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Clinical Medicine PDF
Clinical Medicine
A Textbook of Clinical Methods
and Laboratory Investigations
Editor-in-Chief
KV Krishna Das BSc MBBS FRCP(E) FAMS DTM and H(Edin)
Consultant Physician and Hematologist, Ex-Director and Professor
Department of Medicine, Trivandrum Medical College
Thiruvananthapuram, Kerala, India
Editors
Mathew Thomas MD
Professor and Head, Department of Medicine, Dr Somervell Memorial CSI Medical College
and Hospital, Karakonam, Thiruvananthapuram, Kerala, India
PK Sasidharan MD
Professor and Head, Department of Medicine, Government Medical College
Kozhikode, Kerala, India
S Aswini Kumar MD
Professor, Department of Medicine, Trivandrum Medical College, Thiruvananthapuram, Kerala, India
R Kasi Visweswaran MD DM(Nephrology)
Ex-Professor, Department of Nephrology, Nephrologist, Ananthapuri Hospital and Research Institute
Thiruvananthapuram, Kerala, India
C Sudheendra Ghosh MD(Med) MD(Resp) Dip NB MPH(USA)
Joint DME, Trivandrum Medical College, Thiruvananthapuram, Kerala, India
KR Vinaya Kumar MD DM
Professor and Head, Department of Gastroenterology, Trivandrum Medical College
Thiruvananthapuram, Kerala, India
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ISBN: 978-93-5090-280-6
Printed at
Dedicated to
the memory of all patients who
entrusted their health and life to us
and
who have helped us to shape our
careers as physicians caring for them
There is great need for a textbook of clinical medicine for the use of medical students and practitioners, with
due emphasis on the local conditions. Several books are available which are popular among students and
teachers. All these books are highly informative and useful but emphasis is given to the conditions prevailing
in their countries of origin.
The present medical scenario in addition to many of the diseases caused by poor socio-economic conditions,
most of the diseases encountered in developed countries such as lifestyle-related diseases, diseases of advancing
age and diseases caused by tobacco and biomass fuel smoke, disturbance in family relationships, road accidents,
environmental changes, more migration to townships without adequate development of infrastructure; have
all constituted to a change in disease patterns and epidemiology leading to gross change in the prevalence
and pattern of diseases. There is considerable overall improvement in the financial, socioeconomic, educational
and infrastructural improvement, but still vast areas of the country are deficient in infrastructure, clinical
facilities and availability of appropriate modern medical care. Basic investigations such as simple laboratory
tests, X-rays, electrocardiography (ECG) and even ultrasound studies are available in even remote villages
and towns. There is a rapid proliferation of secondary care and tertiary care hospitals in the private sector,
which provide health care on payment. These are available only to a smaller section of society.
The concept of primary care physician, which dominated till the middle of the twentieth century has
given place to the era of specialists and highly skilled specialists, so that the first entrants into the medical
studies proceed towards postgraduation and further acquisition of skills. Their services are available only in
towns and cities, where most of the secondary and tertiary care private hospitals are located. The students
and young physicians joining the medical profession have to be aware of these facts and it is their bounden
duty to provide medical care to the less affluent masses too. This entails the proper acquisition of clinical
skills, which alone may be adequate to diagnose and manage the vast majority of diseases occurring in the
community. The doctor should use his discretion to plan the investigations which reduce cost and inconvenience
to the patient. It is absolutely essential that cost-effective investigations have to be planned. All these require
a thorough knowledge of the principles underlying clinical examination and the interpretation of investigations.
Moreover, at the present time, when many young doctors may have to practice in remote communities single
handed, many investigations have to be carried out by themselves, e.g. urine examination for glucose, acetone
and deposits, examination of feces for ova of worms, or examine a blood smear for malarial parasites. The
ECGs and skiagrams may have to be interpreted without help. To facilitate the establishment of such laboratory
tests and empower the doctor to interpret the abnormalities, this book gives practical details to perform such
simple tests. In the case of the more complicated tests, only the principles and interpretation of the findings
are given.
The book is designed to provide information on complete clinical examination, correlation of clinical
findings with pathological processes and guidance to select investigations in a cost-effective manner. This
book is produced in two parts. Part I includes Clinical Examination and Investigations required for training
in the general medical wards. Part II contains other medical disciplines included in the undergraduate
curriculum—Pediatrics, Geriatrics, Pregnancy, Dermatology, Leprology and Sexually Transmitted Diseases,
Psychiatry, Ophthalmology, Ear, Nose and Throat, Examination of Oral Mucosa and Teeth, Community
Medicine and Statistics and Information Technology.
All the sections have been thoroughly revised and modified depending on the development in the subject
so as to provide up-to-date information to the learner. Several photographs have been added to facilitate self-
study by the students.
x Clinical Medicine
The book is intended also to cater the needs of undergraduates throughout their course, internship,
further clinical studies, preparation for postgraduate entrance examinations in internal medicine and
practitioners in India. The students of others systems of medicine and practitioners of alternate systems may
also find the interpretation of physical findings and planning of investigations useful. The sections on
Community Medicine and Statistics and Information Technology have been specially designed to help the
students to read and understand modern medical literature, interpret published material critically and plan
research at the basic level. The section on information technology is intended to make the reader aware of
modern developments in this field and to acquaint himself to the use of tools to get further information.
All the contributors, who are veteran teachers, have tried their utmost to bring out the book as a useful
companion for studying clinical medicine.
KV Krishna Das
Preface to the First Edition
There is great need for a textbook of clinical medicine for the use of medical students and practitioners, with
due emphasis on the local conditions. At present, the vast majority of medical students depends on notes
prepared during bedside clinics and supplemented by information obtained from books on clinical medicine.
Though most of these books are highly informative and useful, emphasis is given to the conditions prevailing
in their countries of origin. Many of them are written to cater to the young students who have access to
advanced investigations at hand.
The situation is different from the economically developed countries. A large number of patients flock to
the primary care physician. Facilities for investigations are limited due to the scarcity of services. The cost of
investigations is high and also unaffordable by the patients at large. The physician, therefore, has to be very
careful in planning investigations which are readily available in a cost-effective manner. Detailed clinical
examination is absolutely necessary to achieve this end with the least expense while providing the greatest
benefit and satisfaction to the patient.
Clinical methods have changed considerably depending on the changes in disease patterns and availability
of investigative facilities. The situation is special. The clinical spectrum is a mixture of diseases seen in
underdeveloped regions of the world such as malnutrition, infective diarrheas and tetanus plus those seen in
higher proportion in advanced countries, such as diabetes, ischemic heart disease, hypertension and cancer.
Facilities for basic investigations are available in many parts, but large areas of the country are devoid of
them. In many cases, the primary care physician has to organize investigations. Specialist facilities and
commercially oriented high-technolgoy medical institutions are springing up in many towns and cities.
They mainly cater to the small affluent section of the population. These facilities are beyond the reach of
large masses. Appropriate clinical methods will go a long way in providing medical care to larger sections of
the population. This book is the result of attempts made in this direction, on the advice of my peers and
colleagues, and request from numerous students and young physicians, who have found my Short Textbook
of Medicine quite useful.
The book is designed to provide information on complete clinical examination, correlation of clinical
findings with pathological processes and guidance to select investigations in a cost-effective manner.
Investigations, which the medical student or physician have to perform are described elaborately. The book
is produced in two parts. Part I includes Clinical Examination and Investigations required for training in the
general medical wards. Part II contains other medical disciplines included in the undergraduate curriculum—
Dermatology, Sexually Transmitted Diseases, Pediatrics, Obstetrics, Otorhinolaryngology, Ophthalmology
and Psychiatry. A short section on Community Medicine and Statistical Methods is also included since these
are most essential for the success of any primary health care physician. The use of computers in medicine has
also been included to prepare the students for the future trends in medicine.
Compared to all other sections, section XI on Neurology is relatively longer and more exhaustive. This
has been deliberately done in spite of the apparent disproportion between the sections because in all
postgraduate clinical examinations, the main clinical long case is invariably a neurological problem. This is
xii Clinical Medicine
so, since the elicitation of obvious findings, their interpretation and planning of investigations, etc. lend
themselves for easier and more objective assessment. To the student, who has not understood clinical neurology
well, these exercises are nightmares. At present, the available undergraduate books on clinical medicine deal
with neurology in the same manner as the other sections, since these books cater to the undergraduates. As
such, the student going for postgraduate examinations has to resort to monographs in neurology to acquire
skills required of them in the clinical examinations.
The book is intented also to cater to the needs of postgraduates in internal medicine and, therefore, this
section had to be made comparatively more exhaustive. I wish, it fulfils the need it is intended to provide.
KV Krishna Das
Acknowledgments
My editorial committee members and all the contributors have spent much time in putting considerable
effort to update the material, add newer chapters demanded by the students and teaching communities and
increase the number of illustrations to make the book user-friendly and attractive. Late PK Mohan had
assisted in writing of chapters 31 to 34 of Section 11 (Neurology). Close interaction of the members of the
editorial committee and the contributors has helped to make the text up-to-date and attractive.
Mr Abraham Jacob, did the DTP work and put the illustrations in place. The encouragement, patience
and endurance of my wife, Mrs LN Kamalam, went a long way in encouraging me to complete the editorial
task in time. Dr S Anand (Associate Professor of Ophthalmology) read the proof of chapters in ophthalmology
and did corrections.
Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director), Mr Tarun Duneja (Director-
Publishing), Mr KK Raman (Production Manager), Mr Sunil Kumar Dogra (Production Executive),
Mr Neelambar Pant (Production Coordinator), Manoj Pahuja (Senior Graphic Designer), Sudhir Babu (Graphic
Designer), Dr Mohd Naved (Senior Proofreader), Chandra Dutt (Typesetter) and staff members of Jaypee
Brothers Medical Publishers (P) Ltd, New Delhi, India, extended considerable help and constructive
suggestions to modify the text and make it come up to modern standards of technical details.
Contents
3. Imagiology Studies 44
T Kesavan
• Contrast Studies 45
• Ultrasonography 48
• Computed Tomography 49
• Magnetic Resonance Imaging 51
• Nuclear Imaging 53
Section 9: Endocrinology
• Pain 499
• Common Pain Syndromes 500
PART–II SPECIALTIES
• Conjunctiva 628
• Cornea 629
• Sclera 630
• Anterior Chamber 630
• Iris 631
• Lens 632
• Ophthalmoscopy 633
• Fundus Changes in Systemic Diseases 638
• Refractive Error 640
• Proptosis 640
SECTION
1
Clinical Medicine
Clinical Medicine: An
CHAPTER
Patient identification, History, Environmental factors, Socioeconomic factors, Details of place of residence
and recent travel, Addictions, Evidence-based medicine and diagnostic test evaluation
but physical examination and investigations are The history consists of the following parts:
absolutely necessary for the final outcome. As a 1. Presenting complaints
general rule, the term “symptoms” is used to denote 2. Evolution of the disease including treatment
the complaints given by the patient and they obtained
represent the subjective experience of the patient. 3. Past illnesses
“Signs” denote the findings made out by the doctor 4. Family history
on physical examination and they represent the 5. Social history
objective evidence of disease. In many cases 6. General information on diet, exercise, sleep,
symptoms and signs overlap, for example, a patient hobbies, occupation, recent travel and place of
may complain of an abdominal mass which the residence, addictions, etc.
doctor also may detect on palpation. Presenting Complaints
Interrogation of the Patient These are the complaints for which the patient
approaches the doctor at that time and these are the
General Considerations ones that should receive maximum attention then.
Whenever possible, the history should be taken For example, a patient with chronic peptic ulcer
directly from the patient. If the patient is unable to may be coming for the presenting complaint of
give the history (children, comatose patients, etc.) hematemesis; or a diabetic who is on treatment for
twenty years may approach the doctor for an acute
Part–I: Internal Medicine
may go on to chronicity, e.g. acute hepatitis C going 2. Mumps developing in adolescence or early
on to chronic hepatitis, cirrhosis and even carcinoma. adulthood may be the cause of testicular atrophy
Treatment of these disorders produces dramatic and azoospermia detected later in life.
results. On the other hand, chronic illnesses run for 3. Reactivation of tuberculosis occurring in early
several months or years and in the vast majority cure life and which has been incompletely treated
is not possible. In their natural course they may get may be the cause of meningitis occurring in later
remissions and exacerbations or may proceed life.
relentlessly to death either directly caused by the The student should bear in mind that even
disease or one of its complications. In them, diseases that occurred several decades earlier may
treatment seldom achieves complete recovery. be relevant for the diagnosis of the present illness.
Despite this, proper management helps to relieve Three patterns may be observed.
symptoms and prevent deterioration. In the first group the presenting complaint may
Details of the evolution of the disease should be a late complication of the past illness after a
be elicited carefully. The history should include variable symptom-free period in between the
the progress of symptoms as they developed, original illness and the present one.
appearance of new symptoms, response to treat-
ment, spontaneous remissions and exacerbations Examples
and other related phenomena. Details of treatment 1. Rheumatic fever occurring in childhood leads
ailments. Drugs alter the pattern of disease, and apparently unaffected, but then next generation may
mask the symptoms and signs, e.g. antihypertensive manifest the disease.
drugs lower the blood pressure and bronchodilator
Autosomal dominant inheritance: Examples of
drugs relieve asthma.
autosomal dominant disorders—achondroplasia,
Drugs may lead to complications as their side
Marfan’s syndrome, Huntington’s chorea, hereditary
effects, e.g. corticosteroids precipitate diabetes
spherocytosis, facioscapulohumeral muscular
mellitus, analgesics such as phenacetin lead to renal
dystrophy, dystrophia myotonica, neurofibromatosis,
damage and chloroquine may provoke convulsions.
autosomal dominant polycystic disease of the kidney,
All available information about drugs should von Willebrand’s disease, porphyria, Gilbert’s
be recorded, however trivial they may appear to syndrome and several others.
be. Untoward drug reactions and family history of
The affected members are from different
untoward drug reactions should caution the doctor
generations. The sexes are affected equally. Fifty
against their use in future, e.g. penicillin anaphylaxis.
percent of the children of the affected parents suffer.
Family History Often one of the parents and children show the
affection. Occasionally the parents and grandparents
Several diseases run in families. This may be
may be normal. In such cases the abnormality in the
caused either by genetic predisposition or similar
offspring may be attributable to a mutation.
environmental factors. Family history should be
Sometimes the parents may be apparently
Part–I: Internal Medicine
X-linked recessive inheritance, e.g. hemophilia, In males, presence of extra “X” chromosome
Christmas disease, G6 PD deficiency nephrogenic give rise to Klinefelter’s syndrome.
diabetes insipidus, Duchenne muscular dystrophy Presence of an extra Y chromosome (XYY)
and others. in males confer aggressive and criminal behavior,
The disease affects successive generations. For mental subnormality and morphological abnormalities.
a carrier female the chance of the disease developing After taking an accurate family history, a family
in the sons is 50% and the chance of the daughters tree may be constructed and this will help to
acting as carriers is also 50%. identify the pattern of inheritance in most cases
X-linked dominant inheritance (e.g. hypophos- (Figs 1.1 to 1.4).
phatemic type of vitamin D resistant rickets). Environmental Factors
Since the females contain X-chromosome from
Many diseases occur more frequently in family
both parents, they are sure to contain at least one of
members due to the same environmental factor.
the affected gene, and therefore, almost all the
Typical examples include nutritional disorders,
female children are affected. They manifest the
parasitic infections and contagious diseases.
disease twice as frequently as the males, e.g. Rheumatic fever, tuberculosis, leprosy and post-
hypophosphatemic vitamin D-resistant rickets. streptococcal glomerulonephritis may affect
Y-linked Inheritance: Only males are affected. All several children in the same house. Diseases like
Respiratory system: Chronic bronchitis with (5%), wines (10%), arrack (illicitly made (40-60 %),
emphysema, bronchogenic carcinoma. gin, whisky and brandy (45-60%). One standard
drink contains 12 g alcohol. 180 mL wine, 360 mL
Cardiovascular system: Ischemic heart disease,
hypertension, atheroma, thromboangiitis obliterans. beer or toddy or 45 mL of the spirits give 18- 20 mL
of alcohol. When taken in excess it leads to several
Alimentary system: Acid peptic disease. diseases. Alcohol supplies calories, but it is not a
Passive smoking is the term used to denote the proximate principle of food. In the early stages of
inhalation of tobacco smoke by nonsmokers from alcohol consumption, the person puts on weight, but
an environment which has been contaminated by a as the quantity of alcohol increases progressively,
smoker. Passive smoking is also attended with harm consumption of food articles falls and it leads to
though to a lesser extent. Passive smoking in closed various forms of malnutrition. The liver is the most
environments such as bed rooms or transport vehicles common organ to be affected. Alcoholic hepatitis,
leads to considerable morbidity in those affected, fatty change in the liver and cirrhosis are the
particularly in women and children. common sequelae of alcoholism. Other diseases
Though smoking is more widespread among attributable to alcohol include peripheral neuro-
males, the proportion of smokers among women is pathy, Wernicke’s encephalopathy, Korsakoff ’s
steadily increasing. Smoking during pregnancy can psychosis, cardiomyopathy and immune
lead to ill-effects in the fetus as well. In many suppression.
patient’s confidence and satisfaction in the patient- Most would only accept (1) and (2) in making
doctor relationship. This skill should be developed any emphatic recommendation on management. The
by the young doctor from the early part of his career. other levels of evidence would indicate the need for
randomized controlled studies but may, on the short-
The Diagnostic Process term be used to guide management even before
The history leads the doctor to very near the possible completion and publication of results. Clearly these
groups of diseases which the patient may be suffering criteria for an evidence base do not take into account
from. From there on he has to follow a well-defined clinical judgment and experience; quality factors;
and time tested procedure to arrive at the most likely attitudes of patients and their relatives; and demands
diagnosis. These include physical examination, related to individual clinical consultations. They are
investigations and follow up. All these are described also encumbered by publication bias.
in subsequent chapters. Investigations have become Thus, in designing clinical guidelines, the priority
integral part of the diagnostic process. They are should be to access the evidence base that is
expensive, many of them are invasive (capable of available and to ensure that it has been correctly
doing harm) and some of them are not absolutely interpreted so that when followed, can lead to
conclusive too. Choice of investigation and its improvements in health. It is also important to
performance have to be guided by established norms. establish whether the outcome would be the same
The doctor has to be aware of the evidence base when employed in different clinical circumstances.
Part–I: Internal Medicine
Table 1.1: Selection of diagnostic tests Table 1.2: True status of disease
Test characteristics Definition Test result Disease status Total
Sensitivity Proportion of people with the disease Diseased Not diseased
in whom test is positive (i.e. proportion
Positive (a) True positive (b) False positive a+b
of true positives).
