the abdomen
rises, such as when the patient is standing, coughing or straining
at stool. Internal hernias occur through defects of the mesentery
or into the retroperitoneal space and are not visible.
An impulse can often be felt in a hernia during coughing
(cough impulse). Identify a hernia from its anatomical site and
characteristics and attempt to differentiate between direct and
indirect inguinal hernias.
6
Fig. 6.19 Eliciting a fluid thrill.
6.15 Causes of ascites
Diagnosis Comment
Common
Hepatic cirrhosis with portal
hypertension
Intra-abdominal malignancy with
peritoneal spread
Uncommon
Hepatic vein occlusion (Budd–Chiari
syndrome)
Constrictive pericarditis and right
heart failure
Hypoproteinaemia (nephrotic
syndrome, protein-losing
enteropathy)
Tuberculous peritonitis Low glucose content
Pancreatitis, pancreatic duct
disruption
Transudate
Exudate, cytology may be
positive
Transudate in the acute phase
Check jugular venous pressure
and listen for pericardial rub
Transudate
Very high amylase content
Examination sequence
• Examine the groin with the patient standing upright.
Anterior
superior
iliac spine
Internal
Inguinal
ligament
Pubic
tubercle
Femoral
artery
Femoral
vein
Femoral canal
Fig. 6.20 Anatomy of the inguinal canal and femoral sheath.
inguinal ring
External
inguinal ring
Spermatic
cord
f
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• Inspect the inguinal and femoral canals and the scrotum for
any lumps or bulges.
• Ask the patient to cough; look for an impulse over the femoral
or inguinal canal and scrotum.
• Identify the anatomical relationships between the bulge, the
pubic tubercle and the inguinal ligament to distinguish a
femoral from an inguinal hernia.
• Palpate the external inguinal ring and along the inguinal canal
for possible muscle defects. Ask the patient to cough and feel
for a cough impulse.
• Now ask the patient to lie down and establish whether the
hernia reduces spontaneously.
• If so, press two fingers over the internal inguinal ring at the
mid-inguinal point and ask the patient to cough or stand up
while you maintain pressure over the internal inguinal ring. If
the hernia reappears, it is a direct hernia. If it can be prevented from reappearing, it is an indirect inguinal hernia.
• Examine the opposite side to exclude the possibility of
asymptomatic hernias.
An indirect inguinal hernia bulges through the internal ring and
follows the course of the inguinal canal. It may extend beyond the
external ring and enter the scrotum. Indirect hernias comprise
85% of all hernias and are more common in younger men.
A direct inguinal hernia forms at a site of muscle weakness in
the posterior wall of the inguinal canal and rarely extends into the
scrotum. It is more common in older men and women (Fig. 6.21).
A femoral hernia projects through the femoral ring and into the
femoral canal. Inguinal hernias are palpable above and medial to
the pubic tubercle. Femoral hernias are palpable below the
inguinal ligament and lateral to the pubic tubercle.
In a reducible hernia, the contents can be returned to the
abdominal cavity, spontaneously or by manipulation; if they
cannot, the hernia is irreducible. An abdominal hernia has a
covering sac of the peritoneum and the neck of the hernia is a
common site of compression of the contents (Fig. 6.22). If the
hernia contains bowel, obstruction may occur. If the blood
supply to the contents of the hernia (bowel or omentum) is
restricted, the hernia is strangulated. It is tense, tender and has
no cough impulse, there may be bowel obstruction and, later,
Fig. 6.21 Right inguinal hernia.
signs of sepsis and shock. A strangulated hernia is a surgical
emergency and, if left untreated, will lead to bowel infarction and
peritonitis.
Rectal examination
Digital examination of the rectum is important (Box 6.16). Do not
avoid it because you or the patient find it disagreeable. The
patient’s verbal consent is needed, however, and the examination should be carried out in the presence of a chaperone.
Obstructed
proximal bowel
Neck of hernia
Contents of sac
(small bowel in
this example)
Fig. 6.22 Hernia: anatomical structure.
6.16 Indications for rectal examination
Alimentary
• Suspected appendicitis, pelvic abscess, peritonitis, lower abdominal
pain
• Diarrhoea, constipation, tenesmus or anorectal pain
• Rectal bleeding or iron deficiency anaemia
• Unexplained weight loss
• Bimanual examination of lower abdominal mass for diagnosis or
staging
• Malignancies of unknown origin
Genitourinary
• Assessment of prostate in prostatism or suspected prostatic cancer
• Dysuria, frequency, haematuria, epididymo-orchitis
• Replacement for vaginal examination when this would be inappropriate
Miscellaneous
• Unexplained bone pain, backache or lumbosacral nerve root pain
• Pyrexia of unknown origin
• Abdominal, pelvic or spinal trauma
Collapsed
distal bowel
Covering o
hernia sac
The normal rectum is usually empty and smooth-walled, with
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the coccyx and sacrum lying posteriorly. In the male, anterior
to the rectum from below upwards, lie the membranous urethra,
the prostate and the base of the bladder. The normal prostate is
smooth and firm, with lateral lobes and a median groove between them. In the female, the vagina and cervix lie anteriorly.
