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CHAPTER 4 Physical examination skills and leads
62
The full neurological assessment
The system of examination described here is typical. The blank pages are
there for you to write your comments and amendments. The general
approach is to assess the conscious level (if the patient is not conscious
and alert, then it will not be possible to conduct a full neurological exami-
nation, which needs the patient’s cooperation).
The cranial nerve sequence follows in their numbered sequence.
Motor function can be assessed next, beginning with inspection for wast-
ing and involuntary movements and then palpation, by testing tone and
strength. The upper limbs are examined first and then the lower limbs.
Sensation is then tested in the upper then lower limbs and, finally, coor-
dination, reflexes, and gait.
The order can be changed by addressing the area of abnormality sug-
gested by the history. For example, if the patient complains of difficulty in
walking, then it would be sensible to examine gait, then motor function
and sensory function, and cranial nerves last.
General
- Conscious level
- Glasgow Coma Score (GCS)
- Speech
- Gait abnormalities
Cranial nerves
- Absent sense of smell
- Visual field defects
- Decreased acuity
- Absent corneal reflex
- Loss of facial sensation
- Deviation of tongue
- Nystagmus
- Facial weakness
- Deafness
- Loss of taste
- Palatal weakness
- Neck or shoulder weakness
Eye
Opthalmoscopy
- Corneal opacity
- Lens opacity
- Papilledema
- Pale optic disc
- Cupped disc
- Hypertensive retinopathy
- Dot and blot hemorrhages
- New vessel formation
- Pale or black retinal patches
THE FULL NEUROLOGICAL ASSESSMENT1
63
Other eye findings
- Ptosis
- Pupil
- Constriction
- Irregularities
- Dilatation
- Diplopia
Motor function
Upper limbs
- Arm posture
- Hand tremor
- Wasting of hand
- Wasting of arm
- Tone abnormalities
Weakness of
- Shoulder abduction
- Elbow flexion
- Elbow extension
- Wrist extension
- Handgrip
- Finger adduction and abduction
- Thumb abduction and opposition
- Arm incoordination
Lower limbs
- Limitation of movement
- Wasting
- Fasciculation
- Tone abnormalities
Weakness of
- Hip flexion
- Knee extension and flexion
- Foot
- Plantar flexion
- Dorsiflexion
- Eversion
- Bilateral spastic paraparesis
- Spastic hemiparesis
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CHAPTER 4 Physical examination skills and leads
64
Sensation
Upper limb sensation
- Hypesthesia of
- Palm
- Dorsum hand
- Lateral arm
- Ulnar border arm
- Dissociated sensory loss
- Progressive sensory loss
- Cortical sensory loss
Lower limb
- Hypesthesia of
- Inguinal area
- Anterior thigh
- Shin
- Lateral foot
- Progressive downward loss
- Dissociated sensory loss
- Multiple areas of loss
Reflexes
- Brisk or diminished in biceps, supinator, triceps, knee, ankle,
and plantars
- Abnormal reflexes: Babinski
MENTAL STATUS EXAMINATION1
65
Mental status examination
Think of the sequence of perception, affect, drive and arousal, cognitive
processes (check memory of different duration, ability to reason with
that memory and then the nature of beliefs arrived at with such reason-
ing), and then actions in response to these:
- Perception: attentiveness and any hallucination, visual or auditory
- Mood: depression or elation
- Mental: rate of speech, level of anxiety
- Cognition (6/10 or less correct implies impairment)
- Orientation: time to nearest hour, year, address of hospital
- Short-term memory: repeat a given name and address, name 2 staff
- Long-term memory: own age, date of birth, current president, dates
of wars
- Concentration: count backwards from 20 to 1
- Beliefs: patient’s perception and insight of health, self-confidence, any
extreme convictions
- Activity: physical and social activity, employment, physical signs
of drug use
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CHAPTER 4 Physical examination skills and leads
66
Writing out the examination findings
At the end of the history in the previous chapter, the patient was thought
to have
- ? Viral pharyngitis
- ? Infectious mononucleosis
- ? Acute follicular tonsillitis
- ? Agranulocytosis due to carbimazole
- ?? Meningococcal meningitis
- Inadequate domestic support currently for acute illness
- ?? Undiscovered type 2 diabetes mellitus
The physical examination in such a patient would focus on findings that
may occur in any of the possible diagnoses brought to mind by the his-
tory. If they are absent, this absence is specified, together with all positive
findings. The positive and negative findings may be written out as follows.