Negative (c) False negative (d) True negative c+d
Specificity Proportion of people without the disease
in whom test is negative (i.e. proportion Total a+c b+d a+b+c+d
of true negatives)
Positive predictive value The probability (or likelihood) that a not equate to the presence of infection. Estimates
person that returns a positive test result of true prevalence, however, can be made taking
actually has the disease in question.
into account test sensitivity and specificity where
Negative predictive value The probability (or likelihood) that a
person that returns a negative test result these are known.
actually does not have the disease in Sensitivity and specificity are indicators of the
question.
validity of diagnostic tests. When a cut-off point is
Accuracy The accuracy of a test refers to the level
of agreement between the test result used, sensitivity and specificity show an inverse
and the “true” clinical state. relationship—as sensitivity increases, specificity
Precision Represents the degree of fluctuation of decreases and vice versa. Estimation of the sensitivity
a series of measurements around the and specificity requires testing of persons for which
central measurement.
the disease status is known. This requires the use of
True prevalence Proportion of persons in the population
Part–I: Internal Medicine
“disease-free” zones. On the other hand, if we need Formulae for calculating predictive values are
as few false positives as possible (e.g. to confirm a based on Bayes’ theorem of conditional probability.
tentative diagnosis) a test with a high specificity and Predictive values are functions of prevalence and
reasonable sensitivity is used. It is, however, the test characteristics of sensitivity and specificity.
important to note that the consequence of any As prevalence declines so does positive predictive
diagnostic test with imperfect specificity (less than value. The converse is true for negative predictive
100%) is that if a large number of tests are made on value.
a single uninfected individual, there is a significant If the sensitivity and specificity of a diagnostic
chance of finding a positive result. test are known for a particular target population,
then predictive value graphs can be drawn for the
Predictive Values
range of all possible pretest probabilities of disease
For a diagnostic decision, it is also useful to make from 0 to 1 (100%).
some estimate of the predictive value of a diagnostic
test. The predictive value quantifies the probability Interpretation of New Diagnostic Test
that a positive test result for a particular person or A diagnostic test may not always reveal the patient’s
sample correctly identifies the presence of infection true state. Hence, one has to estimate how much
and a negative test result correctly identifies the the new information has changed the uncertainty.
absence of infection. This requires knowledge of not Bayes’ theorem helps to estimate the change in
only the sensitivity and specificity of the test but the probability. Estimates of probability of a disease
2
General Examination and
Imagiology
CHAPTER
12 General Examination
PK Sasidharan
General examination, Fever, Fever of unknown origin, Level of consciousness, Anthropometry, Congenital
abnormalities, Weight and nutrition, Pallor, Jaundice, Cyanosis, Clubbing of fingers, Nail changes, Skin,
Hair distribution, Edema, Lymph nodes
INTRODUCTION the case of children and persons who are not able
to give consent, permission should be obtained from
Patient evaluation starts the moment we watch the the next of kin or legal guardian. In medicolegal
patient or establish eye contact with the patient. cases, physical examination may have to be done
Be alert, use all faculties of sense (vision, hearing,
under direction from the appropriate authority.
smell, touch) to pick up important clues to the
Irrespective of the presenting complaint, it is
diagnosis, the process of history taking continues
necessary to perform general examination and then
till we complete the clinical examination. The
to proceed to systemic examination. Gentleness
clinician should be observing the way he greets,
and concern for the patient are essential to get the
sits, walks, talks; or in short anything that the
best results.
patient does in front of us is subjected to evaluation
by an astute clinician. Finally some patients and GENERAL EXAMINATION
relatives might get the feeling that the doctor made
the diagnosis by just palpating pulse and some Perform general examination with the following
intelligent persons even conclude that the doctor objectives:
is able to smell the diagnosis !!!. That is good 1. To get an overall impression about the general
clinical skill and is not intuition. Like history taking state of health.
the general examination also continues throughout 2. To obtain cooperation for further detailed
the period of evaluation and finishes only at the examination.
end of the interaction with the patient. In real life 3. To decide on the immediate intervention required,
practice it is desirable that the physical examination for example, a patient in shock requires immediate
should start with the area mainly affected, only to resuscitatory measures to save life, rather than a
give confidence to the patient and to reinforce the detailed physical examination which will lead to
reassurance. Remember that the eyes won’t see delay in instituting life support (Some of the other
what the mind does not know, and be aware of the common situations where the physician has to
abnormalities possible in each area. The order in take immediate resuscitatory measures based on
which physical examination is done is decided by history and general examination are sudden
the convenience of the patient primarily and collapse, respiratory obstruction, trauma,
sometimes decided by the convenience of the doctor. drowning, poisoning, convulsions, snake bite,
Before proceeding to physical examination, anaphylactic reactions, bleeding, hyperpyrexia,
remember to obtain consent from the patient. In coma and the like).
20 Section 2: General Examination and Imagiology
The general examination may draw attention examination of swellings or peripheral pulses. One
to the system that is maximally deranged so that may start with vital signs, especially in a very sick
the physician can start systematic examination with patient, but it may be other way round while sitting
that system first and proceed to the rest, usually in the OPD or while evaluating a stable patient;
done is a head to foot manner. Vital signs include the pulse, respiratory rate, blood
The following signs should be looked for in pressure, temperature and the level of consciousness.
the general examination: Always stand on the right side of the patient unless
1. Behavior, attitude and posture the clinician is left handed and is trained to do the
2. Build and nutrition examination standing on the left side.
a. Height Pulse
b. Weight
The radial pulse should be examined and its rate,
c. Body Mass Index (BMI)
rhythm and character noted. The right radial pulse
d. Anthropometric features
is palpated with the tips of three fingers of the left
e. Congenital abnormalities
hand, with the wrist slightly flexed and supported
3. Temperature by the right hand to relax the muscles (Fig. 2.1).
4. Pallor Normal pulse rate is 80 (60–100) per minute.
5. Jaundice Tachycardia (rate above 100/mt) may occur due to
6. Cyanosis anxiety, exercise, fever, hyperthyroidism and
Part–I: Internal Medicine
7. Clubbing of fingers and toes, abnormalities of tachyarrhythmias. In shock the pulse is rapid and
nails thready, i.e. low volume and fast rate. Bradycardia
8. Abnormalities of skin and hair (rate below 60/minute) is common in those who do
9. Edema hard physical labor and in trained athletes. Rates
10. Lymphadenopathy below 40/minute should raise the suspicion of heart
11. Vital signs. block, especially so if there is no increase on
Do not forget to include those features which exertion.
are not usually mentioned in systemic examination
but noted during a head to foot examination of Respiration
the patient. For example, examination for external Respiratory rate is counted by watching the
features of thyroid disease (hypo and hyper- movement of the abdomen, while the examiner
thyroidism), chronic liver and kidney disease, pretends as if he is palpating the pulse. This is to
connective tissue disease, diabetes, metabolic divert the attention of the patient, from the abdomen
syndrome, etc. should be part of general examination. which the examiner is observing (Fig. 2.2). Normal
Careful observation, inspection and palpation are respiratory rate is 14–18/minute. Rise in respiratory
the methods used for general examination, where rate occurs in conditions with increased work of
required, percussion and auscultation also should breathing or due to stimulation of respiratory center.
be used as part of general examination, e.g. during Diseases like pneumonia, pleural effusion, pulmonary
edema or bronchial asthma increase work of breathing. the heart. Palpating the radial pulse, the cuff is inflated
Stimulation of respiratory center can be due to hypoxia as quickly as possible till the pressure in the cuff is
or low pH hence, can be seen in pulmonary embolism, sufficient to obliterate the pulse and further raise it
and metabolic acidosis. Anxiety also stimulates the to 20 to 30 mm above that level (Fig. 2.3). Keeping
respiratory center. In shock, patients have severe the stethoscope over the brachial artery at the elbow,
tachypnea with signs of respiratory distress due to the pressure in the cuff is released as slowly as
multiple mechanisms. Respiratory rate is considerably possible,1–2 divisions at a time, till the Korotkov
diminished in narcotic poisoning, raised intracranial sounds are heard, the level at which the first sound is
tension and in deep coma. heard corresponds to systolic pressure. Continue the
Blood Pressure deflation of the cuff at the same rate as before, and
note down the pressure at which the sounds muffle
The patient is seated comfortably or lying down, sharply or disappear and that is an estimate of
blood pressure (BP) cuff of adequate size is tied diastolic pressure (Fig. 2.4).
snugly not very loose or very tight, permitting
Blood pressure gives an indication of the overall
introduction of one finger. The center of the cuff
cardiovascular status since it depends upon cardiac
should be lying over the brachial artery, tie the cuff
output and peripheral resistance. Fall in either, leads
in such a way that the tubing of the cuff will not
to drop in blood pressure. Normal blood pressure
interfere with auscultation. The adequacy of the size
of the cuff is assessed by ensuring that it covers three in adults is 100 to 120 mm Hg systolic and 70 to 84
Temperature
Whether or not a patient is febrile is often obvious
by palpation of the forehead with the dorsum
Fig. 2.3: Palpating radial pulse and inflating the cuff of the hand (Fig. 2.5). But the exact temperature
Fig. 2.4: Auscultating brachial artery and deflating the cuff Fig. 2.5: Palpating to detect fever
22 Section 2: General Examination and Imagiology
FEVER (PYREXIA)
It is the abnormal elevation of temperature above
37.2°C in the morning and 37.7°C in the evening.
In many cases it is associated with other features
such as discomfort, burning of the eyes, chills,
rigors, aches and pains and malaise. Presence of
fever is a definite indication for proper evaluation,
and if the cause is not obvious it necessitates
review of history and physical signs, laboratory
investigation and close observation. The temper-
ature is elevated by increasing heat production and
reducing heat loss. Heat production is increased by
Fig. 2.6: Measuring temperature increasing the metabolic rate and rapid muscular
contractions as in rigors. Heat loss by radiation is
has to be recorded in doubtful cases to document
fever and to assess the height of temperature reduced by peripheral vasoconstriction. Rise of
temperature may occur abruptly within hours as in
using a clinical thermometer (see measurement of
temperature) (Fig. 2.6). pneumococcal pneumonia or influenza or it may be
gradual and step-ladder type as in enteric fever and
Part–I: Internal Medicine
Fig. 2.8: The pattern of rise of temperature Fig. 2.9: Pattern of the fall of temperature
(1) Abrupt rise (2) Step-ladder pattern (1) Fall by crisis, (2) Fall by lysis
pyelonephritis, pus collection somewhere and Crisis: This refers to an abrupt fall of temperature
cholangitis. from a high level (40°C or above) to subnormal
values within a few hours, e.g. pneumococcal
Periodicity: Many intermittent fevers show
pneumonia. Crisis is accompanied by severe
periodicity. The fever recurs at regular intervals.
sweating (diaphoresis), often diuresis and in some
Typically seen in malraia, but in P. falciparum
cases diarrhea. The blood pressure may drop and
malaria and in mixed infections by different species
the patient may develop signs of shock.
of parasites, sometimes periodicity may not be
The insensible fluid losses are increased. The measles, before the skin rashes appear. These are
patient tends to get dehydrated. diagnostic.
The heart rate increases at the rate of 18 counts Maculopapular rash over the butterfly area of the
per minute for every 1°C rise of temperature. This face is highly suggestive of systemic lupus
results from increased rate of the SA node. The erythematosus.
relationship between the pulse rate and the Erythema marginatum in rheumatic fever, coppery
temperature level gives diagnostic clues. Fevers in rash in secondary syphilis, hemorrhagic rash in
which the heart rate is not raised proportional to meningococcemia.
the temperature are called slow pulse fevers (relative Erythema chronicum migrans in Lyme disease are
bradycardia), e.g. typhoid, meningitis, influenza. only a few of the many examples.
Those in which the pulse rate rises out of proportion
In addition to these, it is common to get allergic
to the rise in temperature are called rapid pulse fevers,
rashes caused by medications. These have to be
e.g. rheumatic fever, tuberculosis, pneumonia.
distinguished by proper history and clinical features.
Respiratory rate: In general the ratio of the Drug rashes are commonly due to hypersensitivity.
respiratory rate to heart rate is around 1:4. Majority of them are pruritic and associated with
Respiratory rate increases in fevers along with the other allergic manifestations.
heart rate. Abnormal elevation of respiratory rate
out of proportion to the heart rate occurs in Mouth
Part–I: Internal Medicine
respiratory diseases such as pneumonias and pleural Appetite is lost in most fevers and the intake of
effusion. food and fluids come down. The mouth becomes
Rashes dry and coated. Presence of dried up debris over
the teeth at the level of lip margins is called
These are eruptions occurring over the skin or mucous
“sordes”. The pattern of coating of the tongue may
membranes and may of them are associated with
be characteristic. In typhoid fever the tongue shows
fevers. They are of diagnostic importance. The rash
central coating, the margins being free.
may be macular, papular, vesicular, pustular or
hemorrhagic. Fevers characterized by the occurrence In many cases the tongue may show other
of rashes over the skin are called exanthematous changes:
fevers. If the rashes occur in the mucous membranes Soreness of the tongue: Measles.
they are called enanthems. The distribution of the Red beefy tongue: Broad-spectrum antibiotic
rashes and the time of their appearance are therapy.
characteristic. White curdy membrane over the tongue easily
Time of Appearance of the Rash removable: Candidiasis due to prolonged broad-
spectrum antibiotic, corticosteroids or immune
Skin rash occurring on the: suppressed states.
First day of fever Chickenpox
Ulcerations over the tongue and bleeding:
Second day Scarlet fever
Stevens-Johnson syndrome.
Third day Smallpox (eradicated)
Fourth day Measles Invasive candidiasis: Advanced HIV infection/
Fifth day Typhus immunosuppression.
Sixth day Typhoid (rose spots, but usually
Urine and Feces
not seen in Indian patients)
Early administration of antipyretics and other drugs Urine volume comes down as a result of dehy-
alter the natural history of the disease. Rashes may dration. The urine is concentrated and high colored.
also be due to adverse reaction to drugs. Constipation may occur as a result of reduced
food intake, dehydration and reduction in physical
Patterns of Rashes activity. In typhoid fever and bacterial dysentery
Koplik’s spots are bluish gray spots occurring inside diarrhea may occur, always examine urine and feces
the cheeks opposite the upper second molars in macroscopically if it is available and mention any
Chapter 2: General Examination 25
abnormalities noticed along with general interpretation of the normal body temperature,
examination. especially when they are apprehensive of
disease. Rarely temperature may be elevated
Causes of Fever
in severe mental stress.
1. Infection: Commonest cause of fever in all
Fever is only a symptom of disease, which should
countries, especially developing countries like
alert the physician to the underlying abnormality.
India is infection. This could be bacterial, viral,
Careful history and physical examination help to
rickettsial, chlamydial, protozoal, fungal and
identify the cause in many cases. One of the most
helminthic. Almost all infections cause fever
basic step in evaluation of fever is to ensure that
as a general reaction.
there is high temperature. For clinical purposes
2. Inflammatory causes not attributable to infec-
fevers of less than one week duration are called short
tions: Connective tissue diseases, e.g. systemic
fevers, e.g. short viral fevers, tonsillitis, acute
lupus erythematosus, rheumatoid disease.
bronchitis and many of the childhood infections.
3. Hypersensitivity reactions: Reaction to drugs,
antisera, biological products-serum sickness. Fevers that persist for more than two weeks are
4. Trauma: Accidents, blunt trauma and major called prolonged fevers.
surgery are accompanied by fever, even in the Common Causes of Prolonged Fever
absence of infective complications.
5. Extravasation of blood into tissue spaces: Bacterial: Enteric fever, tuberculosis, infective
endocarditis, urinary tract infection, rheumatic
individuals. Generally, children of tall parents also below 0.87, it is suggestive of marfanoid features,
tend to be tall and vice versa. Malnutrition in early eunuchoidism or homocystinuria. Marfan’s syndrome
life leads to stunting of growth and therefore the is accompanied by a higher incidence of congenital
height of a person gives important clue to the state cardiovascular defects. Hypermobility of the joints
of his past nutrition. It is seen that children who are occurs in Marfan’s syndrome and Ehlers-Danlos
malnourished can catch up if proper nutrition is syndrome. Finger joints, wrist and knee are
restored before adolescence is complete. Growth hyperextensible. arachnodactyly (spider fingers) is
in height ceases with the closure of the epiphyses. the condition in which the fingers are long, slender
Common conditions which lead to stunting of and hyperextensible. In diseases affecting the
growth include diseases of early childhood like- vertebrae such as kyphoscoliosis, Paget’s disease
general malnutrition, rickets, kyphoscoliosis, of bone and osteoporosis, the upper segment
tuberculosis and rheumatoid arthritis of the becomes shorter. In achondroplasia, the trunk and
vertebrae, growth hormone deficiency, osteogenesis head are normal, but the long bones of the limbs
imperfecta and Paget’s disease of bone. Conditions and fingers and toes are shorter.
in which there is premature closure of epiphyses
such as adrenogenital syndrome and therapy with Abnormalities of the Skull
androgens or corticosteroids in childhood may result The shape of the head may vary considerably in
in arrest of growth. health:
The height is abnormally increased in 1. Abnormally long antero-posterior diameter
Table 2.1: Common congenital abnormalities with light clothes without footwear, under the same
Congenital abnormality Common associations conditions at every visit. Variations upto 1 kg may
1. Eyes: Micropsia, Congenital rubella syndrome occur as a result of ingestion of food, filling of
coloboma of the iris, urinary bladder and the colon. Variations beyond
congenital cataract
cardiovascular defects this range should draw the attention of the physician.
(e.g. PDA) Weight of an individual represents the state of
2. Ears: Abnormalities Congenital rubella syndrome current nutritional status. In a healthy individual
of the pinna, nerve cardiovascular defects (e.g. the weight remains more or less steady from the
deafness. PDA)
age of 30 to 65 years after which it may tend to fall
3. Hands and feet: Congenital cardiac defects
Polydactyly (extra fingers
gradually. In many diseases such as diabetes
or toes) syndactyly mellitus, thyrotoxicosis, tuberculosis, malignan-
defects (fused fingers cies, and psychiatric disorders there is significant
or toes), lobster fingers
and toes (fingers resembling
loss of weight. As these conditions improve with
the claws of a lobster) treatment the weight returns to normal. Unex-
4. Abnormalities of the radius, Holt-Oram syndrome plained loss of weight by 5 to 10% should evoke
ulna or both and the hands Congenital cardiac defects suspicion about serious underlying disease
(e.g. secundum ASD)
necessitating prompt evaluation.
5. Cafe-au-lait spots Neurofibromatosis type-l
cutaneous neurofibromata cardiovascular defects
Weight in excess of 10% of the ideal body
weight caused by excessive deposition of fat is
Part–I: Internal Medicine
Contd...
JAUNDICE
Niacin (Vitamin B 3) Glossitis, dermatitis over areas exposed to
sunlight, mental changes, diarrhea Jaundice is yellow pigmentation of the sclera, skin,
Biotin Deficiency is more in infants. Lassitude, mucous membranes and other tissues caused by
irritability, paraesthesia, anorexia excess of circulating bilirubin. Normal level of
Pyridoxin (Vitamin B6 ) Peripheral neuropathy, rashes, hair loss,
dermatitis, cheliosis, angulostomatitis,
serum bilirubin is up to 1 mg/ dL. The presence of
glossitis, infantile convulsions scleral icterus indicates a serum bilirubin of at least
Ascorbic acid (Vitamin C) Bleeding gums, follicular keratosis over skin 3.0 mg/dL. Bilirubin attaches to collagenous tissue
and follicular hemorrhages, delay in healing easily and therefore tissues rich in collagen are
of wounds, tendency for infections, scurvy
stained most. After elevating the eyelids ask the
Pantothenic acid Possibly neuromuscular degeneration, dermal
and hair changes patient to look down, and examine the sclera above
Folic acid Megaloblastic anemia the cornea, which is covered by the upper eyelid
Vitamin B 12 Megaloblastic anemia, subacute combined (Figs 2.13 and 2.14). For identifying mild jaundice
degeneration of spinal cord, mental changes the patient should be examined in daylight. Jaundice
Minerals Iron Iron deficiency states, iron deficiency anemia, is best appreciated over the upper part of the sclera,
koilonychia, sideropenic dysphagia
Calcium Hypocalcemia, tetany, osteomalacia
under surface of the tongue, palms, nails and skin.
Iodine Goiter, goitrous cretinism in the newborns
It is best seen in upper sclera as there is more
and children, several iodine deficiency disorders collagen, Also, bilirubin in the sun exposed areas
Magnesium Tetany, cardiac arrhythmias of sclera gets photo oxidized to water soluble
Part–I: Internal Medicine
Fig. 2:11: Examination for pallor Fig. 2.12: Pallor in a patient with severe anemia
Chapter 2: General Examination 31
CYANOSIS
This is bluish, or dark purple coloration of the skin
and mucous membranes caused by the presence of
excessive amounts of reduced hemoglobin in
arterial blood. For cyanosis to become visible the
amount of reduced hemoglobin should exceed
Fig. 2:15: Thalassemic patient with typical facial 5g/dL. In severely anemic patients since this level
appearance and jaundice of reduced hemoglobin cannot be reached, cyanosis
32 Section 2: General Examination and Imagiology
may not develop even when there is hypoxemia. The part may relieve the cyanosis if it is vasospasm.
opposite is true of polycythemia in which cyanosis Peripheral cyanosis is caused by excessive extraction
may be present even under ordinary conditions. of oxygen by the tissues from the capillaries when
Cyanosis may be due to central causes or peripheral there is sluggish flow of blood due to any cause
causes. Mixing of arterial and venous blood at the including reduction in cardiac output. Sometimes
level of the heart or great vessels, due to shunts and dark pigmentation of the tongue and oral mucosa
defective oxygenation in the lungs, give rise to may resemble central cyanosis. In such cases, the
central cyanosis. In central cyanosis, the central peripheries are not blue. On pressing with a glass
parts of the body such as the tongue as well as the slide over the tongue, if the tongue blanches
peripheral parts such as the nail beds, tips of fingers and the part becomes pale, it suggests cyanosis. In
and toes and the tip of the nose are cyanosed. The pigmentation there is no change on applying
extremities are warm. Central cyanosis is seen pressure. Presence of excess of methemoglobin or
characteristically in congenital cyanotic heart sulphemoglobin leads to bluish or leaden color
disease, chronic bronchitis emphysema and other resembling cyanosis. Most often this is caused by
pulmonary diseases impairing gas exchange in the taking drugs or chemicals which alter the color of
alveoli. Inhalation of pure oxygen does not correct hemoglobin, e.g. dapsone, nitrates, marking ink,
the cyanosis in the case of congenital heart disease. dyes and chemicals. A cherry-colored flush, rather
In the case of pulmonary diseases, unless the lesion than cyanosis, is caused by carboxyhemoglobin
is far advanced inhalation of oxygen helps to correct (COHb). Arterial obstruction to an extremity, as with
Part–I: Internal Medicine
the cyanosis partially. Central cyanosis is associated an embolus (Fig. 2.17), or arteriolar constriction, as
with the development of secondary polycythemia in cold-induced vasospasm (Raynaud’s phenomenon)
(Fig. 2.16). generally results in pallor and coldness first followed
Peripheral cyanosis denotes the condition by cyanosis confined to the area affected. Venous
where the extremities (tips of fingers and toes, nail obstruction, as in thrombophlebitis, dilates the
beds and tip of the nose) are cyanosed, while the subpapillary venous plexuses and thereby intensifies
central parts like the tongue are not. Unlike as in cyanosis. Differential cyanosis occurs in patents with
central cyanosis the extremities with cyanosis are Eisenmenger syndrome with patent ductus arteriosus
cold to feel. The mechanism of cyanosis is peripheral (PDA)—the lower extremities are cyanosed where
like arterial obstruction or vasospasm. Warming the as the upper extremities are not.