The upper end of the anal canal is marked by the puborectalis
muscle, which is readily palpable and contracts as a reflex action
on coughing or conscious contraction by the patient. Beyond the
anal canal, the rectum passes upwards and backwards along
the curve of the sacrum.
Spasm of the external anal sphincter is common in anxious patients. When associated with local pain, it is probably due to an anal
fissure (a mucosal tear). If you suspect an anal fissure, give the
patient a local anaesthetic suppository 10 minutes before the examination to reduce the pain and spasm, and to aid examination.
Examination sequence
The physical examination • 127
6
Fig. 6.24 Rectal examination. The correct method for inserting your index
finger in rectal examination.
• Explain what you are going to do and why it is necessary and
ask for permission to proceed. Tell the patient that the examination may be uncomfortable but should not be painful.
• Offer a chaperone; record a refusal. Make a note of the name
of the chaperone.
• Position the patient in the left lateral position with their but-
tocks at the edge of the couch, their knees drawn up to their
chest and their heels clear of the perineum (Fig. 6.23).
• Put on gloves and examine the perianal skin, using an
effective light source.
• Look for skin lesions, external haemorrhoids, fissures and
fistulae.
• Lubricate your index finger with water-based gel.
• Place the pulp of your forefinger on the anal margin and apply
steady pressure on the sphincter to push your finger gently
through the anal canal into the rectum (Fig. 6.24).
• If an anal spasm occurs, ask the patient to breathe in deeply
and relax. If necessary, use a local anaesthetic suppository or
Fig. 6.23 The correct position of the patient before a rectal
examination.
gel before trying again. If pain persists, examination under
general anaesthesia may be necessary.
• Ask the patient to squeeze your finger with their anal muscles
and note any weakness of sphincter contraction.
• Palpate systematically around the entire rectum; note any
abnormality and examine any mass (Fig. 6.25). Record the
percentage of the rectal circumference involved by disease
and its distance from the anus.
• Identify the uterine cervix in women and the prostate in men;
assess the size, shape and consistency of the prostate and
note any tenderness.
• If the rectum contains faeces and you are in doubt about
palpable masses, repeat the examination after the patient has
defecated.
• Slowly withdraw your finger. Examine it for stool colour and
the presence of blood or mucus (Box 6.17).
Haemorrhoids (‘piles’, congested venous plexuses around the
anal canal) are usually palpable if thrombosed. In patients with
chronic constipation, the rectum is often loaded with faeces.
Faecal masses are frequently palpable, should be movable and
can be indented. In women, a retroverted uterus and the normal
cervix are often palpable through the anterior rectal wall and a
vaginal tampon may be confusing. Cancer of the lower rectum is
palpable as a mucosal irregularity. Obstructing cancer of the
upper rectum may produce ballooning of the empty rectal cavity
below. Metastases or colonic tumours within the pelvis may be
mistaken for faeces and vice versa. Lateralised tenderness
suggests pelvic peritonitis. Gynaecological malignancy may
cause a ‘frozen pelvis’ with a hard, rigid feel to the pelvic organs
due to extensive peritoneal disease, such as post-radiotherapy
or in metastatic cervical or ovarian cancer.
Benign prostatic hyperplasia often produces palpable symmetrical enlargement, but not if the hyperplasia is confined to the
median lobe. A hard, irregular or asymmetrical gland with no
palpable median groove suggests prostate cancer. Tenderness
accompanied by a change in the consistency of the gland may
128 • THE GASTROINTESTINAL SYSTEM
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Fig. 6.25 Examination of the rectum. A and B Insert your finger, then rotate your hand. C The most prominent feature in the female is the cervix. D The
most prominent feature in the male is the prostate.
Examination sequence
6.17 Causes of abnormal stool appearance
Stool appearance Cause
Abnormally pale Biliary obstruction
Pale and greasy Steatorrhoea
Black and tarry (melaena) Bleeding from the upper gastrointestinal
Grey/black Oral iron or bismuth therapy
Silvery Steatorrhoea plus upper gastrointestinal
Fresh blood in or in stool Large bowel, rectal or anal bleeding
Stool mixed with pus Infective colitis or inflammatory bowel
Rice-water stool (watery with
mucus and cell debris)
be caused by prostatitis or prostatic abscess. The prostate is
abnormally small in hypogonadism.
tract
bleeding (e.g. pancreatic cancer)
disease
Cholera
• Place the patient in the left lateral position, as for digital rectal
examination.