Looks unwell, flushed
Wt not recorded
Temperature 38.5
o
C, Pulse 100, BP 105/60
Head, eyes, ears, nose, throat (HEENT)/NECK
Bilaterally swollen tonsils, large red with small white patches
Bilateral tender multiple lymph node enlargement in neck. No lymph
node swelling in axillae or groins
Cardiovascular system (CVS)
Pulse 110/min regular low volume
BP 100/60
Heart sounds normal
No murmurs
Respiratory system (RS)
Chest shape and movement normal
Breath sounds normal
GI system
Not jaundiced
Liver 1 finger breadth below costal margin
Spleen not palpable
Central nervous system (CNS)
Conscious and alert
No neck stiffness
Hand and leg coordination normal
Reflexes all normal and symmetrical
THE PROBLEM LIST AND POSITIVE-FINDING SUMMARY1
67
The problem list and positive-finding
summary
It is customary to summarize the history and examination by listing the
positive findings or presenting them in a brief summary. This is how
clinical problems are posed in journals and examinations. If negative
findings are added, then they give an indication of what the writer was
thinking. There is a place for this in a case presentation, but the problem
list or positive finding summary is a preliminary device.
Note that a few laboratory findings are also included in the list below
for completeness. Although these were not discussed above under his-
tory or physical exam, they are included in problem lists.
Problem list
- Severe sore throat for 2 days
- Sweats for 2 days
- Severe malaise for 2 days
- Hyperthyroid 2 months ago (now taking carbimazole)
- Lives alone in a flat
- Unwell, flushed
- Temperature 38.5
o
C
- Bilaterally swollen tonsils, large and red with small white patches
- Bilateral tender, multiple–lymph node enlargement in neck
- Urine testing: + glycosuria
- WBC 18.3 x 10
3
/mm
3
, neutrophils 90%
A clear differential diagnosis may well have occurred to the writer by
now (some were already being considered at the end of the history).
If this is not the case, then the next step is to look at this problem list
and consider which feature(s) will be associated with the shortest list of
possible causes—the best leads. These are shown in bold italics.
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CHAPTER 4 Physical examination skills and leads
68
Looking up the lead
A glance at the following extract from Chapter 5 will suggest immediately
that the patient probably has acute follicular tonsillitis, but this may be
associated with agranulocytosis. The neutrophil cell count is an important
deciding factor. It is high, which by definition excludes agranulocytosis and
makes a viral infection and infectious mononucleosis unlikely (where there
is usually a lymphocytosis). However, in some cases, no streptococcus is
found on the swab culture, leaving a question over the definitive diagnosis.
RED PHARYNX AND TONSILS1
69
Red pharynx and tonsils
Some differential diagnoses and typical outline evidence
Viral tonsillitis Suggested by: enlarged red mass(es) lateral to back of
tongue without white patches
Confirmed by: clinical appearance, fever, and normal
or slightly d WBC and relative lymphocytosis
Acute follicular
tonsillitis
complicated by
peritonsillar
abcess (quinsy),
scarlet fever,
retropharyngeal
abscess
Suggested by: enlarged red mass(es) lateral to back of
tongue with small white patches (“strawberries and
cream”)
Confirmed by: clinical appearance and fever (usually
high). ii WBC. Bacterial culture of streptococcus
Infectious
mononucleosis
due to Epstein–
Barr virus
Suggested by: very severe throat pain with enlarged
tonsils covered with creamy or gray membrane.