Fig. 2.16: Central cyanosis and polycythemia in patient with Fig. 2.17: Cyanosis of index and small fingers plus
COPD and respiratory failure (blue bloater) clubbing in infective endocarditis with embolism
Chapter 2: General Examination 33
Fig. 2.18: Normal appearance Shamroth’s sign Fig. 2.19: Clubbing in a patient with subacute
bacterial endocarditis
34 Section 2: General Examination and Imagiology
Fig. 2.20: Koilonychia and pallor Fig. 2.21: Splinter hemorrhage in nails
Both toe nails and finger nails may show this Multiple longitudinal ridging is constitutional.
change, the former being affected earlier. Koilony- In chronic renal failure, the nails may show pallor
chia is almost always suggestive of severe iron (whitening) of the proximal half and reddish or
deficiency state. The condition subsides when the brownish pigmentation of the distal half “half and
deficiency is rectified. Nail may be brittle with half nail”. Impaired peripheral circulation, especially
Part–I: Internal Medicine
cracked edges or may be flat (platonychia) in early of the lower limbs as in arterial occlusion and
iron deficiency anemia. This is very important as neurological disorders such as nerve root compression
iron deficiency can be diagnosed in early stages and by disk prolapse may lead to thinning, longitudinal
proper treatment can be initiated. Angular ridging and onycholysis.
stomatitis—fissures at the corners of the mouth is
another manifestation of severe iron deficiency SKIN
anemia.
The skin closely mirrors several systemic disorders.
Whitish discoloration of the nail (leuconychia): Skin should be examined under day light or bright
Small white patches on the nail may be seen in illumination. Normal skin is smooth, lustrous,
normal persons. White bands on the nails may uniformly pigmented and having normal distribution
indicate hypoalbuminemic states like chronic liver of hairs. Skin color depends upon the pigmentation
disease or nephrotic syndrome. and vascularity underneath. When pinched up and
Splinter hemorrhages in the nail-beds (Fig. 2.21): released, normal skin resumes the original shape
These are seen in infective endocarditis and certain without leaving any wrinkles. Detailed description
forms of vasculitis like polyarteritis nodosa, is given in Section 15.
vasculitis associated with scleroderma, rheumatoid Look for changes in color, texture and distribution
arthritis, etc. of hair. Loss of elasticity and wrink-ling may occur
Fungus infection of the nails may make them in the elderly, but if it occurs in the younger age
thick, rough and distorted (onychomycosis). Pitting groups, it should suggest rapid loss of weight or
of the nails and sometimes onycholysis (separation dehydration. Hyperelasticity (ability to be pinched
from nail bed) occurs in psoriasis. Onycholysis can up freely) occurs in conditions like Ehlers-Danlos
occur due to candidal infection also. Nails may fail syndrome where the structure of collagen is
to develop normally in genetic disorders such as abnormal. Particularly look for rashes, parasites
nail-patella syndrome. such as head louse, body louse and pubic louse,
Brittle nails develop due to external causes like ticks, mites, scabies, pigmentary disturbances such
solvents, detergents and soaps. Soaps cause vitiligo, ‘cafe au lait’ spots, hyperpigmentation
weakening of nail edges, splitting and softening. fungal infections of the skin and nails, neuro-
Transverse ridging is called Beau’s lines which fibromata, nevi, hemangiomas and eschars
develop due to arrest of growth during a period of (Figs 2.22 and 2.23). Eschars are necrotic ulcers,
serious illness followed by recovery of growth. often painless and unnoticed by the patient,
Chapter 2: General Examination 35
Fig. 2.22: Hyperpigmentation of knuckles and Fig. 2.23: Adenoma sebaceum in tuberous sclerosis
pallor in megaloblastic anemia
Fig. 2.24: Absence of body hair, axillary hair in hypogonadism Fig. 2.26: Note the excessive hair growth over the face and
and cirrhosis due to hemochromatosis in 28 years old male moustache area. Often the whole body is affected (Hirsuitism)
Part–I: Internal Medicine
Fig. 2.25: Female pattern pubic hair in the same Fig. 2.27: Premature graying in 20 years
patient in Fig. 2.24 old with B 12 deficiency
the hair root is destroyed, the baldness becomes in men and with age the extent of baldness increases.
permanent. Alopecia may involve not only the Baldness in women should suggest the possibility of
scalp, but all parts of the body. Administration of hyperan-drogenism or hyperadrenal corticism.
anticancer drugs is a common cause of temporary Abnormal frontal baldness develops in dystrophia
hair loss at all ages. myotonica.
Failure of hair growth over the genitalia and Graying of hair is a natural process most
face should suggest hypogonadism (primary or frequently associated with aging. In some cases
secondary) (Figs 2.24 and 2.25). grey hair develops even in young. Rapid depigment
When an adult male develops hypogonadism ation of the hair may develop in severe protein
the facial and the body hair may be lost. Hair loss malnutrition. B12 deficiency is a cause for premature
or absence of hair in the axillae and pubic region graying of hair (Fig. 2.27).
suggests hypopituitarism. Systemic diseases like
cirrhosis liver and lepromatous leprosy and therapy EDEMA
with estrogens may lead to loss of facial and body
hair in males. Clinical Examination
Excessive hair over the face and body in women Excessive accumulation of fluid in interstitial tissue
is called hirsuitism (Fig. 2.26). This occurs in spaces is called edema. Edema may be generalized
conditions where there is excessive androgen or localized. In generalized edema (syn. dropsy,
secretion. Frontal baldness is a normal phenomenon anasarca) there is retention of excessive fluid in
Chapter 2: General Examination 37
tissues resulting in increase in total body fluids. cleared at night due to improvement in cardiac
This excessive fluid is due to transudation of fluid output. As the condition progresses, the edema
into the tissue spaces, increase in fluid in cells and becomes established at all times. With diuretic
increase of fluid volume in the venous and capillary therapy the urine volume increases and the edema
sides of the circulation. Along with the retention clears. Cardiac edema is accompanied by other
of water, there is retention of sodium and chloride. signs of cardiac failure such as exertional dyspnea,
Generalized edema results in rapid increase in engorged jugulars and hepatic enlargement. In the
weight (more than 500–1000 g daily), oliguria early stages of left-sided heart failure, pulmonary
(urine volume falling below 400 mLIday) and congestion and pulmonary edema occur. Later right
accumulation of fluid in all tissues. heart failure supervenes and generalized edema
In edema, the patient complains of tightness of develops.
the part and unusual heaviness. The skin is stretched
Renal causes: Generalized edema is a common
and shiny and the normal wrinkles are obliterated.
accompaniment of acute nephritic syndrome and
Superficial veins become less prominent. The
nephrotic syndrome. In acute nephritic syndrome,
confirmatory sign of edema is pitting on pressure,
the edema is most prominent over the eyelids
i.e. pressure over the edematous part displaces the
and face, especially on waking up after sleep. In
fluid and this leads to the formation of a dimple.
nephrotic syndrome, the edema is caused by
The test is performed by exerting gentle pressure
hypoalbuminemia and it is also dependent in nature.
with the flat of the thumb for ten seconds over a
A B
Figs 2.28A and B: (A) Demonstration of pitting on pressure, (B) Pit caused by pressure (arrow)
38 Section 2: General Examination and Imagiology
Groups of nodes Drainage area Intra-abdominal nodes: These occur in relation to abdominal organs.
Occipital Occipital scalp and back of neck and Several groups are recognizable: pyloric, splenic, porta hepatis, mesenteric
retro-orbital area and others. They lie in relation to major vessels which supply viscera
viz. branches of coeliac axis and superior and inferior mesenteric vessels.
Parotid (preauricular) Face (posterior)
Efferents from these drain to the retroperitoneal (para aortic) nodes.
Buccal Face, anterior and upper lip, tongue,
floor of mouth, lower jaw Some important nodes Groups of lymph nodes enlarged
Submandibular Lower lip, tip of tongue, central part of to remember
floor of mouth Lesions of the scalp Occipital, postauricular
Upper anterior cervical Nose, mouth, pharynx, upper larynx and Larynx, vocal cords Upper deep cervical
tonsil and tonsils
Lower posterior Lower neck, upper chest and afferents Oral cavity Submental, submandibular
(supraclavicular) from axilla and mediastinum Lungs Tracheo-bronchial, mediastinal and
scalene.
Scalene node right Right lung and lower parts of left lung,
mediastinum Breasts Axilla, (anterior, central, apical) internal
mammary group and supraclavicular
Scalene node left Upper parts of left lung, mediastinum
Esophagus
Upper third Lower cervical
Middle third Paraesophageal and tracheobronchial
The term Virchow’s nodes is given to the group gastric
of supraclavicular nodes which are situated between Lower third
the two heads of sternocleidomastoid on the left Stomach
side. They enlarge due to metastatic deposits from Fundus Splenic, left gastric
Pylorus Supra and sub-pyloric groups
Fig. 2.30: Palpating submental nodes and Fig. 2.33: Palpating scalene nodes, method-1
submandibular nodes
Part–I: Internal Medicine
Fig. 2.31: Palpating cervical and supraclavicular Fig. 2.34: Palpating scalene nodes, method-2
lymph nodes
the arm ensuring that its weight is supported on the Popliteal nodes: Flex the knees and palpate deep
examiners arm and manipulates it so as to relax by introducing the fingers into the popliteal fossa.
the axillary floor. The nodes are systematically Abdominal lymph nodes: These can be identified
palpated in the apex and anterior, medial, lateral as discrete nodular or matted masses in the abdomen
Chapter 2: General Examination 41
more often. Posterior cervical groups are affected secondary to testicular or abdominal tumors.
in lesions of the scalp, secondary syphilis and Mesenteric nodes may be secondary to neoplasms
leukemias. In lymphomas both anterior and posterior of the intestines, iliac nodes and pelvic nodes may
groups may be affected. Supraclavicular nodes are be secondary to lesions of the cecum, ileocecal
affected in pulmonary lesions such as malignancy. region, pelvic organs and prostate. Massive
In african trypanosomiasis enlargement of posterior lymphadenopathy may occur in lymphomas and
cervical nodes is characteristic (Winterbottom’s secondary malignancy.
sign). Tuberculosis affecting the mesenteric nodes
The pretracheal nodes (scalene nodes, situated produce mild to moderate lymphadenopathy.
in between the scalene muscles and behind the
Inguinal Nodes
sternal head of the sternocleidomastoid) are involved
early in metastatic pulmonary carcinoma. In Characteristically inguinal adenopathy is seen in
advanced malignancy of the esophagus the lower syphilitic chancre over the penis, lymphogra-nuloma
cervical nodes may be enlarged. Tuberculosis can venereum, filariasis, other infective and malignant
present with isolated scalene node enlargement lesions of the penis and vulva, melanoma in the feet
as well. and bubonic plague (rare).
extremities such as infected scabies. Ocassionally German measles, infectious mononucleosis and
small axillary nodes may be seen in normal children AIDS the size is small or only moderate (1–2 cm).
and manual laborers. In women neoplasms of Large sizes are attained in lymphomas, metastatic
the breast have to be particularly looked for. malignancy, lymphogranuloma venereum and
Lymphomas, filariasis (especially B. malayi) and diphtheria. Presence of large nodes in the upper
tuberculosis may involve the axillary nodes. part of the neck in faucial diphtheria gives rise to
“bull neck” appearance. This is seen only rarely at
Epitrochlear (Supratrochlear) Nodes present.
These are enlarged secondary to sepsis in the hands Number of Nodes
and forearm. They may be enlarged in non-
Hodgkin’s Lymphoma, secondary syphilis and acute Enlargement may be confined to a single node or
leukemias. Tuberculosis can present with enlarge- only a group in localized disease and in early stages
ment of any lymph nodes. of systemic diseases. Increase in the number of
nodes and involvement of different groups signifies
Mediastinal Nodes extension.
These are enlarged in lymphomas, acute lymphatic Consistency
leukemia (T-cell type), secondary deposits from Normal consistency (soft to firm) occurs in
pulmonary neoplasms and in extensive metastases inflammatory diseases. When abscess formation or
from abdominal and testicular tumors. Tuberculosis tuberculous caseation occurs, the nodes become soft
and sarcoidosis can present with mediastinal or fluctuant. In lymphomas and chronic lymphatic
lymphadenopathy and constitutional symptoms leukemia the nodes are firm and rubbery. In primary
especially in primary tuberculosis. syphilis the nodes are hard and discrete (shotty) and
can be rolled under the skin. In metastatic carcinoma
Abdominal Lymph Nodes
the nodes are firm to hard.
Regional groups are enlarged as a result of meta-
stases from the areas of drainage. For example, Tenderness
pyloric nodes and nodes in the porta hepatis maybe Pain on palpation and spontaneous pain are
secondary to gastric carcinoma or tumors of suggestive of inflammatory lesion. Lymphomas and
the hepatobiliary tract. Para-aortic nodes may be metastatic lesions are nontender and painless.
Chapter 2: General Examination 43
3
1 Imagiology Studies
T Kesavan
Plain X-ray, Computed radiography, Digital radiography, Contrast studies, Digital subtraction angiography,
Ultrasonography, Computed tomography, Magnetic resonance imaging, Nuclear imaging, Single photon
emission tomography, Positron emission tomography
INTRODUCTION
Radiology, the art and science of imaging, has
developed technically and technologically since the
discovery of X-rays in the last part of 19th century.
Though the basic concepts remain the same,
refinement in all aspects of imaging and addition of
newer techniques have widened the scope from
purely diagnostic to interventional radiology. The
specialty of radiology and imaging has application
in all the branches of medicine.
German physicist Dr Wilhelm Conrad Roentgen
(Fig. 3.1) discovered mysterious electromagnetic
radiations of short wavelength which have the unique
property of penetrating matter on 8th November
1896. He was experimenting with cathode ray tubes
and as he was not able to find out the exact origin
of the mysterious rays, he called them ‘X-rays’. X-
rays are electromagnetic radiations of very short
wave length and are produced when fast moving
electrons from a heated and negatively charged Fig. 3.1: WC Roentgen (1845-1923)
German physicist who discovered X-rays in 1896 and was
cathode hit a positively charged, high melting point
awarded the first ever Nobel prize in 1901
anode, usually made of tungsten. The cathode and
anode are enclosed in a completely evacuated glass in the static mode or in the dynamic mode depending
tube. The energy of the electrons is converted to upon the clinical need and type of imaging modality.
heat and X-rays. Only about 2% of the energy is Modern imaging techniques can reveal considerable
converted to X-rays and the rest is converted to heat. details of anatomy and pathophysiology of the
The heat is removed from the anode by various various organs of the human body. Various types of
methods of dissipation. Various modalities of contrast media can be introduced through oral,
imaging are aimed at visualizing the internal rectal, intravenous or intra-arterial route to facilitate
structure of the human body. Imaging can be either visualization of the organs and tissues. The various
Chapter 3: Imagiology Studies 45
methods to produce diagnostic imgages include plain a laser beam to convert the information on the IP
X-rays, contrast studies and computed tomography into a digital image. After reading, the IP is erased
(CT). by the same reader and is ready for reuse. The IP
needs replacement after an average of about 50,000
Plain X-Ray to 60,000 exposures. The image is displayed on a
X-rays penetrate tissues and are absorbed differ- monitor within seconds and can be manipulated,
entially depending on the basic elements contained edited and printed. The image can be converted into
in the tissues. Elements with low atomic number hard copy using a laser camera or directly uploaded
absorb little radiation (e.g. air, gas) and those with into a picture archiving and communication system
high atomic number absorb more (e.g. bones). The (PACS). The advantages of CR are clarity of
degree of absorption by fat and soft tissues comes pictures, elimination of the dark room with
in between. The attenuated X-rays coming out of environment unfriendly chemicals, long-term cost
the body are captured as an image on a photographic saving due to lesser spending on film, available
plate. The densities cast on the film vary from the X-ray equipment can be used, space saving because
extreme black produced by air or gas to extreme of storage and retrieval using CD/DVD, integration
white cast by bones. Fat and soft tissues cast with PAC System for remote viewing and is a
densities in between these two, the fatty tissue being cheaper alternative to fully digital systems, which
less black than air. Thus, radiographically, we are at present prohibitively expensive. The main
recognize four basic densities, namely air, fat, fluid disadvantages are the very expensive imaging plates
A B
Figs 3.3A and B: Spot film of duodenal cap of the same case showing
active ulcer crater with marked edema around the ulcer (arrows)
Chapter 3: Imagiology Studies 47
The former procedure is called intravenous inflammatory lesions of the urinary tract.
urography/pyelography (IVU/IVP) and the latter is Micturating cysto-urethrography (MCU) is done by
known as micturating cysto-urethrography (MCU). introducing dilute water-soluble contrast into the
The contrast media are tri-iodinated compounds bladder using a catheter which is removed
produced by substituting three hydrogen atoms of immediately. Exposures are made during voiding
an organic molecule with iodine, the organic to assess the lower urinary tract dynamically. MCU
molecule being basically the benzene ring. 127 Iodine is used to diagnose vesico-ureteric reflux, bladder
is responsible for the opacification and is found to outlet obstruction (congenital or traumatic)
be the most satisfactory element to be introduced neurogenic bladder, study the posterior urethra and
into sensitive organs like the kidneys, heart and look for posterior urethral valve (Fig. 3.4).
brain. Contrast media available earlier had their
Myelography
molecules in the solution in an ionized form. But
the currently available contrast media are nonionic, This is done to visualize the subarachnoid space
that is the anions and cations do not dissociate in along with spinal cord. Myelography is performed
the solution. The ionic media caused more reactions by injecting contrast into the subarachnoid space
than the newer nonionic media, which are better through a lumbar puncture (Figs 3.5A to C) or
tolerated by the patients after administration. After rarely a lateral cervical puncture. The oily contrast
IV injection, the contrast is removed from the blood materials used earlier have been completely
by glomerular filtration. It is not reabsorbed but replaced by safer water soluble nonionic media
A B C
Fig. 3.4: Micturating cystourethrogram showing large
trabeculated bladder with unilateral dilated ureter and Figs 3.5A to C: Myelography using water soluble contrast
pelvicalyceal system when dye is introduced by catheter. Reflux showing large bilateral lateral intervertebral disk prolapse at
is noted even during the bladder filling phase L3/4 (arrows)
48 Section 2: General Examination and Imagiology
diagnostic purposes is often combined with nausea, vomiting and urticaria to severe laryngeal
therapeutic maneuvers since most of the information edema, cardiac arrest or even death. Currently used
obtained by angiography can be obtained by less nonionic agents have remarkably reduced incidence
invasive procedures like ultrasonography, CT and of adverse effects. These reactions are not
MRI. anaphylactic but are termed anaphylactoid as the
severity of adverse reaction is not dose related as is
Digital Subtraction Angiography
the case in anaphylactic reactions. Hence every
Digital subtraction angiography (DSA) is made precaution to prevent and/or treat such adverse
possible due to the ability of modern angiography events should be taken whenever intravascular
machines to acquire data digitally which facilitates contrast agents are used. Complications peculiar to
easy storage, processing and retrieval. It is also arteriography are in addition to those relating to
possible to make masks before injection of contrast contrast agents. Some of the common complications
so that the masks can be subtracted from the contrast are directly related to arterial puncture and
image to get rid of dense bony parts like the skull, introduction of the catheter. They are local hematoma,
spine, etc. The digitally acquired image can be local sepsis, dissection, thrombosis of the artery,
manipulated using post-processing algorithms. pseudoaneurysms, AV fistula, etc.