• With gloved hands, separate the buttocks with the forefinger
and thumb of one hand. With your other hand, gently insert a
lubricated proctoscope with its obturator in place into the
anal canal and rectum in the direction of the umbilicus.
• Remove the obturator and carefully examine the anal canal
under good illumination, noting any abnormality. Check for
fissures, particularly if the patient reports pain during the
procedure.
• Ask the patient to strain down as you slowly withdraw the
instrument to detect any degree of rectal prolapse and the
presence and severity of any haemorrhoids.
Proctoscopic examination of the anus and lower rectum can
confirm or exclude the presence of haemorrhoids, anal fissures
and rectal prolapse. Rectal mucosa looks like buccal mucosa,
apart from the presence of prominent submucosal veins. During
straining, haemorrhoids distend with blood and may prolapse. If
the degree of protrusion is more than 3–4 cm, a rectal prolapse
may be present.
Proctoscopy
Proctoscopy is the visual examination of the anal canal; it is an
invasive procedure and should only be practised after appropriate training. Always undertake a digital rectal examination first.
If examination of the rectal mucosa is required, perform flexible
sigmoidoscopy rather than proctoscopy.
Investigations
Selecting the relevant investigation depends on the clinical
problem revealed on history and examination. Investigations are
costly and many carry risks, so choose tests capable of distinguishing the likely diagnoses and prioritise the most decisive
ones (Box 6.18 and Figs 6.26–6.30).
6.18 Investigations in gastrointestinal and hepatobiliary disease
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Investigation Indication/comment
Clinical samples
Stool:
Faecal occult blood by quantitative
Faecal Immunochemical Test (qFIT)
Faecal H pylori antigen test Dyspepsia
Faecal calprotectin Inflammatory bowel diseasedraised
Urine: dipstick or biochemistry Jaundice (see Box 6.8)
Ascitic fluid: diagnostic tap Clear/straw-coloureddnormal
Radiology
Chest X-ray Suspected acute abdomen, suspected perforated viscus or subphrenic abscess
Abdominal X-ray Intestinal obstruction, perforation, renal colic
Barium swallow and meal Only indicated when gastroscopy is not possible and there is suspicion of oesophageal dysmotility,
Small bowel follow-through Subacute small bowel obstruction, duodenal diverticulosis
Small bowel magnetic resonance imaging or magnetic
resonance enteroclysis (real-time imaging of liquid
moving through the small bowel)
CT colonography Altered bowel habit, iron deficiency anaemia, rectal bleeding: alternative to colonoscopy in the frail,
Abdominal ultrasound scan Biliary colic, jaundice, pancreatitis, malignancy
Abdominal CT Acute abdomen, suspected pancreatic or renal mass, tumour staging, abdominal aortic aneurysm
MR cholangiopancreatography (MRCP) Obstructive jaundice, acute and chronic pancreatitis
Pelvic ultrasound scan Pelvic masses, inflammatory diseases, ectopic pregnancy, polycystic ovary syndrome
Invasive procedures
Upper gastrointestinal endoscopy Dysphagia, dyspepsia, gastrointestinal bleeding, gastric ulcer, malabsorption
Lower gastrointestinal endoscopy (colonoscopy) Rectal bleeding, obscure gastrointestinal bleeding, altered bowel habit, iron deficiency anaemia
Video capsule endoscopy Obscure gastrointestinal bleeding with bidirectional negative endoscopies, suspected small bowel
Endoscopic retrograde cholangiopancreatography
(ERCP)
Endoscopic ultrasound Æ fine-needle aspiration (FNA)
or Tru-Cut needle biopsy
Laparoscopy Suspected appendicitis or perforated viscus, suspected ectopic pregnancy, chronic pelvic pain (e.g.