Petechiae on palate. Profound malaise. Generalized
lymphadenopathy, splenomegaly. Lymphocytosis
Confirmed by: heterophile antibody test positive.
Viral titers
A
granulo-
cytosis
(e.g., caused by
carbimazole)
Suggested by: sore throat, background history of
taking a drug or contact with noxious substance
Confirmed by: low or absent neutrophil count
Meningococcal
meningitis
Suggested by: sore throat, red pharynx without
purulent patches, neck stiffness and positive
Kernig’s sign. High blood neutrophil count
Confirmed by: lumbar puncture showing pus or
neutrophil count and organisms on microscopy
or culture
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CHAPTER 4 Physical examination skills and leads
70
The working diagnoses
The finding of white patches on red tonsils occurs commonly in acute
follicular tonsillitis but less commonly in infectious mononucleosis or
anything else, including viral pharyngitis, thus making other conditions
improbable. Despite all of this, it is still possible that there could
be agranulocytosis due to carbimazole sensitivity. However, the raised
leukocyte count with 90% neutrophils excludes this diagnosis because a
low or absent WBC is obviously a necessary condition for the diagnosis
of agranulocytosis. There is no need, therefore, to stop the carbimazole
immediately.
The glycosuria and random blood sugar of 151 mg/dL makes the diagno-
sis of diabetes mellitus (DM) probable. If the patient has no symptoms of
diabetes and an active intercurrent illness (as in this case), two fasting
sugars >126 mg/dL would be needed to satisfy the World Health Organi-
zation (WHO) criteria so that the diagnosis would be acceptable to other
doctors.
Look at the other positive findings and consider if they would all
resolve if the acute follicular tonsillitis resolved. Use common sense,
experience, and imagination from your knowledge of physiology. The
only remaining problems would be the glycosuria, prior thyrotoxicosis,
and the patient living alone when very ill.
The main working diagnosis therefore is
- Acute follicular tonsillitis
The other diagnoses are
- Probable type II diabetes mellitus
- Controlled thyrotoxicosis
- Inadequate home care
The plan is
- Start
- Penicillin V 500 mg four times a day (qid)
- Acetaminophen 650 mg qid
- Continue
- Carbimazole 5 mg once a day (qd)
- Help patient to contact family
Chapter 5
71
General examination
physical signs
General principles 72
Fingernail abnormality 74
Clubbing 76
Terry’s lines: dark pink or brown bands on nails 78
Vasculitic nodules on fingers 79
Hand arthropathy 80
Hand and upper limb rashes 81
Lumps around the elbow 81
Neck stiffness 82
Hair loss in a specific area 84
Diffuse hair loss 85
External ear abnormalities 86
Painful ear 87
Ear discharge 88
Striking facial appearance 90
Proptosis of eye(s) or exophthalmos 92
Red eye 94
Iritis (anterior uveitis) 96
Clinical anemia 97
Fever 98
Possible hypothermia 98
Mouth lesions 99
Red pharynx and tonsils 100
Parotid swelling 101
Lump in the face (non-parotid lesion) 102
Submandibular lump—not moving with tongue nor on swallowing 104
Anterior neck lump—moving with tongue and swallowing 106
Neck lump—moving with swallowing but not with tongue 106
Bilateral neck mass—moving with swallowing but not with tongue 107
Solitary thyroid nodule 108
Lump in anterior triangle 109
Lump in posterior triangle of neck 110
Supra clavicular lump(s) 111
Galactorrhea 112
Nipple abnormality 11
3
Breast lump(s) 114
Gynecomastia 115
Axillary lymphadenopathy 116
Hirsuitism in female 117
Abdominal striae 118
Obesity 119
Pigmented creases and flexures (and buccal mucosa) 120
Spider nevi (nevus araneus) 121
Thin, wasted, cachectic 122
Purpura 123
Generalized lymphadenopathy 125
Localized groin lymphadenopathy 126
Pressure sores 126
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