The DSA is indispensable to the interventional
radiologist as catheter advancing and positioning ULTRASONOGRAPHY
can be observed real time and display of the
Part–I: Internal Medicine
color and can also measure velocities of flowing on a monitor. CT scanners have three basic
blood. Hence Doppler is an excellent method to components:
diagnose various lesions of the arteries and veins 1. The gantry which houses the X-ray source,
like stenosis, aneurysms, thrombosis, etc. Transducers detectors and high voltage generators.
with various frequencies are used depending upon 2. A patient couch to ‘feed’ the patient into the
the tissue to be imaged. Lower frequencies are used gantry.
to visualize deeper tissues and higher frequencies 3. Computer system with monitors for processing
for more superficial structures as penetrability is and display of images.
inversely proportional to the frequency. Thus, to Figures 3.7 and 3.8 show normal CT brain and
scan the abdomen, a 2 to 5 MHz transducer is used CT abdomen.
and to visualize the thyroid, a frequency range of Over the past almost four decades, CT
10 to 12 MHz is appropriate. Usually the images technology has advanced exceptionally both in the
obtained with an ultrasound machine is called a 2D
image. Now special transducers which can produce
3D images are also available. Ultrasound has the
advantage of being noninvasive, comparatively
cheap, easily reproducible and without the hazard
of ionizing radiations with no known ill effects or
discomfort to the patient. However, ultrasonography
COMPUTED TOMOGRAPHY
Computed tomography (CT) was invented by Sir
Godfrey Hounsfield and was first used in 1972. First
CT scanners could only be used to scan the brain as
scan times were prolonged and could not scan
moving structures. The basic principle of CT is
that the internal structure of an object can be
reconstructed from multiple projections of the
object. The energy used in CT is X-ray. Thin beam
of X-ray is passed through the body from various
angles of 180 to 360 and the emerging X-ray
photons are picked up by an array of detectors. The
signals from the detectors are processed by a
powerful computer to reconstruct the image using
Fig. 3.8: CT abdomen with oral and IV contrast. Liver, stomach,
mathematical algorithms into slices of desired kidneys, aorta, inferior vena cava and pancreas are seen in this
thickness. The reconstructed images are displayed picture (serially numbered 1–6)
50 Section 2: General Examination and Imagiology
development of high capacity X-ray tubes and With the advancement of spiral or helical CT,
tremendous computer power such that the scanners there are no areas of the human body, which cannot
have become extremely fast with scan times as low be imaged using this technology. Helical scanning
as 250 milliseconds as compared to the scan times with very fast acquisition times and advanced
of the original scanners which took more than 5 detector designs have made 2D and 3D reconst-
minutes for one slice. Instead of sequential single ructions and CT angiography (CTA) extremely
slices obtained by earlier scanners, helical scanning simple and effective. Reconstructed 3D images can
with multiple row of detectors has made acquisition be rotated in any desired direction for viewing and
of a volume of tissue in thin slices, as thin as 0.25 analysis. Softwares are available for making various
mm possible so that exquisite 3D images of any measurements like percentage of stenosis, length of
organ can be reconstructed. CT can be used in a stenotic segment, etc. Straightening out tortuous
variety of clinical conditions, ranging from trauma, portions of an artery, like coronary vessels, can
inflammatory and neoplastic conditions to also be done with virtual vascular endoscopy.
noninvasive coronary imaging. (Figs 3.9 to 3.11)
Part–I: Internal Medicine
Fig. 3.9: CT brain showing intracranial hemorrhage Fig. 3.11A: Plain CT showing ill-defined hyperdense lesion
with intraventricular extension in the left posterior parietal area (arrow)
Fig. 3.10: Frontal meningioma. Contrast CT brain showing Fig. 3.11B: Postcontrast CT of the same case showing
marked enhancement of the tumor (arrow) serpiginous vascular channels in the posterior parietal area
typical of arteriovenous malformation (arrow)
Chapter 3: Imagiology Studies 51
CT Angiography
CT angiography (CTA) is a noninvasive procedure
which can be used to study the arteries and veins of
any part of the body. Usually about 100 ml of water
soluble contrast is injected intravenously at a high
rate (2–5 ml/sec) using a pressure injector and
images can be acquired in the arterial and venous
phases. The exposures can be triggered automatically
by programming the machine when the contrast
reaches a particular concentration in the desired
artery (Figs 3.12 to 3.14).
as far as is understood has no ill effects on the human oscillating pulse of a matching radio frequency is
body. Now let us try to understand the term MRI. applied on the group of protons, there is a strong
interaction or resonance. This phenomenon is called
The Magnet (M) magnetic resonance. In the interaction, energy is
This is the most important component of the absorbed by the protons causing a change in
equipment and its strength is measured in Tesla. direction of their magnetic field. The angle of
The machines in use at present have field strengths deviation of the magnetic field depends on the
of 0.2 to 9 tesla. The basic unit of magnetism is strength and duration of the pulse. Usually 90 degree
Gauss (1 tesla =10,000 gauss). The earth’s magnetic and 180 degree pulses are used. When the signal is
field is 0.5 gauss. So it is evident how powerful the turned off, the nuclei come back to their original
magnets are. There are different types of magnets equilibrium and in the process release energy. This
like permanent magnets, resistive magnets and induces a small voltage in a receiver coil kept near
superconductor magnets. Permanent magnets are the patient. This signal is called the free induction
very heavy and large hence only smaller field decay (FID). The magnitude and length of the signal
strengths are practical. Resistive magnets need is determined by the nuclear relaxation times. First
constant supply of large current without interruption of these relaxation times is T1 which is the
and not commonly used. Today, large field strength longitudinal relaxation time and is the time taken
magnets are superconductors. Superconductivity is by nuclei to return to thermal equilibrium. T2 is
a phenomenon in which there is zero resistance to transverse relaxation time, that is the characteristic
Part–I: Internal Medicine
the flow of current when certain materials are cooled time of FID. T1 and T2 are important determinants
to near absolute zero (about 4 K). This means that of tissue contrast. The pulse has two selectable
when an electric current is passed through the times which are called TR and TE. TR is the time
material to achieve the desired magnetic strength, interval between two 90 degree pulses or Time
the current will continue to flow even when the Repetition. TE is the time interval between the
external power supply is turned off. The extreme middle of a 90 degree pulse and the middle of a 180
cooling is achieved by immersing the magnet in degree pulse. Typical TR intervals are between 500
liquid helium in an evacuated stainless steel to 3000 ms and TE intervals range from 30 to 150
container. ms. When a short TR and short TE are used a T1
weighted image is obtained and a long TR and long
Resonance (R) TE results in a T2 weighted image. Various tissues
Nuclei of certain atoms like hydrogen when placed in the body have different relaxation times. For
in a strong magnetic field absorb and emit energy example, T1 of brain tissue is short and that of CSF
of a specific frequency. Hydrogen atoms have a is long. So in a T1 weighted sequence, the brain
single proton in their nuclei and so possess a net will appear bright but the CSF will appear dark as
charge and angular movement. Hydrogen atoms its T1 is long. This means that brain will give a
are abundant in the body and behave like freely signal earlier than CSF in T1. The reverse is true
suspended small bar magnets spinning rapidly with T2. Here CSF will appear bright and the brain
about their magnetic axes. Other atoms which have will appear dark. Once the signals are collected by
the same property are sodium, phosphorus, carbon, the rf coils, these are processed by the computer in
etc. Rare gases like helium and xenon can be made a complex mathematical analysis called Fourier
sensitive to the same phenomenon and can be used analysis and the transformation of the signals to the
in the study of the airways and for blood perfusion visual image is called Fourier transformation. Slices
respectively. The hydrogen nuclei when placed in of desired thickness are obtained by selective
an external magnetic field align themselves in the excitation by the application of a gradient field
direction of the magnetic field and continue to during the rf pulse so as to isolate the plane of
rotate in the same frequency about the magnetic interest. The main magnetic field opposes the
field. This is called “precession”. The frequency is gradient field and the noise that is heard in the MR
directly proportional to the external magnetic field machine is due to this. The higher the field strength
and is called the Larmor frequency. When an of the main magnet, the more will be the noise which
Chapter 3: Imagiology Studies 53
can reach as high as 85 dBS. Patients need to be radiopharmaceuticals contain99m technetium which
offered ear plugs to reduce the discomfort. Other is tagged with various molecules to make them organ
imaging techniques using MR are MR angiography, specific. Other radionuclides include 123iodine, and
MR spectroscopy, functional MRI, etc. Paramagnetic 131
iodine,11carbon, 13nitrogen, 15oxygen, 18 fluorine, etc.
substances like chelates of gadolinium are injected There are two types of imaging in nuclear medicine,
intravenously and these substances alter the signal they are SPECT and PET.
intensities by reducing the T1 and T2 relaxation
times to varying extents in various tissues. Single Photon Emission
Computed Tomography
Safety and Hazards
Single photon emission computed tomography
MRI produces no ill effects on the body. But (SPECT) involves detection of gamma rays singly
remaining still for considerable period of time inside from a radionuclide like 99m technetium or 201 thallium
the closed tunnel like gantry with all the noise cannot to produce a tomographic image.
be tolerated by many who are claustrophobic.
Magnetic substances like pacemakers, orthopedic Positron Emission Tomography
devices like plates and joint implants, aneurysms These equipments are designed to detect paired
clips, etc. are absolute contraindication for doing photons which are 180 degrees apart emitted by the
MRI as these can act as dangerous missiles in the annihilating positron. There is a ring of detectors
high magnetic field. The MR contrast media are made of bismuth germinate. These are designed to
3
Alimentary System
CHAPTER
KR Vinaya Kumar
time for food from stomach to the cecum is Table 4.1: Peptide hormones of the gastrointestinal tract
2.5 to 3.0 hours. The progress of a radiopaque 1. Gastrin
contrast material can be followed up from the mouth 2. Cholecystokinin
to the anal canal by radiography (barium meal). 3. Secretin
4. Vasoactive intestinal polypeptide (VIP)
GUT FLORA 5. Glucagon
6. Glucose dependent insulinotropic polypeptide
It is a complex microbial ecosystem, colonizing the 7. Pancreatic polypeptide
gut wall, living together in harmony in the gut. In 8. Substance P and the tachykinins
health, these microbes are prevented from entering 9. Somatostatin
the systemic circulation by natural mucosal and other 10. Motilin
11. Leptin
defense mechanisms.
12. Ghrelin
Colonization of GI tract of newborn infants
starts immediately after birth and occurs within a
few days. (neurocrine) or autocrine. Specialized signaling
The composition of gut flora varies from mouth cells that secrete transmitters into the blood are
to the colon. The intestinal mileu favors the growth known as endocrine cells. The transmitters they
and multiplication of several microbes, both aerobic produce are called hormones (Table 4.1).
and anaerobic. The milieu in the cecum and
PATTERN OF ALIMENTARY DISEASES
Part–I: Internal Medicine
In addition, alimentary tract is a common site is still an important problem. Cirrhosis and hepato-
for lymphomas, particularly ileocecum, stomach and cellular carcinomas are increasing. Widespread
rectum. use of drugs such as aspirin, non-steroidal anti-
Changing Pattern of the Diseases inflammatory drugs (NSAIDs), statins, cortico-
steroids and others are causing gastrointestinal
Esophageal cancers are becoming increasingly
common now and are observed more in the lower problems such as gastritis, bleedings and other GI
end than in the middle third. Chronic calcific emergencies. Diseases such as non-alcoholic fatty
pancreatitis, pancreatic neoplasms and colonic infiltration of the liver, alcohol related problems and
neoplasms are on the increase. Ulcer disease due to others are also showing an increasing trend.
H. pylori is increasingly being encountered. Reflux However, intestinal tuberculosis, amebic liver
disease, irritable bowel syndrome and inflammatory abscesses and tropical sprue are showing a
bowel diseases are also increasing. Viral hepatitis decreasing trend.
Symptoms in Alimentary
51 Diseases
KR Vinaya Kumar
Dysphagia, Dyspepsia, Heartburn, Vomiting, Diarrhea, Constipation, Alteration of bowel habits, Flatulence,
Gastrointestinal (GI) bleed, Hematemesis, Melena, Hematochezia, Bleeding per rectum (PR), Abdominal
pain, Abdominal distension, Jaundice, Pruritus, Steatorrhea, Weight loss, Fever
The important symptoms in gastrointestinal diseases Table 5.2: Common causes of dysphagia
are given in Table 5.1. Oropharyngeal dysphagia Esophageal dysphagia
Structural Causes Motility Disorders
Table 5.1: Important symptoms in GI diseases Carcinomas Achalasia
Dysphagia Zenker’s diverticulum Diffuse esophageal spasm
Dyspepsia Webs Nutcracker esophagus
Heartburn Prior surgery/radiation Spasm of lower esophageal sphincter
Vomiting Infections of pharynx/neck Ineffective esophageal motility
Diarrhea Thyromegaly Scleroderma
Constipation Areal dysphagia Reflux-related dysmotility
Alteration of bowel habits
Neuromuscular causes Structural disorders
Gastrointestinal (GI) bleed
Hematemesis, melena, Stroke Tumors
Hematochezia, bleeding per rectum (PR) Parkinson’s disease Peptic stricture
Abdominal pain, flatulence Myasthenia gravis Lower esophageal (Schatzki) ring
Abdominal distension Multiple sclerosis Other esophageal rings and webs
Jaundice Myopathies Diverticula
Pruritus CNS tumors Medication induced strictures
Steatorrhea, weight loss, fever Motor neuron diseases Foreign bodies
Gastrointestinal (GI) bleed after flatulence Extrinsic compression
DYSPEPSIA
Table 5.4: Important causes of vomiting
Dyspepsia is the persistent pain or discomfort GI causes Non-GI causes
centered in the upper abdomen of more than three Obstructive disorders Cardiopulmonary
months duration. This is one of the common Pyloric stenosis Cardiomyopathy, myocardial infarction
symptoms in gastroenterology. Dyspepsia may be Intestinal obstruction
caused by many factors like foods, medications, Superior mesenteric
artery syndrome
systemic disorders and disorders of the GI tract.
GI infections Labyrinthine diseases
Fifty to seventy percent of the patients with chronic Viral Motion sickness
dyspepsia do not have a focal or structural lesion Bacterial Labyrinthitis
identifiable at upper GI endoscopy. Dyspepsia Inflammatory diseases Intracerbral disorders
requires detailed evaluation when there are alarm Cholecystitis, pancreatitis Abscess, hemorrhage, malignancy,
symptoms (Table 5.3). appendicitis, hepatitis hydrocephalus, raised intracranial tension
Motility disorders
Table 5.3: Alarm symptoms in dyspepsia Gastroparesis Psychiatric illness
Weight loss Unexplained anemia Intestinal Depression, bulimia
Progressive dysphagia Jaundice pseudo obstruction Postoperative
Persistent vomiting Lymphadenopathy Functional vomiting Drugs
Gastrointestinal bleed Palpable abdominal mass Abdominal irradiation Metabolic/endocrine toxins
62 Section 3: Alimentary System
Table 5.9: Common causes of constipation Table 5.10: Five ways of bleeding from GI tract
Colonic obstruction Neoplasm, stricture, ischemia, diverti- 1. Hematemesis: Vomitus of fresh red blood or coffee ground
culae, inflammatory diseases material
Anal sphincter spasm Anal fissure, painful hemorrhoids 2. Melena: Altered partly digested blood which makes the stool
Irritable bowel syndrome Constipation predominant, alternating tarry and foul smelling
type 3. Hematochezia: Passage of bright red or maroon blood from
Medications Calcium channel blockers, anti- rectum
depressants, anticholinergics, opioid
4. Occult GI bleed: Not visible to the naked eye, but identified by
agonists, iron supplements
testing for occult blood in faces or the presence of iron deficiency
Colonic pseudo obstruction Slow transit constipation, megacolon anemia
Disorders of rectal evacuation Pelvic floor dysfunction, descending
5. Symptoms of blood loss and anemia
perineum syndrome, rectal mucosal
prolapse
Endocrinopathies Hypothyroidism, hypercalcemia, Hematemesis indicates an upper GI site of
pregnancy
bleeding. If the bleeding is slow and blood remain
Psychiatric disorders Depression
Neurological diseases Parkinsonism, multiple sclerosis,
in contact with gastric acid for sometime the
spinal cord injury, raised intracranial colour turns brownish black and is described as
tension in children coffee ground vomitus.
Progressive systemic sclerosis
Generalized muscle disease The black tarry character of melena results from
the partial digestion of blood to acid hematin or
Table 5.12: Assessment of patients with upper GI bleed Differentiation between upper and lower
Table 5.15:
Hemodynamic status Blood loss % Severity of bleed GI bleed
Shock (resting hypotension) 20–25 Massive Features Upper GI bleed Lower GI bleed
Postural (orthostatic Site Above the ligament Below the ligament
hypotension and tachycardia) 10–20 Moderate of Treitz of Treitz
Normal <10 Mild Presentation Hematemesis Hematochezia
/melena
identified, malignancy
by which patient presents to a gastroenterology
No stigmata clinic (Tables 5.16 and 5.17).
of recent Types of abdominal pain:
hemorrhage
(SRH) 1. Parietal pain arises from the abdominal wall,
Signs of None or dark Blood in upper peritoneum or surface of solid organs—steady
recent spot only GI tract and aching in character and is located over
hemorr- Adherent clot the inflamed area. The pain of peritoneal
hage Visible or
(SRH) spurting vessel
The following details about the pain must be
Table 5.16:
asked for
Table 5.14: Forrest classification 1. Site 6. Duration
Type I: Active bleeding Ia: Spurting hemorrhage 2. Mode of onset 7. Frequency
Ib: Oozing hemorrhage 3. Intensity 8. Aggravating or relieving factors
4. Character and constancy 9. Associated features
Type II: Stigmata of IIa: Non bleeding 5. Areas of radiation
recent hemorrhage visible vessel
IIb: Adherent clot Characteristics of pain arising from important
IIc: Flat pigmentation Table 5.17:
intra-abdominal organs
Type III: Clean Peptic ulcer Epigastric, burning or gnawing, meal related,
based ulcer wakes the patient, relieved by antacids
Gastric cancer Epigastric, severe, partly meal related, not relieved
The Forrest classification of peptic ulcer by antacids
bleed is used to classify the rate of rebleeding Pancreatic High epigastric, severe, felt front to back, immedi-
ately after eating, relieved by sitting forwards
(Table 5.14).
Midgut Periumbilical, colicky, some relation to meals
HEMATOCHEZIA Lower gut Periumbilical or suprapubic, colicky, some relief
from bowel action
If the blood is bright red and is separates from the Biliary Right upper quadrant, severecolicky (over long
stool, it usually indicates a source in the sigmoid time period), radiates to right shoulder, accom-
panied by nausea
colon, rectum or anal canal, hemorrhoids being
Renal colic Loin to groin, colicky (shorter duration compared
the commonest cause. If the blood is dark red and to biliary colic), very severe, accompanied by
mixed with the stools, this usually indicates a nausea
source above the rectum. Carcinoma is the most Functional Anywhere in the abdomen, colicky, accom-
important cause. Approximately 10% of the patients panied by bloating, relieved by bowel action
Chapter 5: Symptoms in Alimentary Diseases 65
Table 5.19: Systemic conditions associated with pruritus Table 5.22: Causes of anorexia
Cholestasis Thyroid disease Local causes Gastritis
Malignancy Polycythemia vera Gastric lymphoma
Chronic renal disease Delusions of parasitosis Gastric carcinoma and
Pregnancy Drug reactions other upper GI malignancies
Gastric ulcer
bile salts in blood may be the cause of this symptom. Atrophic gastritis
In many cases, the severity of jaundice and extent Systemic illnesses Infections like tuberculosis
of pruritus do not directly correlate. Several other Cirrhosis, hepatic failure, renal failure
Drugs like fenfluramine
systemic diseases (lymphomas, chronic kidney Psychological factors Anxiety
disease, allergic conditions and others also lead to Depression
generalized pruritus) (Table 5.19). Anorexia nervosa
tends to stick to the hand and have a greasy feel cultural and psychosocial factors also influence
after normal washing (Table 5.20). the regulation of appetite.
CONSTITUTIONAL SYMPTOMS IN GI DISEASES
Weight Loss
Anorexia: This term refers to loss of appetite. It Unintentional loss of 10% of body weight over 6
often indicates an important pathology, particularly to 12 months is significant. Mechanisms of weight
in the upper GI tract. Appetite and metabolism are loss include decreased food intake, malabsorption,
regulated by a delicate network of neural and loss of calories and increased energy requirement
hormonal factors. Hypothalamic feeding and (Tables 5.24 and 5.25).
satiety centers play a central role in these processes
(Tables 5.21 to 5.23). Fever
Table 5.20: Causes of steatorrhea Fever may be associated with GI infections, hepatitis,
Intraluminal maldigestion cholangitis, lymphoma and others.