Ultrasound- or CT-guided aspiration cytology
and biopsy
Liver biopsy Parenchymal disease of the liver
Others
Pancreatic function tests Faecal elastase, pancreolauryl test
Gastrointestinal haemorrhage; sensitive but not specific; used as a population screening tool for
colorectal cancer
Acute abdominal pain
Uniformly blood-staineddmalignancy
Turbiddinfection
Chylousdlymphatic obstruction
High protein (exudate) dinflammation or malignancy
Low protein (transudate) dcirrhosis and portal hypertension
Pneumonia, free air beneath diaphragm, pleural effusion, elevated diaphragm
Fluid levels, air above the liver, urinary tract stones
or pharyngeal or gastric outlet obstruction on clinical symptoms (dysphagia or vomiting)
Oesophageal obstruction (endoscopy preferable, especially if previous gastric surgery)
Crohn’s disease, lymphoma, obscure gastrointestinal bleeding
sick patient, if colonoscopy is unsuccessful or if not acceptable to the patient to diagnose colon
cancer, inflammatory bowel disease or diverticular disease; useful in colon cancer screening
Gallstones, liver metastases, cholestasis, pancreatic calcification, subphrenic abscess
Confirms or excludes metastatic disease and leaking from the aortic aneurysm
Pelvic structures and abnormalities
Ascitic fluid
Gastric and/or duodenal biopsies are useful
Able to biopsy lesions and remove polyps
disease (vascular malformations, inflammatory bowel disease)
Obstructive jaundice, acute and chronic pancreatitis
Mainly therapeutic role
Stenting strictures and removing stones
Staging of upper gastrointestinal or pancreatobiliary cancer
Gallstone detection in the biliary tree
Drainage of pancreatic pseudocysts
due to endometriosis or pelvic inflammatory disease), suspected ovarian disease (e.g. ruptured
ovarian cyst), peritoneal and liver disease
Liver metastases, intra-abdominal or retroperitoneal tumours
Tissue biopsy by percutaneous, transjugular or laparoscopic route
6
CT, computed tomography.
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A
B
A
B
Fig. 6.27 Ultrasound scan of the gallbladder. A, Thick-walled gallbladder
containing gallstones. B, Posterior acoustic shadowing.
A
C
Fig. 6.26 Radiography in gastrointestinal disease. A Air under the
diaphragm on chest x-ray due to a perforated duodenal ulcer.
small bowel due to acute intestinal obstruction.
due to sigmoid volvulus.
C Dilated loop of large bowel
B Dilated
B
Fig. 6.28 Gastrointestinal endoscopy. A Gastric ulcer. B Gastric varices.
Fig. 6.29 Colonoscopy. Colon cancer.
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OSCE example 1: Abdominal pain and diarrhoea
Investigations • 131
A
6
Fig. 6.30 Computed tomogram of the pelvis. A, Diverticular abscess.
Mr Reid, 29 years old, presents with a 6-month history of anorexia, 7 kg weight loss, abdominal pains and diarrhoea (liquid stool). He underwent appendicectomy 4 months ago following severe right iliac fossa pain.
Please examine the gastrointestinal system
• Introduce yourself and clean your hands.
• Start with a general inspection: body habitus, signs of dehydration, fever and pallor.
• Inspect the hands: palmar erythema, finger clubbing, leuconychia, koilonychia, nicotine stains and swollen finger or wrist joints.
• Inspect the face: signs of anaemia (pallor, angular stomatitis), swollen lips and aphthous mouth ulcers.
• Inspect the skin: erythema nodosum or pyoderma gangrenosum.
• Inspect the abdomen: laparoscopy/laparotomy scars or skin fistulae.
• Palpate for right iliac fossa tenderness or the presence of a firm, non-tender mass.
• Offer to examine the perianal area for the presence of dusky blue discolouration, oedematous skin tags and the presence of fissures, fistulae or
ulcerations.
• Thank the patient and clean your hands.
Summarise your findings
This 29-year-old man with a history of weight loss and diarrhoea appears comfortable at rest but looks thin. He has a recently healed appendicectomy scar,
mild periumbilical and left iliac fossa tenderness, and normal bowel sounds.
Suggest a differential diagnosis
The differential diagnosis is Crohn’s disease and irritable bowel syndrome.
Suggest initial investigations
Full blood count, C-reactive protein, liver function tests, urea, creatinine and electrolytes, iron studies, vitamin B12and folate levels, ileocolonoscopy and small
bowel magnetic resonance imaging, faecal calprotectin.
132 • THE GASTROINTESTINAL SYSTEM
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OSCE example 2: Jaundice
Mr MacDonald, a 61-year-old retired salesman, presents with increasing tiredness and loss of appetite over 4 months. Two weeks ago, he noticed dark urine
and pale stools, and his friends have remarked that his eyes have become yellow. He has drunk a litre of whisky a day for the last 5 years, although recently
he has cut down to a bottle of whisky every 3 days.
Please examine this patient’s abdomen
• Introduce yourself and clean your hands.
• Unless prompted otherwise, proceed to peripheral examination prior to concentrating on the abdomen.
• Carry out a general inspection: body habitus, evidence of malnutrition, pallor or jaundice, scratch marks on the forearm and back, bruising.