Chronic pancreatitis
Cystic fibrosis of the pancreas
Table 5.24: Mechanisms of weight loss
Pancreatic duct obstruction
Somatostatinoma Decreased caloric intake Caloric loss Increased energy
Small intestinal bacterial overgrowth (SIBO) expenditure
Mucosal malabsorption Socioeconomic factors Malabsorption Hypermetabolic states
Celiac disease (poverty) Movement disorders
Tropical sprue Anorexia Excessive exercise
Whipples’s disease
Medications
Abetalipoproteinemia
Difficulty in eating
Postmucosal lymphatic obstruction (surgical conditions)
Congenital intestinal lymphangiectasia Cytokines
Acquired lymphatic obstruction Depression/dementia
Table 5.21: Central controllers of appetite
Table 5.25: Causes of unexplained weight loss
Increases Decreases
Depression/anxiety
NPY (Neuropeptide Y) MSH (Melanocyte stimulating Chronic pain or sleep deprivation
hormone)
Psychosocial deprivation/malnutrition in the elderly
MCH (Melanin concentrating hormone) CART (Cocaine and
Existing conditions like COPD/cardiac failure, diabetes mellitus
AgRP (Agouti related peptide) Amphetamine related
Orexin transcript) hyperthyroidism
Endocannabinoid GLP-1 (Glucagon-related Occult malignancies in the proximal colon/renal/lymphoma
peptide) Anorexia nervosa in atypical group, e.g. young men
Serotonin Endocrine diseases like Addison’s disease, panhypopituitarism
CHAPTER
KR Vinaya Kumar
General examination, Oral cavity, Physical examination of the abdomen, Surface marking of the abdominal
organs, Palpitation, Percussion, Auscultation of the abdomen, Examination of the genitalia, Anus and
rectum, Appendix-1: Clinical points to identify abdominal masses, Appendix-2: Common causes of
enlargement of abdominal organs
GENERAL EXAMINATION Table 6.2: Body mass index and body habitus
<18 Underweight
Nutritional Status (Tables 6.1 to 6.4) 18-25 Ideal weight
>25-30 Overweight
Proper nutrition depends on normal function of the
>30-40 Obese
alimentary tract. Diseases which lead to vomiting,
>40 Super obese
diarrhea or dysphagia lead to starvation and severe
Table 6.3: GI causes of clubbing
malnutrition. Bleeding from benign and malignant
ulcers lead to iron deficiency anemia, e.g. carcinoma Cirrhosis of liver, amebic abscess liver
Inflammatory bowel diseases
stomach, inflammatory bowel diseases, hemorrhoids GI malignancy
and others. On the other hand, several nutritional
Table 6.4: Peripheral stigmata of chronic liver disease (CLD)
disorders such as kwashiorkor and pellagra lead to
• Alopecia
diarrhea.
• Parotid enlargement
There is no single tool that is an accurate • Fetor hepaticus—characteristic sweet smelling breath
predictor of nutritional status. The subjective global • Palmar erythema seen on thenar and hypothenar eminence often
assessment (SGA), a comprehensive nutritional with blotchy appearance
• Leukonychia—nail appears pale and opaque
Table 6.1: Subjective global analysis (SGA) • Dupuytren’s contracture—usually affects palm and rarely plantar
History fascia. There is localized thickening of palmar fascia mainly on the
Weight change medial part, which leads to flexion of ring finger and to some extent
Dietary change the little finger. Exact cause is not known.
Gastrointestinal symptoms • Bruising, gynecomastia, paucity of axillary and pubic hair
Functional capacity • Spider naevi—small telangiectatic superficial blood vessels with
Disease and relation to nutritional requirements central feeding vessel—an arteriole
Physical examination • Asterixis (flapping tremor)—failure to actively maintain posture or
Subcutaneous fat position
Muscle wasting • Eye signs mimicking hyperthyroidism
Ankle edema • Signs of chronic cholestasis
Sacral edema
• Pruritus
Ascites
SGA rating • Scratch marks
A—Well nourished • Xanthelasma
B—Moderately malnourished • Clubbing
C—Severely malnourished • Shiny nails
68 Section 3: Alimentary System
preferably in direct or artificial sunlight. If the cause of ascites is right-sided heart failure,
Differential diagnosis is yellowish staining of the JVP will be raised and hepato jugular reflux
the skin seen in carotinoderma which (spares sclera) can be elicited. In Budd-Chiari syndrome, hepato
and exposure to quinacrine or phenol. jugular reflux will be absent due to obstruction to
Hemolytic jaundice leads to a lemon yellow the hepatic veins.
tinge. In obstructive jaundice, the color is dark Asterixis is caused by the abnormal function of
yellow or with an orange tinge. There may be motor centers that regulate the tone of the agonist
scratch marks due to itching evoked by bile salts. and antagonist muscles normally involved in main-
taining posture. This can be elicited by two methods:
Cyanosis 1. Classic method: Elicited by dorsiflexion of the
Hepatopulmonary syndrome can lead to central patient’s hand, with arms outstretched and
cyanosis less commonly. Vast majority of cyanosis fingers separated. The postural lapse that
are caused by cardiac, respiratory and other diseases. occurs consists of a series of rapid, involuntary,
flexion-extension movements of the wrist.
2. Alternative method: Ask the patient to clench
his fingers around the examiner’s fingers.
Asterixis can be appreciated by the subtle
movements of the patient’s wrist.
Constructional apraxia is the phenomenon in
which the patient is not able to perform complex
acts requiring sequential regulated action, in the
absence of any demonstrable motor paralysis. This
can be seen in minimal hepatic encephalopathy.
Constructional apraxia can be elicited with Reitan
number connection test (Refer Neurology).
Other Clinical Signs that may be Seen in
GI Disorders
Signs of Malabsorption
Fig. 6.1: Jaundiced sclera in moderately severe jaundice.
Note: The level of serum bilirubin and depth of icterus do not Malabsorption has to be suspected in a person who
directly correlate loses weight despite taking adequate amounts of
Chapter 6: Physical Examination of the Alimentary System 69
food and in the vast majority of cases associated diseases has to depend on contrast imaging (barium
with large bulky greasy stools with or without swallow) and endoscopy.
diarrhea. Malabsorption leads to nutritional defici-
encies characterized by Bitot’s spots, stomatitis, PHYSICAL EXAMINATION OF THE ABDOMEN
angular cheilitis, aphthous ulcers, acrodermatitis, REGIONS (FIG. 6.2)
hyperkeratosis, muscle wasting, koilonychia and
Abdomen can be arbitrarily divided into 9 regions
others.
by two lateral vertical planes passing from femoral
Other findings picked on general examination artery below to cross the costal margin close to the
which point to gastrointestinal disease include tip of ninth costal margins. Two horizontal planes
pigmentation of the lips in Peutz-Jeghers syndrome, the subcostal and inter-iliac, pass across the
Kayser-Fleischer ring in Wilson’s disease, leg ulcers abdomen to connect the lowest points on the costal
in inflammatory bowel disease, lipemia retinalis in margin and tubercles of iliac crests respectively.
diabetic ketoacidosis, Purtschers retinopathy Figure 6.2 gives the regions of the abdomen.
(discrete flame-shaped hemorrhages with cotton
wool spots) seen in acute pancreatitis and others. Inspection
Malignancy of internal organs may give rise to Patient should be lying supine with the arms on the
superficial markers. This include: sides, on a couch or mattress, the head and neck
Acanthosis nigricans: It is the velvety hyper-plasia supported by pillows comfortably. The examiner
Oral Cavity
Mouth and throat should be examined using a pen
torch and tongue depressor. Examine systematically
the inner and outer surfaces of the lips, angles of the
mouth, gingiva, teeth, floor of the mouth, upper and
lower surface of the tongue, tonsils, palate and
pharynx. The tongue should be protruded to bring
its posterior third into view. Gentle pressure on the
anterior aspect of the relaxed tongue held in mouth
will enable the inspection of the oropharynx, part of
the nasopharynx and down to the epiglottis.
Swallowing has to be enquired into and any
symptom of dysphagia and odynophagia has to be
Fig. 6.2: Regions over the abdomen. (1) right hypochondrium,
checked by making the patient swallow liquids and
(2) epigastrium, (3) left hypochondrium, (4) right lumbar region,
solids respectively. Since the esophagus is a deeply- (5) umbilical region, (6) left lumbar region, (7) right iliac fossa,
placed structure, further investigation of esophageal (8) hypogastrium, and (9) left iliac fossa
70 Section 3: Alimentary System
Generalized fullness or distension is seen in obesity Purple striae are seen in Cushing syndrome or
and ascites. Localized fullness which is symmetri- as a complication of prolonged corticosteroid
cal and centered around umbilicus is seen in small therapy.
bowel obstruction. Asymmetrical fullness may
be caused by organomegaly such as liver, ovary or Scars: Their site and whether they are old (white)
other masses. Extremely sunken abdomen is seen in or recent (red or pink) should be noted. Thinned
advanced starvation, malignancy and cachexia. out scars are likely to be weak and they may be the
sites for development of incisional hernias.
Umbilicus
Pigmentation
Normal umbilicus is inverted and retracted. It is
everted in umbilical hernia, vertical in pelvic or Erythema ab igne is brown mottled pigmentation
ovarian tumours and horizontal in ascites. produced by constant application of heat usually
by hot water bottle or heat pad. It may be a sign that
Movements of Abdominal Wall the patient is experiencing severe ongoing pain such
Normally there is a gentle rise in inspiration and as trophic ulcers, chronic pancreatitis and other
fall during expiration. Movements should be free lesions.
and equal on both sides. In peritonitis the abdomen Linea nigra is pigmentation in the midline below
is still or silent. umbilicus, seen in pregnancy.
Visible Pulsations Grey Turner’s sign is bluish discoloration of loins
or flanks, seen in acute hemorrhagic pancreatitis.
In normally nourished individuals pulsations other Cullen’s sign is bluish discoloration of periumb-
than the aortic pulsations are not visible. Abdominal
ilical region seen in acute hemorrhagic pancreatitis.
aortic pulsations may be visible in the epigastrium.
This may be felt as arterial pulse and is not Prominent Superficial Veins
expansile. It must be differentiated from aneurysm
of abdominal aorta where the pulsations are more In normal individuals, veins are not seen prominently
obvious, extensive and is felt on palpation (expansile over the abdominal wall. Their presence underlies
pulsation). abnormalities in drainage or underlying disease
process. Thin veins over the costal margins are of
Visible Peristalsis no significance.
Visible gastric peristalsis: Occurs when there is Classically distended veins over the abdominal
obstruction at the pylorus caused by stricture wall occurs in portal hypertension (PHT) and
Chapter 6: Physical Examination of the Alimentary System 71
Fig. 6.4: Direction of blood flow in veins on the abdominal wall. (1) Obstruction to superior vena cava,
(2) Obstruction to inferior vena cava, and (3) Obstruction to portal vein-caput medusae
obstruction to the inferior vena cava (IVC). The umbilicus to one side, as in the case of tumors arising
direction of blood flow in the veins should be noted. from the iliac fossae.
Distended veins radiating from the umbilicus
Liver
Place the flat of the hand parallel to the right
subcostal margin lateral to the rectus abdominis with
fingers pointing upwards towards the ribs. Exert
gentle pressure and ask the patient to breathe in
deeply. Palpate for the edge of the liver which can
be felt moving downwards and under the examining
hand. Repeat this from lateral to medial regions to
trace the liver edge as it passes upwards to cross Fig. 6.7: Palpation of the liver for expansile pulsation
from right hypochondrium to epigastrium.
Alternatively, place the right hand below and Table 6.8: Causes of hepatomegaly
parallel to the right subcostal margin. The liver edge Soft, smooth, tender liver Congestive cardiac failure, acute viral
will then be felt against radial border of the index hepatitis, amebic hepatitis, cholangitis,
septic conditions
finger. Avoid placing hand over rectus abdominis.
Firm and regular Fatty liver/chronic obstructive jaundice
Do not begin palpation too close to costal margin. Early stages of cirrhosis
Fig. 6.8: Palpation of spleen with the patient lying in Thalassemia Hemangiomatosis
the right lateral position with thigh flexed Chronic malaria, leishmaniasis
Chapter 6: Physical Examination of the Alimentary System 75
Urinary Bladder
Normally urinary bladder is not palpable when
empty. In thin individuals, even a normally distended
bladder is visible and palpable. It is palpable as a
smooth, firm, regular, oval-shaped swelling in the
suprapubic region and its dome may reach even as
far as the umbilicus (Table 6.6). The borders are
rounded. The lateral and upper border can be readily
made out, lower border cannot be felt. In normal
persons, the mass disappears on micturition. It should
be differentiated from:
1. Gravid uterus: It is firmer, mobile side-to-side
and is felt as a solid persistent mass.
2. Fibroid uterus: When the size is moderate or
Fig. 6.9: Bimanual palpation of right kidney large the uterus may be palpable to varying
See text for details heights above the symphysis pubis. The uterus
Kidneys
is firm, nontender and irregular in contour.
Bimanual technique is used for palpating kidneys. 3. Ovarian cysts: These presents as a mass (at
C D
Vibrations caused by tapping the abdomen in tense and when they come back to the cyst wall, a
ascites will be transmitted across the fluid to the characteristic sensation is felt. This is hydatid thrill.
opposite side. These vibrations (called fluid thrill)
can be appreciated by palpation. At least 2000 mL AUSCULTATION OF THE ABDOMEN
of free fluid should be present to elicit this thrill. The following findings are looked for by auscult-
Method: Sharply tap the abdomen at the flank by ation:
the fingers of the right hand while palpating the 1. Bowel sounds 2. Succussion splash
opposite flank with the left palm. Thrill can be 3. Arterial bruit 4. Venous hum
appreciated At times when the abdomen is fatty the 5. Friction rubs.
adipose layer may transmit the thrill. This is avoided
Bowel Sounds
by placing the patient’s hand on the abdomen to
interrupt the vibrations. An alternate method is to The stethoscope should be placed on one site on the
elicit the thrill diagonally in which direction the abdominal wall (just to the right of the umbilicus is
adipose layer does not transmit the thrill. This sign the best) and kept until the sounds are heard.
may not always be reliable. Normal bowel sounds are heard as intermittent low
or medium pitched gurgles interspersed with an
Puddle Sign
occasional high pitched noise or tinkle. Bowel
This sign is elicited to detect the presence of mild sounds heard with unaided ear are called
ascites around 250 mL. It can be elicited by borborygmi. Increased bowel sounds with colicky
percussion or ausculto-percussion in the knee elbow pain is pathognomonic of small bowel obstruction.
position in which the anterior abdominal wall In between bouts of colicky pain, the bowel is quiet
becomes most dependent and even small quantities and no sounds are audible (Table 6.13).
of fluid collect around the umbilicus and produce
dullness. Table 6.13: Abnormalities of bowel sounds on auscultation
Method Increased bowel sounds Absent bowel sounds
Small bowel obstruction Paralytic ileus
1. Percussion: The patient is made to lie in the
Malabsorption Peritonitis
prone position for five minutes and then assume
Severe GI bleeding
the knee elbow position. Dullness to percussion
Carcinoid syndrome
around the umbilicus is evidence of fluid
Chapter 6: Physical Examination of the Alimentary System 79
Table 6.14: Causes of succussion splash Table 6.17: Causes of splenic rub
Succussion splash seen in Splenic rub may be heard in:
Pyloric stenosis • Chronic myeloid leukemia
Advanced intestinal obstruction • Infective endocarditis
Paralytic ileus • Sickle cell anemia
Normal stomach within two hours after the meal • After splenic puncture
APPENDIX-2
Common Causes of Enlargement of Abdominal Organs
Investigations in
7
1 Gastrointestinal Disorders
KR Vinaya Kumar
Examination of feces, Examination of vomitus, Ascitic fluid analysis, Radiology of GI tract, Ultrasound
scanning, Computed tomography, Magnetic resonance imaging, Gastrointestinal endoscopy, Manometry,
Radioisotope studies, Helicobacter pylori, Gastric secretory studies, Tests used in pancreatic diseases,
Studies for malabsorption states, Tumor markers, Fine needle aspiration cytology, Laparoscopy
of fecal suspension is added to 1ml of orthotoluidine Presence of fat globules and muscle fibers in
solution in glacial acetic acid. 0.25 ml of hydrogen feces indicate malabsorption states. Charcot-Leyden
peroxide is added to this mixture. A dark green color crystals are seen in chronic ulcerative lesions of
which develops within 3 minutes indicates positive intestine such as chronic dysentery and ulcerative
reaction for occult blood. colitis.
Causes for False-Positive Tests EXAMINATION OF VOMITUS
Exogenous Peroxidase Activity
Examination of whole of the vomitus is important.
• Red meat (nonhuman hemoglobin) Carefully look for the presence of blood (hemate-
• Uncooked fruits and vegetables (vegetable mesis), bile (bilious vomiting), parasites like round
peroxidase) worms, food particles and toxic substances like
• Any other source of GI blood loss (e.g. epistaxis, drugs and poisons. Vomitus containing undigested
gingival bleeding, upper GI tract pathology,
food materials taken 4 to 6 hrs previously indicates
hemorrhoids)
• Medications: Iron, vitamin C, NSAIDs.
Causes for False-Negative Tests
Storage of Slides
• Degradation of hemoglobin by colonic bacteria
Part–I: Internal Medicine
Fig. 7.5: Ova in stools. (1) Trichuris trichiura, (2) Ascaris lumbricoides—embryonated egg, (3) Hookworms, (4) Enterobius
vermicularis, (5) Taenia (tapeworm), (6) Schistosoma hematobium, (7) Schistosoma japonicum, and (8) Schistosoma mansoni
gastric outlet obstruction or gastroparesis. Altered substances and drugs when poisoning is suspected.
blood in the vomitus gives rise to coffee ground It is important for medicolegal purposes.
appearance. If there is any doubt, presence of blood
should be confirmed by chemical examination. Fecal ASCITIC FLUID ANALYSIS
odor of the vomitus indicates gastrocolic fistula or Aspiration of peritoneal fluid is undertaken for
hind gut obstruction. A sample of the vomitus should diagnostic and therapeutic purposes. Site of
be sent for chemical examination for toxic aspiration is preferably two finger breadth
86 Section 3: Alimentary System
cephalad and two finger breadth medial to anterior Table 7.2: Other biochemical and microbiological tests
superior iliac spine in the left lower quadrant. Routine Optional Required in special situations
However, it can also be done in the midline below Cell count Culture in blood TB smear and culture
culture bottles
the umbilicus or in the right iliac fossa. In a
Albumin Glucose Cytology
patient with multiple abdominal scars, ultrasound
Total protein LDH Triglyceride
guidance aspiration may be safer (Fig. 7.8). The Amylase Bilirubin
fluid aspirated should be subjected to the following Gram stain
tests (Tables 7.2 to 7.4).
Table 7.3: Classification of ascitic fluid infections
Gross Appearance of Ascitic Fluid
• Spontaneous bacterial peritonitis
It may be watery when the protein concentration • Monomicrobial non-neutrocytic bacterial ascites
is low. It is transparent and slight yellow in • Culture-negative neutrocytic ascites
transudates with low cellular content. Cloudy • Secondary bacterial peritonitis
• Polymicrobial bacterial ascites (needle perforation of the bowel)
appearance is caused by neutrophils in ascitic fluid.
Chapter 7: Investigations in Gastrointestinal Disorders 87
1. A positive ascitic fluid culture for a single High Gradient ≥ 1.1 g/dL (11 g/L) Low Gradient <1.1 g/dL (11 g/L)
organism Cirrhosis Peritoneal carcinomatosis
2. An ascitic fluid polymorphonuclear (PMN) Alcoholic hepatitis Tuberculous peritonitis
Cardiac ascites Pancreatic ascites
count lower than 250 cells/mm3 (0.25×109/L)
Mixed ascites Bowel obstruction or infarction
3. No evidence of an intra-abdominal surgically
Massive liver metastases Biliary ascites
treatable source of infection.
Fulminant hepatic failure Nephrotic syndrome
Culture-negative neutrocytic ascites (CNNA) Budd-Chiari syndrome Postoperative lymphatic leak
is diagnosed when: Portal vein thrombosis Serositis in connective tissue
1. The ascitic fluid culture grows no bacteria diseases
2. The ascitic fluid neutrophil count is > 250 cells/ Sinusoidal obstruction syndrome
mm3 (0.25×109/L) Myxedema
3. No antibiotics have been given (not even a single Fatty liver of pregnancy
dose), and
4. No other explanation for an elevated ascitic fluid
neutrophil count (e.g. hemorrhage into ascites, be considered to have portal hypertension with an
peritoneal carcinomatosis, tuberculosis, or accuracy of approximately 97% (Table 7.4).
pancreatitis).
Contraindication for taking X-ray abdomen: (diatrizoate sodium). Unlike barium sulphate which
Viable pregnancy. has to be given in large quantities and which is
unpalatable, the iodinated compounds are more
Contrast Radiography pleasant to take. Moreover, they are less irritant
X-ray contrast studies are indicated in the following even when introduced into the peritoneum or body
conditions: cavities. Therefore, their main indications are in
1. To demonstrate anatomical abnormalities such as suspected perforation of esophagus, perforated
change in shape and size of hollow viscera, ulcers, duodenal ulcer, leaks from surgical anastomosis and
new growths, fistulae, strictures, diverticulae, acute diverticulitis.
blind loops, intrinsic or extrinsic compression of
Esophagus
normal viscera and the like.
2. To study abnormalities in motility of the gut: Barium swallow forms the initial investigation in
Passage of the contrast material can be followed esophageal evaluation. High density thick barium
up by serial radiographs, or on the fluorescent paste is swallowed and pictures are taken as the
screen. This will reveal abnormalities of gut contrast material fills the lumen and coats the
motility as in corkscrew esophagus and mucosal surface. These demonstrate anatomical
congenital megacolon, obstruction to flow as in abnormalities and motility disorders (Fig. 7.9).
pyloric stenosis and diagnostic changes in Malignancy of the esophagus is seen as an
intestinal hurry, malabsorption states and so on irregular filling defect and distal obstruction. The
Part–I: Internal Medicine
Fig. 7.9: Achalasia cardia barium swallow. Note dilated Fig. 7.10: Barium swallow corkscrew esophagus
esophagus above. Smooth narrowing of lower part (arrow) (due to spasm)
Chapter 7: Investigations in Gastrointestinal Disorders 89
Fig. 7.11: Barium meal showing narrowing of duodenal Fig. 7.12: Barium meal follow-through showing polyposis in
Enteroclysis (small bowel enema) is a technique colitis and the like. In ulcerative colitis, colon becomes
by which a tube is passed into jejunum under shorter with loss of haustrations and the mucosa
fluoroscopy and barium is given through the tube becomes granular. Fine mucosal ulcers can be seen.
directly into the jejunum. Small intestinal dilatation Later, pseudopolyps and strictures appear.
(more than 3 cm in diameter) is seen in mechanical Malignancy is often seen as filling defects-apple
and dynamic obstructions, diabetes, hypercalce- core deformity, or as strictures.
mia, postvagotomy state and in sprue. The mucosal
Selective Angiography
folds are thickened (more than 3 mm) in giardiasis,
strongyloidosis, lymphoma, Zollinger-Ellison The celiac and mesenteric arteries or their branches
syndrome, hypoproteinemia and rare diseases can be selectively catheterized and contrast injected
like Whipple disease. Submucosal lesions are seen (Fig. 7.13).
as thumb impressions and are observed in
Indications
submucosal hemorrhage, lymphoma, Crohn’s
disease and amyloidosis. Intestinal loops are a. For detecting the site and lesion in obscure GI
tethered together in conditions such as radiation bleeding such as angiodysplasia and heman-
enteritis, tuberculosis and Crohn’s disease gioma which can also be embolized.
(desmoplastic effect). Small intestinal fistulae and b. For detecting functioning microtumors of
ulcerations are better visualized by enteroclysis. pancreas which may be missed even in CT scan.
One of the common causes of ileal ulceration and c. Preoperative assessment of vascularity and
Part–I: Internal Medicine
abdominal lesions, especially of the parenchymal to USS especially for vascular lesions (Figs 7.14 to
organs. All the abdominal and pelvic organs can be 7.16).
well delineated by USS. With proper positioning of COMPUTED TOMOGRAPHY
the probes all the solid and hollow organs can be
Computed Tomography (CT) scan can demonstrate
imaged. The size, shape, consistency, movement and
tumors, abscesses, fluid collections, lymph nodular
presence of pathological lesions can be accurately
masses and several other abnormalities in the
charted. The size of the lesions can be measured
abdomen. Details of parenchymal lesions of the liver,
and documented and this will give immense help spleen, pancreas, kidneys, adrenals, lymph nodes,
for following up the progress of the lesion. Pelvic uterus and its adnexa can be made out clearly. The
structures can be better imaged by vaginal probes. CT scan is superior to ultrasound scan for detecting
Intervention procedures such as aspiration and pancreatic lesions, defining lymph node masses as
biopsy can be done under ultrasound guidance with in lymphoma, common bile duct stones, adrenal
a higher degree of accuracy and safety. The yield of tumors and hepatic metastases. Hence it is very useful
picking up of lesions can be enhanced and more for assessing operability of intra-abdominal neo-
accurately delineated by the use of doppler attached plasms and staging of lymphomas (Fig. 7.17).
Fig. 7.15: Ultrasound scan showing gallbladder stone (arrow) Fig. 7.17: CT scan showing focal hepatic lesion
abscess (arrow)
92 Section 3: Alimentary System
Virtual Colonoscopy
Helical CT generates high resolution two dimen-
sional images of abdomen and pelvis. From this
data, the computer reconstructs three-dimensional
images of colon. It is noninvasive and quick and
does not require elaborate bowel preparation.
For these reasons it is more acceptable to the patients,
but their absolute reliability is not yet firmly
established. The disadvantage is that interventions
such as biopsy, polypectomy and other procedures
cannot be performed simultaneously.
GASTROINTESTINAL ENDOSCOPY
Direct endoscopy is the technique of direct visualiz-
ation of the interior of hollow viscera in any part of
the body using appropriate flexible instruments,
fiberoptic light sources, operating channels, cameras
or ultrasound instruments and special tools for
imaging and intervention such as lithotomy,
polypectomies, clipping or occluding blood vessels
biopsy and even submucous resection of neoplasms
and several other surgically amenable conditions.
Endoscopies have developed and reached a state
of near perfection at present. The findings within
hollow viscera can be seen on the television screen,
imaged digitally, stored and used for follow-up. GI
Fig. 7.20: Magnetic resonance cholangiopancreatography
endoscopy is available in several secondary and (MRCP) showing stricture (green arrow) of common bile duct
tertiary care hospitals in India at moderate costs (CBD). PD indicates panacreatic duct
Chapter 7: Investigations in Gastrointestinal Disorders 93
(Rs 1000-5000). Endoscopic diagnosis with biopsy Colonoscopsy is performed by passing a flexible
is the most reliable direct method to diagnose colonoscope though the anal canal into the rectum
mucosal and submucosal lesions. This investigation and colon. It requires bowel preparation prior to
should be done wherever possible if the diagnosis the procedure. Cecum can be reached in more than
by indirect methods is still in doubt. 95% of the cases, and terminal ileum can also be
examined. Colonoscopy is the gold standard for
Upper GI Endoscopy (Esophagogastro- diagnosis of colonic mucosal disease. Colonoscopy
duodenoscopy—OGD scopy) has greater sensitivity than barium enema or CT
This is performed by passing a flexible endoscope scan for colitis, polyps and cancer. It permits
through the mouth into the esophagus, stomach, bulb directed biopsy, and other interventions (Figs 7.24
and second part of duodenum. The procedure is the to 7.26). Helminths attached to colonic flora can
best method for the examination of upper GI be seen.
mucosa. OGD scopy is superior for the detection Flexible Sigmoidoscopy
of gastric ulcers and flat mucosal lesions like
It visualizes rectum and variable portion of left
Barrett’s esophagus. It permits directed biopsy and
colon, typically upto 60 cm from the anal verge.
endoscopic therapy, including foreign body retrieval
Flexible sigmoidoscopy is primarily used for
(Figs 7.21 to 7.23).
evaluation of diarrhea and rectal outlet bleeding.
Colonoscopy Mucosal lesions like ulcerative colitis, diverticulitis,
Fig. 7.21: Esophagoscopy showing Barrett’s esophagus, i.e. Fig. 7.22: Upper GI endoscopy showing bleeding gastric
squamous epithelium is replaced by intestinalized columar ulcer (arrow)
epithelium (arrows)
94 Section 3: Alimentary System
Fig. 7.23: Upper GI endoscopy showing carcinoma of the Fig. 7.24: Colonoscopic appearance of tuberculosis
stomach with everted margins and bleeding (arrow)
Part–I: Internal Medicine
A B
C D
Figs 7.25A to D: Ulcerative colitis stage 1. (A) Note easy friability of the mucosa and tendency to bleed (arrow), (B) Progressive
granularity and tendency to bleed, (C) Extension of ulcers and exudates, (D) Polypoid muscosa with ulceration and bleeding.
These polypoid lesions are precancerous
Chapter 7: Investigations in Gastrointestinal Disorders 95
RADIOISOTOPE STUDIES
Radioisotope studies are used for the following
indications:
1. Absorption of material from the intestinal tract
can be studied using labeled substances e.g. fats,
cyanocobalamin, etc. These tests are employed
for the investigation of malabsorption states.
2. To study the rate of destruction of labeled
erythrocytes in the spleen, in the diagnosis
of hemolytic anemias, and to decide upon
splenectomy as a therapeutic measure.
3. Isotope labeled erythrocytes to detect the site of
gastrointestinal bleeding
4. Study of obstructive jaundice.
5. Use of labeled neutrophils to locate intra-
abdominal abscesses.
6. Radioisotope of technetium or colloidal gold is
useful in detecting primary or secondary hepatic
Part–I: Internal Medicine
Fig. 7.27: Record of dynamic pressure changes tumors, abscesses and cysts by a gamma camera.
by esophageal manometry in normal
HELICOBACTER PYLORI (H. PYLORI)
H. pylori infection is well recognized to be causally
Manometry also measures the minimum sensory
related to duodenal and gastric ulcers, atrophic
volume (usually 10–15 ml)—determined by
gastritis, gastric adenocarcinoma and gastric MALT
instilling volume into rectal balloon until sensed lymphoma. Detection of H.pylori and eradication
by urge to defecate. of this infection are important steps in the prevention
Another parameter tested is Resting Anal and management of these disorders.
Inhibitory Reflux (RAIR) which corresponds to Tests commonly used to detect H.pylori are
decrease in resting pressure attributed to balloon given in Table 7.5.
distension in the high pressure zone, with an
associated external anal sphincter contraction. GASTRIC SECRETORY STUDIES
Indications of Manometry In the past, studies of the gastric aspirate were
used extensively for the diagnosis of various
1. Fecal incontinence
diseases affecting the stomach. With the universal
2. Constipation
availability of direct methods such as endoscopy
3. Dyssynergic defecation
and biopsy, gastric acid estimation has become rare
4. Hirschsprung’s disease
in clinical practice. Still, this test is done occasionally
5. Anal fissures.
Table 7.5: Tests to detect H.pylori
Uses Test Sensitivity/specificity %
1. Anorectal manometry can define hypo- or Invasive (Endoscopy/Biopsy)
hyper-functional disorders of the sphincter Rapid urease 80-95/95-100
Histology 80-90/>95
mechanism. Culture -/-
2. Manometry can compare objective function with Non-Invasive
patient’s subjective sensation of rectal fullness. Serology >80/>90
3. Often performed in conjunction with other Urea breath test >90/>90
Stool antigen >90/>90
diagnostic modalities like video defecography.
Chapter 7: Investigations in Gastrointestinal Disorders 97
biopsy studies are helpful in investigating cases of a. Carcino embryonic antigen (CEA) in colon
malabsorption, chronic diarrhea, intestinal cancer.
obstruction, granulomatous disease and tumors. b. Alpha fetoprotein (AFP) in hepatocellular
carcinoma.
Breath Analysis c. Human chorionic gonadotropin (HCG) in
When there is bacterial contamination in the small gonadal tumors and choriocarcinoma.
intestine, test substances like lactulose are degraded d. Acid phosphatase and prostate specific antigen
with the production of hydrogen or carbon dioxide (PSA) in prostatic enlargement—both benign
which is absorbed and eliminated in expired air. and malignant.
Determination of hydrogen or carbon dioxide level e. CA 19-9 in pancreatic cancer.
in expired air gives clue to the presence of bacterial
colonization of the small intestine, thereby revealing FINE NEEDLE ASPIRATION CYTOLOGY
the cause of malabsorption. Fine needle aspiration cytology (FNAC) is a safe
D-Xylose Absorption Test and simple office procedure, especially for the
detection of cancer, where reliable result can be
D-Xylose is absorbed passively from the ileum and obtained within 30 minutes. The lesion is aspirated
excreted as such in urine. 5g of d-xylose is given with a 5 to 10 mL syringe through a 24 to 26 G
orally dissolved in water. The urinary excretion over needle of suitable length. The aspirate is spread on
the next five hours is estimated. Normally 20% of
Part–I: Internal Medicine
4
Hepatobiliary System
CHAPTER
81 Hepatobiliary System:
General Considerations
KR Vinaya Kumar
General considerations, Pattern of diseases affecting the liver and biliary system in India
GENERAL CONSIDERATIONS
Liver occupies the right hypochondrium and
epigastrium and it weighs around 1.5 kg in adults.
It is in close apposition with the diaphragm above.
It is held in place by loose folds of peritoneum. The
intra-abdominal pressure prevents it from dropping.
Normally, the lower border of the liver is just
palpable as a soft edge below the right costal margin,
on inspiration. In the epigastrium it is palpable 3 to
5 cm below the costal margin. When the abdominal
muscles become lax, the liver may drop down and
become more palpable. Liver is the main seat of
metabolic activity. Hepatocytes are endowed with
several enzymes, acting specifically in different
metabolic pathways. When liver cells undergo
injury or necrosis, intracellular enzymes are
released into circulation, e.g. aspartate transaminase
(AST) and alanine transaminase (ALT), previously Fig. 8.1: Segmental anatomy of liver. IVC—inferior vena cava,
known as SGOT and SGPT respectively. MP—main portal vein, RHV, MHV and LHV—right, middle and
left hepatic veins
Hepatic Segments
Liver anatomy can be described using two different Major functions of liver are discussed below.
aspects: morphological and functional. The
traditional morphological anatomy is based on the Carbohydrate Metabolism
external appearance of the liver. Couinaud divided Glycogen formation and release of glucose from
the liver into eight functionally independent glycogen.
segments. Each segment has its own vascular inflow,
outflow and biliary drainage. In the center of each Protein Metabolism
segment there is a branch of the portal vein, hepatic Synthesis of albumin, deamination and transami-
artery and bile duct. In the periphery of each segment nation of amino acids and peptides. Production of
there is vascular outflow through the hepatic veins complement and other proteins. Conversion of
(Fig. 8.1). ammonia into urea for excretion.
102 Section 4: Hepatobiliary System
The portal venous system is unique. It carries Table 8.1: Causes of portal hypertension
the venous blood from the upper and lower • Prehepatic causes—obstruction to portal vein developing as a result
gastrointestinal tract, spleen and pancreas. After of portal vein thrombosis or cavernomatous change
entering the liver, the portal vein further breaks up • Intrahepatic causes—mainly cirrhosis
into branches and drains blood into the sinusoids • Posthepatic causes—obstruction to hepatic veins caused by
thrombosis or other causes of obstruction (Budd-Chiari syndrome).
from where the blood is collected into hepatic veins
for drainage. It carries products of digestion and
insulin secreted by the pancreas. During the sluggish development of ascites in the presence of hypoal-
flow of blood in the sinusoids, the liver cells act buminemia in patients with chronic liver disease.
upon the absorbed nutrients and further metabolic Causes of portal hypertension may be classified
processes take place. Kupffer cells which are according to the level of obstruction (Table 8.1).
reticuloendothelial cells, are phagocytes which
Biliary Drainage System
engulf particulate matter such as bacteria, preventing
them from entering the systemic circulation. Normal Bile formed by the hepatic parenchymal cells is
portal venous pressure is 5 to 12 cm of water. drained into bile canaliculi which form the common
Venous drainage of the liver is through the hepatic duct which emerges from the porta hepatis.
hepatic veins which join the inferior vena cava The cystic duct from the gallbladder joins it to form
directly. In chronic venous congestion, the liver is the common bile duct which passes down to open
in the second part of the duodenum along with the
some parts of South India. Its incidence has come used to be a common cause of tender hepatomegaly
down. Several toxins such as aflatoxins present in without jaundice. Amoebic liver abscess used to be
food cause acute and chronic hepatic damage. very common before 1970. At present it is seen much
Veno-occlusive disease occurs in small outbreaks. less frequently. Alcoholism predisposes to it.
Noncirrhotic portal fibrosis (NCPF) is also more
common in India. Tumors
Primary carcinoma is a common neoplasm in the
Acute Liver Disease
younger age groups. Secondary carcinoma is seen
The most common is viral hepatitis. Hepatitis A more in older age groups.
and hepatitis E which are mainly transmitted by the
feco-oral route are common, affecting children and Chronic Liver Disease
young adults. Epidemics may occur when the Among the chronic liver diseases, cirrhosis tops the
drinking water is contaminated with sewage. list. All types of cirrhosis are seen. Viral hepatitis
Hepatitis B virus (HBV) is also common. The and alcoholism account for the majority. Portal
prevalence of HBsAg positivity ranges in the hypertension developing in noncirrhotic portal
general population from 4 to 6% as is shown in small fibrosis (NCPF) is a less common cause for massive
isolated studies. Vertical transmission from mother splenomegaly and hematemesis.
to infant is common. Other modes of transmission
include the use of contaminated needles, transfusion Hepatic Failure
Part–I: Internal Medicine
of blood and blood products and also through the Viral hepatitis and poisoning by drugs, chemicals
sexual route. The coexistence of HIV and HBV is and toxins account for the majority of causes of
common. This has brought in additional problems acute hepatic failure. Cirrhosis liver is the most
in the management of such patients. frequent cause for chronic hepatic failure.
Hepatitis C also is increasingly recognized.
Outbreaks of hepatitis C have been reported. Many Gallbladder and Biliary Tract
cases of transfusion induced hepatitis are due to Diseases of the gallbladder and biliary tract are
hepatitis C. frequent. Gallstones may be detected in a good
Acute hepatic failure as a result of viral hepatitis, number of persons (10–15%) or routine ultrasound
poisoning, and Plasmodium falciparum malaria of the abdomen, but these may be silent in the vast
is frequently seen. Hepatic amoebiasis may occur majority. Calculous cholecystitis accounts for many
in young and middle aged adults, more so in men. It cases of gallbladder dyspepsia.
CHAPTER
Noninvasive Investigations
19 in Diseases of Hepatobiliary
System
KR Vinaya Kumar
Biochemical tests, Coagulation factors, Viral screening, Tests for hereditary metabolic liver diseases
(GGT). Normal level of alkaline phosphatase (ALP) Table 9.1: Serological markers of HBV infection
in serum is 4 to 13 King Armstrong Units (KAU) Surface antigen HBsAg Screening test for HBV infection—
or 35 to 125 IU/L. The source of alkaline phosphatase presence of recent or past infection
in blood is primarily from the bone and liver. e antigen HBeAg Suggest infectivity. Presence of
HBeAg is evidence of viral multi-
Hepatic alkaline phosphatase is increased in plication in the liver.
obstructive jaundice. Values above 30 KAU are Core antigen HBcAg Not seen in blood
suggestive of obstruction to biliary drainage. ALP Antibody to Anti-HBs Indicates presence of protective
is a more sensitive and reliable parameter to HBsAg IgG IgG antibody
diagnose biliary obstruction than serum bilirubin Antibody to Anti-HBc- Signifies the occurrence of active
level. ALP is also elevated in hepatocellular HBcAg IgM IgM infection
carcinoma. Antibody to Anti HBc- In low titers suggestive of past
HBcAg IgG IgG infection, high titers suggest
5-nucleotidase and GGT are rarely elevated in continuing infection
conditions other than liver disease. Antibody to Anti-HBe Loss of infectivity. Virus may be in
HBeAg Anti-HBe the integrated phase
Tests that Measure Biosynthetic
Liver Function
antibody against core antigen. Detection of
• Serum albumin anti-HBc IgM is diagnostic of HBV hepatitis.
• Serum globulins HBe antigen is indicative of active replication
Part–I: Internal Medicine
The specificity rate is 99% for both tests. Antinuclear antibody (ANA) Autoimmune hepatitis Type I
Anti smooth muscle (ASMA) antibody
Quantitative Assays Liver-kidney-microsomal antibody Autoimmune hepatitis Type II
(LKM-1)
Useful for monitoring antiviral therapy.
Soluble liver antigen (SLA) Autoimmune hepatitis Type III
1. Signal amplification: Represented by the third
Antimitochondrial antibody (AMA) Primary biliary cirrhosis
generation branched chain DNA (bDNA) assay.
2. Target amplification: The lower limit of detection Anti-HDV IgG antibody detection and real time
of HCV RNA with current assays ranges from PCR for the virion are diagnostic. HDV can be
30 to 615 IU/mL. genotyped by molecular assays.
HCV Core Antigen Assay TESTS FOR HEREDITARY METABOLIC
HCV core antigen can be detected and quantified LIVER DISEASES
with an EIA.