• Examine the hands: palmar erythema, finger clubbing, leuconychia, Dupuytren’s contractures.
• Check for a flapping tremor.
• Examine the face: telangiectasias, xanthelasmas, bilateral parotid enlargement and jaundice (yellow sclera of the eyes and skin).
• Smell for alcohol or fetor hepaticus.
• Inspect the neck and chest for spider naevi, gynaecomastia; look for axillary and chest hair loss.
• Inspect the abdomen for distension, everted umbilicus, caput medusae or scars of recent drain insertion.
• Palpate and percuss the abdomen for hepatomegaly and splenomegaly.
• Percuss for shifting dullness.
• Auscultate for hepatic bruits.
• Look for peripheral oedema.
• Thank the patient and clean your hands.
Summarise your findings
This patient is jaundiced with multiple spider naevi on the chest and abdomen. He has generalised abdominal swelling with shifting dullness and a firm liver
edge palpable 2 cm below the costal margin.
Suggest a differential diagnosis
The differential diagnosis is alcoholic cirrhosis, chronic hepatitis and hepatoma.
Suggested initial investigations
Liver function tests, ferritin, viral hepatitis screen, full blood count and prothrombin time, urea, creatinine and electrolytes, alpha-fetoprotein, abdominal
ultrasound scan and upper digestive endoscopy (to check for oesophagogastric varices).
Integrated examination sequence for the gastrointestinal system
• Position the patient: supine and comfortable on the examination couch. Expose the abdomen from the xiphisternum to the pubic symphysis.
• Inspection: start with general observation, then inspect the skin, face, neck and chest, and finally the abdomen.
• Palpation:
• Begin with light, superficial palpation away from any site of pain, then repeat with deeper palpation.
• Describe any mass and decide whether there is an enlarged abdominal organ.
• Palpation for hepatomegaly:
• Ask the patient to breathe in deeply through the mouth and feel for the descent of the liver edge on inspiration.
• Move your hand progressively up the abdomen, between each breath, until you reach the costal margin or detect the liver edge.
• Percussion to confirm hepatomegaly:
• Ask the patient to hold their breath in full expiration.
• Percuss for liver dullness and measure the distance in centimetres below the costal margin.
• Palpation and percussion for splenomegaly:
• Start with your hand over the umbilicus, moving diagonally up and left to feel for the splenic edge as it descends and moves towards the midlineon inspiration.
• Check for ascites (shifting dullness):
• Percuss from the midline out to the flanks for dullness.
• Keep your finger on the site of dullness in the flank; ask the patient to turn on to their opposite side and then percuss again. If the area of dullness is
now resonant, shifting dullness is present.
• Check for a fluid thrill:
• Place the palm of your left hand flat against the left side of the patient’s abdomen and flick a finger of your right hand against the right side of the
abdomen. If you still feel a ripple against your left hand, a fluid thrill is present.
• Auscultation:
• Listen to the right of the umbilicus for bowel sounds, above the umbilicus over the aorta for arterial bruits, lateral to the umbilicus for bruits from renal
artery stenosis, and over the liver for hepatic bruits.
• Check for peripheral oedema.
• Consider a rectal examination (always with a chaperone).
Richard Davenport
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Hadi Manji
The nervous system
7
Anatomy and physiology 134
The history 134
Common presenting symptoms 134
Past medical history 138
Drug history 138
Family history 138
Social history 138
The physical examination 139
Assessment of conscious level 139
Meningeal irritation 139
Speech 139
Dysphasia 140
Cortical function 140
Cranial nerves 142
Olfactory (I) nerve 142
Optic (II), oculomotor (III), trochlear (IV) and abducens (VI) nerves 144
Trigeminal (V) nerve 144
Facial (VII) nerve 145
The vestibulocochlear (VIII) nerve 148
Glossopharyngeal (IX) and vagus (X) nerves 148
Accessory (XI) nerve 148
Hypoglossal (XII) nerve 149
Motor system 150
Anatomy 150
Stance and gait 151
Inspection and palpation of the muscles 152
Tone 153
Power 154
Deep tendon reflexes 155
Primitive reflexes 158
Coordination 158
Sensory system 159
Anatomy 159
Common presenting symptoms 160
Sensory modalities 161
Peripheral nerves 162
Median nerve 162
Radial nerve 164
Ulnar nerve 164
Common peroneal nerve 164
Lateral cutaneous nerve of the thigh 164
Interpretation of the findings 164
Investigations 165
Initial investigations 165
Specific investigations 165
OSCE example 1: Headache history 167
OSCE example 2: Tremor 167
Integrated examination sequence for the nervous system 168
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