Screening tests for common hereditary and
HCV Genotyping metabolic disorders such as hemochromatosis,
Genotyping is important for determining the drug alpha-1-antitrypsin deficiency and Wilson’s disease
dosage and duration of antiviral therapy since the should be done in all forms of chronic liver disease.
Invasive Investigations in
10
1 Diseases of Hepatobiliary
System
KR Vinaya Kumar
4. Family members of HHC or Wilson’s disease:. 6. For monitoring of transplanted liver and to
In order to assess their metabolic state and detect rejection early.
prophylaxis liver biopsy is needed. At present 7. In jaundice complicating pregnancy, biopsy may
gene screening methods are available in selected be required for distinguishing acute fatty liver
centers. These are noninvasive and therefore, are of pregnancy (AFLP) from the various types of
preferable. hepatitis.
5. Liver biopsy may be required for the diagnosis When liver disease is advanced and there is
of systemic illnesses such as pyrexia of unknown coagulation failure percutaneous liver biopsy is
origin. Obscure cases of miliary tuberculosis unsafe. Transjugular liver biopsy can be done with
may reveal glanulomas in the liver. a biopsy device introduced into the jugular vein.
5
Respiratory System
CHAPTER
11
1 General Considerations
Conducting system—airways, nasal cavity and paranasal sinuses, Larynx, Trachea and bronchi, Lungs,
Pleura, Physiological considerations, Air entry and production of breath sounds, Control of ventilation
and respiratory rhythm, Surfactant, General pattern of respiratory diseases in India
The thorax is an osseocartilaginous cage which This extends from the nose to the terminal
extends from the root of the neck to the abdomen. It bronchioles. This can be divided into upper and
houses the principal organs of respiration—the lower respiratory tracts. The upper respiratory tract
lungs, which are separated from each other by the consists of the nose, paranasal sinuses, nasopharynx
and larynx. The lower respiratory tract includes
mediastinum. The thoracic cage is constructed in
trachea, bronchi and bronchioles up to the terminal
such a way that its movements result in increase
bronchioles. The larger air passages are provided
and decrease of the anteroposterior and lateral
with rigid cartilaginous rings which prevent them
diameters and its vertical height, thereby increasing
from collapsing during strong respiratory
or decreasing the intrathoracic volume during
movements. The bronchi branch repeatedly in a
inspiration and expiration.
dichotomous manner becoming smaller and
In inspiration, the anteroposterior and transverse narrower progressively.
diameters of the thorax are increased. Movements
Air passages less than 1 mm in diameter are
of the ribs at the costovertebral joints result in
termed bronchioles. The bronchioles and the distal
increased anteroposterior diameter (pump-handle
passages are devoid of cartilage. One bronchiole
movement). The transverse diameter is further
enters each lung lobule. This lobular bronchiole
increased by the ribs swinging outwards (bucket- leads to terminal bronchioles which further
handle movement). The diaphragm which is attached subdivide into respiratory bronchioles which open
to the lower margin of the thoracic cage acts like a into alveolar ducts. These ducts are thin walled
piston. The vertical diameter increases by the tubes ending in alveolar sacs which are studded with
contraction of diaphragm which results in opening small pouches known as acini or alveoli. It is
up of the costodiaphragmatic recesses, and estimated that with about 350 million alveoli in the
elongation and narrowing of the mediastinum. adult lungs, the surface area provided for gas
During quiet respiration, expiration is brought exchange goes up to 100 m2.
about by the elastic recoil of the chest wall and the
lungs. During forced expiration abdominal muscles Nasal Cavity and Paranasal Sinuses
pull the ribs down and the relaxed diaphragm is The nasal cavity is concerned with respiration,
pushed up to reduce the vertical height. olfaction, exchange of heat and water vapor, and
114 Section 5: Respiratory System
to a small extent, modification of the voice. See cervical vertebra to the upper border of fifth thoracic
Chapter 51. vertebra, where it divides into two principal bronchi
(Figs 11.1A and B). The trachea is in the median
The Larynx
plane, though at the bifurcation it is a little to the
It is that part of the respiratory tract which connects right. It is slightly flattened posteriorly. In adults
the pharynx to the trachea. In the adult it is situated the lumen is about 12 mm. The right principal
opposite the third to sixth cervical vertebrae. It is a bronchus is about 2.5 cm long. It is wider and
cartilaginous structure, made up of thyroid, cricoid, shorter than the left and it proceeds as the direct
arytenoid and epiglottic cartilages. It acts as an air- continuation of the trachea. Hence, inhaled foreign
passage and it has a sphincteric mechanism. bodies enter the right bronchus more frequently than
Essentially it is an organ of phonation. The vocal the left. The left main bronchus which is about 5
cords which are supported on cartilages and supplied cm long, enters the hilum of the left lung opposite
with muscles serve to produce sounds. Tension of the sixth thoracic vertebra. It runs more horizontally
the cords and the vocal aperture can be altered by than the right. The main bronchus divides into lobar
muscular action and this helps to alter the quality bronchi and further into segmental bronchi. Each
of sounds. By closing the vocal aperture, entry of segmental bronchus supplies a self-contained,
foreign bodies into the trachea can be prevented. functionally independent unit of lung tissue termed
Normally, breathholding is possible by closing the the bronchopulmonary segment. Figures 11.2 and
vocal aperture. In bilateral vocal cord paralysis 11.3 give the anatomy of the lungs.
Part–I: Internal Medicine
A B
Figs 11.1A and B: Tracheobronchial tree. Bronchopulmonary anatomy (1) Thyroid cartilage, (2) Cricoid cartilage, (3) Trachea,
(4) Right and left principal bronchi, (5) Lobar bronchus, (6) Segmental bronchus, (7) Terminal bronchus, (8) Lobular bronchiole,
(9) Respiratory bronchiole, (10) Alveolar duct, (11) Atrium, (12) Alveolar sac, (13) Alveolus
Chapter 11: General Considerations 115
A B
Figs 11.2A and B: (A) Segmental anatomy of the lungs with divisions of the bronchi;
(B) Lateral surface of the lungs showing bronchopulmonary segments
Right lung Left lung
Upper lobe Upper lobe
1. Apical 1. Apical
2. Posterior 2. Posterior
3. Anterior 3. Anterior
Middle lobe Lingula
middle and the lower. The left lung has only two
lobes—the upper and the lower. The portion
corresponding to the middle lobe on the right is
incorporated in the left upper lobe as the lingular
segments (Table 11.1 and Figs 11.2A and B)
The parts of each lung are apex, base, hilum, Abnormalities in the lungs often manifest as
three borders and two surfaces. The apex is rounded. abnormal physical findings over the corres-
It rises above the thoracic inlet and lies 2.5 cm above ponding portions on the chest.
the medial third of clavicle. The base which is
Anatomy of the Pleura
concave and semilunar, rests on the diaphragm.
Costal surface corresponds to the shape of the inner Pleura is a serous membrane lining the thoracic
aspect of the chest wall. The medial surface has cavity which forms two pleural sacs, one on either
two parts, the posterior portion being in apposition side of the mediastinum and invaginated on its
with the vertebral bodies and the anterior portion medial aspect by the lung. It has two layers—
pulmonary or visceral and parietal pleura. The
with the mediastinum. At the hilum the bronchi,
pulmonary pleura is closely adherent to the lungs.
pulmonary vessels, lymphatics and nerves pass to
The parietal pleura lines the inner aspect of the chest
and from the lung. The borders are anterior,
wall. At the hilum both these layers are continuous.
posterior and inferior. The posterior border is
In between these two layers is a potential space
rounded whereas the other two are sharp.
known as pleural cavity which contains a small
The right lung consists of three lobes and two quantity of fluid. Intrapleural pressure is always
fissures. The oblique fissure runs from the interval negative compared to atmo-spheric pressure and this
between the third and fourth thoracic vertebrae, negative pressure keeps the lungs distended. This
downwards and forwards. At the mid axillary line negative pressure is abolished when air enters the
it lies in the fifth intercostal space. It ends anteriorly
Part–I: Internal Medicine
Inframammary region 6th rib Part of middle lobe on the right, and through the capillary bed. Diffusion of oxygen,
to costal margin lingular segment of the upper lobe on carbon-dioxide and other volatile substances across
the left. Parts of lower lobes on both
sides the alveolocapillary membrane is also instantan-
eous in normal subjects. Conditions which lead to
Lateral Aspect impairment of diffusion include pulmonary edema,
Axilla-up to 6th rib below Lateral aspect of the upper lobe. interstitial fibrosis, hyaline membrane disease, acute
Infra-axillary region 6th rib In front, lateral aspect of the middle lobe respiratory distress syndrome (ARDS), progressive
to costal margin on the right and lateral aspect of the
lingular segments on the left. Behind pulmonary vascular occlusions and several others.
and below these regions, the lateral Ventilation, perfusion with blood and diffusion
aspects of the lower lobes on both sides of gasses should all be optimal in order to ensure
Posterior Aspect adequate respiratory function.
Suprascapular region—portion Apical segment of upper lobe
above the upper border of Air Entry and Production of
scapular spine Breath Sounds
Interscapular region—region Posterior aspect of the apical
between the medial border of segment of the lower lobe About 500 mL of air passes into the respiratory tract
scapula and vertebral spines during each inspiration. Only about 350 mL reaches
02-07 the alveoli. The rest remains in the trachea and
Infrascapular region—portion Posterior aspect of the basal bronchi which forms the dead space, since gas
below angle of scapula, i.e. segment of the lower lobes
Breath Sounds
PHYSIOLOGICAL CONSIDERATIONS
These are produced by the movement of air in the
Ventilation is the mass movement of air in and out larger air passages. Turbulence of air and the
of the air passages. It depends upon the: consequent vibration of the vocal cords and various
• Effectiveness of the respiratory movements tissues are responsible for the production of sounds.
• The bony structures of the thoracic age Two types of breath sounds can be heard over the
• The physical state of the lungs chest on auscultation—vesicular and bronchial.
• The respiratory muscles-diaphragm and the Vesicular breath sound is heard over areas of normal
muscles of the chest wall lung tissue which attenuates and filters part of the
• Patency of the air passages sounds. On the other hand, bronchial breath sounds
• Integrity of the neurological connections which (also known as laryngeal) are heard over the chest
innervate the muscles of respiration when the normal processes of attenuation and
• Functioning of the respiratory centers situated filtration do not take place. In pathological states
in the brain. such as consolidation, collapse and fibrosis of the
All contribute to the effectivness of ventilation. lungs, the processes of attenuation do not take place
In the normal adult 6 to 10 liters of air is moved in as in normal lung.
and out in one minute.
Control of Ventilation and
Perfusion of Blood in the Respiratory Rhythm
Pulmonary Capillaries Two major groups of cells connected with
A volume of blood equal to the cardiac output respiratory control are situated in the medulla
perfuses the pulmonary arterioles and capillaries. oblongata. The dorsal respiratory group contains
The blood is separated from air in the alveoli by a predominantly inspiratory cells while the ventral
thin layer composed of the vascular endothelium respiratory group contains both inspiratory and
and alveolar lining cells with intervening basement expiratory groups of cells. The rhythmicity of
membrane and pulmonary interstitium (the respiration depends upon inhibitory and excitatory
alveolocapillary membrane). Diffusion of gases interactions between these respiratory cells. From
across this membrane occurs rapidly within a the respiratory center, impulses reach the spinal
fraction of the time the blood takes to travel motor neurones via the reticulospinal tracts. Besides
118 Section 5: Respiratory System
these, there is a pneumotaxic center in the pons, the tension and thereby enables the alveoli to remain
exact function of which is not fully understood. fully patent without collapsing. Synthesis of
Many factors influence their activity. Among surfactant begins only after 16 weeks of gestation
them are neural inputs from higher centers, and it is released from the alveolar wall only after
chemoreceptors and vagal influences which are the 26th week. Therefore, babies born before 26th
described below. week of gestation are at risk of acute respiratory
distress syndrome.
Higher Centers
Most areas are inhibitory to respiration though some GENERAL PATTERN OF RESPIRATORY
motor and premotor areas may be excitatory. DISEASES SEEN IN INDIA
Chemoreceptors During childhood, respiratory infections are
i. Carotid chemoreceptors are present in carotid common and they account for considerable mor-
bodies which are situated at the bifurcation bidity and mortality. In undernourished children,
of common carotid artery. Ventilation is acute respiratory infections carry higher mortality.
stimulated when these receptors are excited by Tonsillitis, bronchitis, bronchopneumonia and
hypoxia, hypercapnia or acidosis. The principal lobar pneumonia account for the majority of
stimulus for respiration in health is fall in respiratory illnesses during childhood. Primary
arterial oxygen saturation (PaOJ). tuberculosis affects children more frequently than
Part–I: Internal Medicine
ii. Central chemoreceptors are present on the adults. Acute respiratory failure occurring in
ventral surface of medulla. They are influenced children may be due to respiratory distress syndrome
by changes in arterial carbon dioxide (PaCO2) (RDS) complicating several severe systemic
and H+ ion concentration in both arterial blood illnesses, or other extensive pulmonary diseases
and cerebrospinal fluid. Presence of CO2 in such as broncho-pneumonia or asthma. In the
inspired air is a very strong stimulus to increase syndrome of septic shock, multiorgan failure is
ventilation. common. Respiratory distress syndrome may
develop in many of them.
Vagus and Sympathetic Nerves In all age groups, pneumonias, bronchitis,
These give rise to filaments which ramify to form asthma and tuberculosis are common. In adults,
pulmonary plexuses and accompany the ramifi- chronic bronchitis and emphysema, asthma,
cations of the bronchi. Vagus supplies motor fibers pulmonary tuberculosis, bronchiectasis and
to broncho-constrictor muscles. Afferents to the occupational lung diseases account for the major
bronchial mucosa and alveoli are derived from these proportion of respiratory illnesses. Malignancy
plexuses. of lungs increases with advancing age. Acute
i. Pulmonary stretch receptors are located in the respiratory failure in adults may be caused by
bronchi. Bronchopulmonary inflation and asthma, bilateral pleural effusion, pneumothorax,
deflation reflexes (Hering-Breuer) are prominent aspiration pneumonia or acute respiratory distress
in infants and anesthetized persons but they syndrome (ARDS). Chronic respiratory failure in
are less pronounced in normal adults. adults is mostly due to chronic bronchitis and
ii. J-receptors are responsible for rapid shallow emphysema, asthma or pulmonary fibrosis.
breathing and these are stimulated by Pleural diseases include pleural effusion,
pulmonary congestion, edema or microemboli. pneumothorax, pleural fibrosis or thickening and
iii. There are some receptors which are activated malignancies.
by irritants in inhaled air. With the advent of newer therapeutic inter-
iv. There are also receptors which initiate cough ventions such as intensive care room and assisted
reflex. ventilation continued for several days, special pro-
blems arise which impair cardiorespiratory function.
Surfactant Extensive burns as occurring in fire accidents and
This is composed of phospholipids synthesized by inhalation of noxious gases lead to damage to air
type II pneumonocytes. Surfactant lowers surface passages and alveolocapillary apparatus.
CHAPTER
12
1 Examination of the
Respiratory System
Cough, Expectoration of sputum, Hemoptysis, Chest pain, Dyspnea, Abnormal patterns of respiration,
Sleep apnea syndrome, Wheeze, Stridor, Hoarseness of voice, Past history, Physical examination,
Respiratory system examination, Inspection, Palpation, Percussion, Auscultation, A scheme for recording
physical findings, Interpretation of physical findings, Common pathological changes in the lungs and pleura
cardiac asthma) is a feature of left sided heart This has a psychosomatic background. Most of the
failure. It occurs most often within an hour or two patients are in the age group of 6 to 17 years. Usual
of going to bed. By contrast, dyspnea and cough investigations for respiratory diseases are normal.
due to bronchial asthma are generally aggravated As a result of the debilitating cough the child adopts
in the early hours of morning. a sick role and becomes the main focus for anxiety
for the patients. Cough may be a manifestation of
Otogenic Cough
also a tic disorder.
This is a form of reflex cough caused by stimulation Table 12.1 gives the salient clinical features of
of the Arnold’s nerve which is a branch of the vagus. cough commonly observed in practice.
Arnold’s nerve arises from the jugular ganglion and
supplies the posterior and inferior wall of the Expectoration of Sputum
external auditory meatus. Lesions such as impacted Sputum is a mixture of bronchial secretions, cells
wax in the meatus or presence of foreign bodies and organisms which are discharged from the
may evoke reflex cough, which subsides with the airways. Normal sputum may be colorless and
removal of the cause. mucoid, it is loose and nonsticky in character. Most
persons do not spit out sputum. The secretions pass
Habit Cough Syndrome up from the respiratory tract by ciliary action and
This is seen in patients who present with sustained cough, and are swallowed. Normal quantity does
repetitive coughing without any cough during sleep. not exceed a few milliliters in 24 hours.
Sticky and Tenacious Sputum respiratory tract. Injuries to the lung occurring in
accidents and following rib fractures give rise to
Whenever infection complicates chronic bronchitis
hemoptysis. Hemoptysis may manifest in several
or there is exacerbation of chronic bronchial asthma,
forms depending on the underlying disease:
the sputum becomes sticky and tenacious. It is
a. Acute inflammations like pneumonia may lead
difficult to expectorate. Obstruction of the airways
to blood mixed with sputum.
by thick secretions worsens the dyspnea. Expector-
b. Bronchiectasis and lung abscess: In bronchie-
ation gives relief. With clearance of infection the
ctasis the history extends over several years
sputum becomes less tenacious and easier to
expectorate. with the expectoration of large quantities of
purulent sputum often with postural cough.
Purulent Sputum Hemoptysis may be streaky or massive and
The sputum resembles pus and it is yellow or blood may be mixed with sputum or may be
greenish. Often it is large in amount and brought expectorated as such. Often the general
out easily with cough. Purulent sputum is a sign of condition of the patient is satisfactory.
infection. It is seen in bronchitis, pneumonia, In lung abscess, there is deterioration of
bronchiectasis, lung abscess, asthma with infection, general condition of the patient. Hemoptysis
bronchopleural fistula and others. may be moderate or massive and postural
cough may occur.
Rusty Sputum c. Pulmonary tuberculosis: In pulmonary
This is suggestive of pneumococcal pneumonia. Rust tuberculosis, hempotysis is a common
color is due to admixture of altered blood with complication and the character of hemoptysis
sputum. Sputum resembling red jelly (red currant may vary. Blood may be present only in streaks
jelly) results from admixture of mucus and blood or there may be massive hemoptysis. Lesser
and this is sometimes seen in bronchogenic degree of hemoptysis may occur in early
carcinoma. stages of pulmonary tuberculosis. Massive
hemoptysis occurs in cavitary pulmonary
Foul Smelling Sputum tuberculosis due to rupture of blood vessels
Severe foul smell may be present when infection traversing the cavity (Rasmussen’s aneurysms).
is caused by anaerobic bacteria as may be seen In post-tuberculosis bronchiectasis, hemoptysis
in bronchiectasis, lung abscess or necrotizing may recur even after the tuberculosis is cured
pneumonia. with treatment.
Chapter 12: Examination of the Respiratory System 123
surgical measures may have to be adopted to Massive hemoptysis occurs in cavitary pulmonary
save life. tuberculosis, bronchial adenoma, bronchogenic
f. Pulmonary embolism: This is a common carcinoma, pulmonary embolism, bronchiectasis
complication of several diseases in which and rupture of an aneurysm into a bronchus. Careful
thrombosis occurs in peripheral veins with interrogation and proper physical examination help
subsequent ernbolization. It may be massive to arrive at the diagnosis in most cases. Massive
and fatal, or smaller and recurrent. The latter hemoptysis is an indication for urgent hospital-
type results in pulmonary infarction which is ization and treatment.
characterized by catching pain in the chest and
streaky or large hemoptysis. Chest Pain (Table 12.3)
g. Trauma to chest: Injuries to the chest may lead a. Chest pain: It arising from lung parenchyma
to contusion of lungs. Penetrating wounds of may not be typically localized, as the lung
the lungs may be caused by broken ribs or parenchyma and the visceral pleura covering
foreign particles. All these may result in it are less sensitive to painful sitmuli. Even
hemoptysis. when there is massive destruction of lung
h. Left heart failure: The sputum is frothy, watery parenchyma pain may be absent or may be only
and blood stained. Hemoptysis is due to acute mild. Pain is more prominent and characteristic
pulmonary edema. when the parietal pleura, major airways, chest
i. Hemorrhagic diathesis: Purpuric disorders wall, diaphragm or mediastinal structures are
Part–I: Internal Medicine
d. Muscle pain: Paroxysmal coughing may lead k. Hysterical pain: Chest pain may be a common
to rupture of muscle fibers which might present symptom in hysterical subjects and malin-
as superficial pain and local tenderness over gerers. The descriptions may vary from subject
the affected region of the chest wall. Move- to subject and at different times in the same
ments aggravate the pain. Bornholm’s disease subject. Distinction from other genuine causes
caused by Coxsackie B virus causes severe may be difficult at times and may require
muscular pain which may mimic pleurisy. It is prolonged observation and investigations.
accompanied by fever, malaise and headache.
e. Costochondritis: This common condition Dyspnea (Table 12.4)
presents as dull localized pain and tenderness Dyspnea is defined as uncomfortable awareness
over the costochondral junctions. Chest move- of respiratory effort. Tachypnea is increased
ments, sneezing and coughing tend to aggravate respiratory rate, the normal being 14 to 18/minute.
pain. Hyperpnea denotes increased volume of ventilation.
f. Rib fractures present with history of sudden Dyspnea occurs whenever the work of breathing is
pain in the chest increasing with movement, increased. Dyspnea may be due to diseases of
respiration, coughing or sneezing. Fractures bronchi, lungs, pleura or thoracic cage, cardiac
may result from trauma or pathological lesions failure, increased demand for oxygen, neurological
such as secondary deposits or myeloma. diseases and psychogenic causes.
Pathological fractures may be silent.
Part–I: Internal Medicine
Acute asthma Episodic breathlessness and wheezing that Pre-existing history of reactive airway disease
arise spontaneously or after exposure to family history of asthma or atopy
specific stimuli (e.g. allergen, URI, cold,
exercise) and mental stress, bilateral rhonchi
Pneumothorax Acute onset of sharp chest pain, tachypnea, Occur spontaneously in emphysema, COPD,
diminished breath sounds, and hyperres- and Marfan’s syndrome, and following injury,
onance to percussion and TB
Foreign body inhalation Sudden onset of cough or stridor in a patient Typically an infant or young child. Risk factors
without URI or constitutional symptoms, for aspiration in adults include alcoholism and
Café coronary anesthesia
Pulmonary embolism Abrupt onset of sharp chest pain, tachypnea, Cancer, immobilization, DVT, pregnancy, use
and tachycardia of oral contraceptives or other estrogen-
containing drugs, recent surgery or
hospitalization
Toxic airway damage (e.g. inhalation Sudden onset of suffocation and cough Onset after occupational exposure or
of chlorine or hydrogen sulfide), burns inappropriate use of cleaning agents
Cardiac causes
Acute myocardial ischemia or Substernal chest pressure with or without Particularly in patients with risk factors
anxiety precipitate the attacks. Often the duration structures give rise to dyspnea. The patient is
of dyspnea extends over several years. Family tachypneic. Expansion of the chest is asymmetrical
history of asthma and other atopic disorders may and non-uniform. Repeated respiratory infections
be present in many cases. Other allergic and progressive changes in the lungs lead to the
manifestations may coexist with asthma. development of cor-pulmonale and respiratory
Chronic obstructive airway disease: In the initial failure.
phases of chronic bronchitis and emphysema, Metabolic causes—acidosis: In metabolic acidosis
attacks of cough and wheezing develop during cold caused by renal failure, diabetic ketoacidosis,
seasons (winter cough). These spells recur at shorter prolonged starvation or poisoning by salicylates or
intervals and persist for longer periods as the disease methyl alcohol the respiration becomes deep and
progresses. Later dyspnea persists at all times with sighing in character. It is known as Kussmaul’s
periodic exacerbations caused by infection or breathing. The patient may or may not complain of
irritants. respiratory discomfort.
Pulmonary embolism: The general pattern is that Neurological disorders: In cerebral hemorrhage
multiple small embolic episodes occur preceding a leading to coma, irregular and deep labored
major embolus, which may be fatal in some cases. breathing may be present. Cheyne-Stokes
The minor episodes may be associated with acute respiration may occur in brain stem lesions.
dyspnea, chest pain and hemoptysis. In many cases
Part–I: Internal Medicine
the episodes are silent. A major attack comes on Hysterical dyspnea: It is one of the frequent causes
with sudden onset of severe dyspnea, cyanosis and of dyspnea in those without systemic diseases.
loss of consciousness. Unless recognized early and Dyspnea is more prominent at rest than during work.
promptly managed, the patient dies. Exercise tolerance is often unimpaired. In extreme
cases patient resorts to hyperventilation which
Pleural causes: Pleurisy, pleural effusion and produces dizziness, light headedness, tingling in
pneumothorax commonly lead to dyspnea. fingers and even tetany as a result of respiratory
Pneumothorax causes breathlessness of sudden alkalosis. Breathing returns to normal during sleep.
onset. It may be severe and life-threatening in Features suggestive of underlying anxiety or
tension pneumothorax. As the intrapleural pressure depression may be evident.
increases the dyspnea worsens and this is a medical
emergency. Pleural effusion may be associated with Abnormal Patterns of Respiration
pleural pain and dyspnea. The dyspnea is more
pronounced if the effusion collects rapidly and Cheyne-Stokes Respiration (Fig. 12.1)
becomes massive. Chronic pleural effusions may It is characterized by alternating periods of apnea
even remain silent in some cases. lasting for 10 to 12 seconds, and hyperpnea. The
Diaphragmatic paralysis: Bilateral diaphragmatic breathing shows waxing and waning character.
paralysis leads to dyspnea. Transverse myelitis and Breathing starts slowly at first, increases in rate and
demyelinating diseases such as Guillain-Barre amplitude, and slows again to culminate in apnea.
syndrome may lead to diaphragmatic paralysis. Cheyne-Stokes breathing is seen in cerebral hem-
Pressure on the phrenic nerves by tumors gives rise orrhage, head injuries, poisoning, left ventricular
to uni-or bilateral paralysis. The patient is failure, and chronic hypoxia. It may also occur in
tachypneic. The abdominal wall is sucked in during
inspiration and this is termed paradoxical
respiration.
Diseases of the chest wall: Gross kyphoscoliosis
and pectus excavatum which reduce the
intrathoracic volume and distort intrathoracic Fig. 12.1: Cheyne-stokes respiration
Chapter 12: Examination of the Respiratory System 129
trauma to the chest, aspiration of foreign body Table 12.5: Common occupational lung diseases
or near-drowning, whooping cough, measles, Coal dust Anthracosis
anesthesia, surgery and seizures. Primary Silica dust Silicosis
tuberculosis in early life may lead to lobar or Cotton dust Byssinosis
segmental bronchiectasis later. Thoracic or upper Sugar cane dust Bagassosis
abdominal surgery may be complicated by Asbestos Asbestosis,
atelectasis (collapse) of the lungs. Patients who pleural mesotheliomas
recover from near-drowning may develop aspiration Beryllium Berylliosis
Isocyanates Asthma
pneumonia, atelectasis and lung abscess. Whooping
Wood dust, grain flour, Asthma
cough may lead to bronchiectasis. Recurrent vegetable dust
pneumonia may be a secondary complication Fungi in food products Allergic alveolitis
of an underlying bronchiectasis or bronchogenic
carcinoma.
The Table 12.5 shows some of the common occupa-
Extensive bilateral tuberculosis can lead to
tional lung diseases seen in India.
massive pulmonary fibrosis and respiratory failure.
Exact details of the duration of work, the amount
History of BCG vaccination should be taken. BCG
of exposure, development of similar disease in fellow
vaccination offers a good degree of protection from
workmen, and familial tendency to develop such
tuberculosis during childhood and adolescence.
diseases, should be recorded.
Immunity produced by BCG vaccination is only
Part–I: Internal Medicine
Several Drugs Cause Damage to Lungs failure leads to secondary polycythemia which
Methotrexate, busulphan, melphalan, bleomycin, further aggravates the cyanosis.
mustine hydrochloride and similar antimitotic drugs 8. Lymphadenopathy: Lymph node enlargement
may lead to pulmonary fibrosis. Weight reducing may be seen commonly in pulmonary
drugs such as fenfluramine and phenteramine used tuberculosis, carcinoma, sarcoidosis and
in the treatment of obesity lead to valvular diseases lymphomas. Supraclavicular, scalene, cervical
of the heart. Immuno-suppressive drugs such as and axillary nodes should be carefully palpated
corticosteroids, cyclophosphamide and azathioprine, to detect early lymph node enlargement.
predispose a person to exacerbation of tuberculous Mediastinal lymph node enlargement is
focus, viral infections, fungal infections such as commonly secondary to bronchogenic car-
candidiasis and aspergillosis and protozoal cinoma, sarcoidosis, lymphomas and primary
infections such as pneumocystis pneumonia. tuberculosis. Enlarged lymph nodes in
Similarly, acquired immunodeficiency syndrome bronchogenic carcinoma and lymphomas may
(AIDS) is also associated with increased risk of all lead on to mediastinal obstruction.
these infections. 9. Clubbing of fingers: Bronchiectasis, lung
abscess, bronchogenic carcinoma, chronic
PHYSICAL EXAMINATION pulmonary tuberculosis, empyema (collection
of pus in pleural cavity) and pulmonary
General Examination
interstitial fibrosis lead to clubbing of fingers.
11. Jugular veins: With patient recumbent at 45°, midline. Tracheal shift may be caused by pulmonary
the internal jugular veins are examined for and pleural lesions. Pulmonary fibrosis and collapse
abnormalities. Elevation of jugular venous pull the trachea towards the side of lesion while
pressure (JVP) may point to pulmonary heart pneumothorax and pleural effusion push the trachea
disease, i.e. cor pulmonale. Other signs to be to the opposite side.
looked for include tender hepatomegaly, Local lesions in the neck such as thyroid mass
dependent edema, and ascites (for further and lymphadenopathy also displace the trachea. In
details see Chapter 2). In asthmatic patients kyphoscoliosis involving cervicodorsal regions of
filling of jugular veins during expiration and the spine there is apparent shift of the trachea.
emptying during inspiration may be noticed.
Examination of cervical lymph nodes and thyroid
Respiratory System Examination are described in Chapters 2 and 26.
Nose, paranasal sinuses, ears and throat should be Examination of Chest
examined before proceeding to the chest (See
Chapters 52 and 53). The procedure for examining the chest includes
inspection, palpation, percussion and auscultation.
Movement of Accessory Muscles
Inspection
When there is respiratory distress as in chronic
obstructive airway disease and bronchial asthma, The chest should be examined in good light, with
Part–I: Internal Medicine
accessory muscles come into play. the patient preferably sitting up, the body exposed
1. Sternomastoids, scaleni and trapezius become down to the waist. Systematically observe the front,
prominent during inspiration. back and also from above downwards by looking
2. Abnormal recession of supraclavicular and over the shoulders. In the acutely ill and recumbent
suprasternal fossae during inspiration indicates patient, the chest should be inspected from the foot
excessive inspiratory effort. Yet another feature end of the bed towards the neck and from the head
suggesting increased respiratory effort is the flare end of the bed over the clavicles. Normally the
of the nostrils due to the action of alae nasi. trachea does not move visibly during respiration.
Inspiratory indrawing of the trachea is caused by
Nose and Throat
increased respiratory effort as seen in emphysema
The nose, paranasal sinuses and the throat should and tracheal obstruction. Movement of the trachea
be examined. Examination of throat may reveal from side-to-side may occur in fibrosis of the upper
congestion and enlargement of adenoids and tonsils, lobes.
which may be related to pulmonary disease. When For purposes of description and recording of
indicated, laryngoscopic examination may have to abnormal findings, the chest is divided into nine
be done to detect tuberculous ulceration in larynx, regions as described in Chapter 11.
carcinoma and paralysis of vocal cords (for details
Presence of abnormal findings over different
see Chapter 51).
regions of the chest helps to localize the lesion to
Examination of the Neck the underlying portions of the lungs.
Neck should be examined for:
Shape of the Chest
i. Posture
ii. Movements of accessory muscles Normally the anteroposterior diameter is less than
iii. Jugular veins the transverse diameter. Changes which occur in the
iv. Position of the trachea chest with ageing include increasing kyphosis of the
v. Abnormalities of the lymph nodes and thyroid, dorsal spine, increase in anteroposterior length of
and the chest and diminution in the amplitude of
vi. Other abnormalities if any. respiratory movements. If these changes occur in
Inspect the position of the trachea and its the young or in the middle aged, they are likely to
movement with respiration. Normal trachea is in the be due to emphysema.
Chapter 12: Examination of the Respiratory System 133
Alteration in the Physical State of the Pneumothorax: Air enters the pleural cavity. The
Lungs in Disease negative pressure in the pleura is abolished. The lung
collapses towards the hilum by its own recoil and it
Before proceeding further to examine the respiratory
does not take part in ventilation. Pneumothorax may
system, the student should get familiarized with
be complete or partial.
physical alterations that take place in the lungs and
pleura as a result of disease. These are responsible In tension, pneumothorax air collects inside the
for the abnormal physical findings on examination. pleural cavity under pressure, compresses the lung
Normal lung is soft, air containing, sponge like and and pushes the mediastinum to the opposite side.
capable of full aeration. The air passages do not Deformities of the Chest
contain secretions in excess.
Shape of the chest may be altered in several
Consolidation conditions:
1. Respiratory obstruction and adenoids, (see
This term refers to the state of the lung in which, Chapter 51).
due to inflammatory or neoplastic processes, the lung 2. Rickets.
assumes the physical state of a solid organ. The The usual abnormalities that may be
consolidated area does not contain air, does not take associated with rickets are pigeon chest,
part in ventilation and does not change in volume Harrison’s sulci and rickety rosary. Pigeon
from the normal. It becomes more conductive to chest (Syn: Pectus carinatum) is seen usually
Barrel shaped chest: The chest is held in inspiratory narcotic poisoning (e.g. morphine), some forms of
position, with ribs held more horizontally, and respiratory failure, raised intracranial tension and
anteroposterior diameter is increased. This is seen head injury.
in emphysema.
While inspecting the chest, one should look for Types of Breathing
unilateral bulging, flattening or retraction which In children and men diaphragmatic action is more
may be localized to one area or involve a whole prominent. The downward movement of diaphragm
side. Unilateral bulging and widening of rib spaces during inspiration causes the abdominal wall to bulge
may be seen in pleural effusion, pneumothorax, and forwards. During expiration the abdominal wall
compensatory emphysema. Precordial bulge may be recedes. This type of respiration is termed abdominal
caused by gross cardiomegaly developing in early respiration. In contrast, in women, action of the
life, pericardial effusion and aortic aneurysm. intercostal muscles is more prominent and then
Malignant disease of chest wall, mediastinum or respiration is mainly thoracic. The pattern of
lungs, local diseases of ribs and sternum, and spinal respiratory movements may change in several
deformities lead to localized bulge on the chest wall. diseases. In conditions where diaphragmatic
Pulmonary collapse and fibrosis leads to localized movements are restricted because of pain, as
retraction and crowding of the ribs. Wasting and occurring in liver abscess, the respiration becomes
retraction are particularly seen below the clavicle thoracic. Conversely, in conditions where the chest
and the upper part of the trapezius in apical movements are restricted as in pleurisy, the
Part–I: Internal Medicine
3. Decreased resonance:
a. Impaired
b. Dull
c. Stony dull (flat).
Hyper-resonant note: Increased or excessive
resonance is elicited in conditions where lungs are
over distended as in emphysema or when there is
free air in the pleural cavity as in pneumothorax.
Tympanic: As its name implies, this is an extreme
form of hyper-resonant note. This “drum-like” note
is heard over viscera which contain gas without
loculation, e.g. in stomach, or intestine. Percussion
note over a large superficial cavity in lung or
pneumothorax is tympanic.
Impaired percussion note: This is obtained when
the underlying lung becomes comparatively airless
Fig. 12.6: Percussion of the chest. Arrow points to the as is seen in consolidation, collapse and fibrosis. In
Tidal Percussion
This method is employed to distinguish whether the
cause of dullness over the lower part of the chest is
due to upward enlargement of liver or spleen, or due
Fig. 12.7: Defining the upper border of the liver by percussion. to an intrathoracic pathology. The technique is to
Part–I: Internal Medicine
expiration. Localised rhonchi should suggest e. Crunching sounds: These may be heard while
the possibility of bronchial obstruction due to auscultating over areas of surgical emphysema,
secretions, carcinoma, lymph nodes or a foreign and sometimes over pericarditis.
body. In diffuse interstitial pulmonary fibrosis f. Knocks: Sharp adventitious sounds may be
inspiratory wheezes may be heard over the produced by movement of the collapsed lung
lower parts of the chest. against the mediastinum on the side of a
b. Crackles (Syn: crepitations): Interrupted pneumothorax. At times pericardial knocks may
bubbling or crackling sounds are called be heard.
crepitations or rales. They are of two types:
Vocal Resonance
1. Fine crepitations: Mostly these are inspir-
atory and are produced by sudden opening The mechanism of production of vocal fremitus and
of intrapulmonary airways which are the method to elicit it have been described. The same
apposed during expiration. They are heard laryngeal vibrations can be auscultated over the chest
in the early stages of pneumonia and in heart wall. The patient is asked to repeat syllables like
failure. “one, two, three” or “ninety-nine” (in local
2. Coarse crepitations: These are produced by language) and the intensity and character of these
the movement of air through small and sounds are compared over corresponding areas of
medium air passages which are filled with the chest on both sides. The examiner should get an
fluid and the sudden opening of relatively idea of the normal intensity of vocal resonance in
Part–I: Internal Medicine
stiff alveoli as in fibrosing alveolitis. thin and stout individuals by practice. Increased
Sometimes, crepitations may be heard over vocal resonance is known as bronchophony. This is
the dependent parts of lungs after prolonged heard over areas of consolidation. Vocal resonance
recumbency, even in the absence of disease. is decreased or absent in pleural effusion and in
These disappear on coughing. Crepitations that pneumothorax.
persist even after coughing, and those which If the sounds are heard clearly and syllables can
appear or increase with coughing should be made out distinctly it is known as pectoriloquy.
suggest pathological lesions. In conditions like Pectoriloquy obtained when the patient whispers is
tuberculous cavities, lung abscess, and other known as whispering pectoriloquy. This is present
inflammatory lesions, crepitations become generally over areas where bronchial breathing is
more prominent after coughing (post-tussive present, such as consolidation, cavities comm-
crepitations). unicating with bronchi and others.
c. Pleural friction rub: It is a superficial, leather- In some cases of pleural effusion, above the level
creaking sound heard when the pleura is of effusion, the vocal resonance may be high pitched
thickened as in inflammation, malignancy or with a characteristic nasal quality. This is called
infarction. It is heard during the same phases egophony.
of the respiratory cycle, often during both Special Procedures in Auscultation
inspiration and expiration. It is not altered by
coughing. Succussion splash: This is a splashing sound which
d. Pleuropericardial sounds: If pleurisy and can be auscultated (even palpated at times) over a
pericarditis coexist, pleuropericardial rub may hydropneumothorax or a large superficial cavity
be heard when the lungs come into more containing air and fluid. While auscultating over the
intimate contact with the pericardium in upper level of fluid, the patient is shaken from side-
inspiration. The hallmark of pleuropericardial to-side and the splash of fluid can be heard. Presence
friction is accentuation when the breath is held of succussion splash is a definite evidence of
in inspiration. Sometimes friction rub may be presence of fluid and air in a cavity.
heard over a wider area and may not be limited Post-tussive suction: This is a sucking noise
to the precordium. produced when air rushes into a thin walled collapsed
Chapter 12: Examination of the Respiratory System 141
cavity during inspiration. It is generally heard over examiner auscultates from the opposite side.
superficial empty cavities communicating with Normally the lungs do not transmit the ringing
bronchi. metallic sounds distinctly. When there is free air
Method: While auscultating, the patient is made to between the areas, the sounds are heard with a
cough. Post-tussive suction is heard during the ringing metallic quality.
inspiration that follows.
Sputum
Post-tussive suction and post-tussive crepitations
strongly suggest the presence of cavitating lesions After completing the physical examination, special
in the lung. Thick walled cavities such as lung enquiry should be made regarding the quantity and
abscess and cavitating tumors do not collapse with nature of sputum. A specimen of fresh sputum should
coughing and therefore post-tussive suction may not be observed and taken for further examination.
be present in them. Tuberculous cavities commonly
give rise to this sign. A Scheme for Recording Physical Findings
Coin sound: This is a special auscultatory sign in the Respiratory System (Table 12.6)
which can be elicited over areas containing free air, Upper Respiratory Tract
such as pneumothorax, large pulmonary cysts, and
bullous emphysema. The chest is percussed at the Nose: Nostrils, nasal septum, sinuses
back or front using two coins (one acting as the Mouth: Mucous membrane, teeth, tongue
Variable Outcome
Contd...
Variable Outcome
Auscultation
Breath sounds -
Intensity Normal
Reduced
Increased
Type of breathing Normal-(vesicular)
Bronchial
If bronchial type Tubular, cavernous, amphoric
Added sounds Present
Absent
Rhonchi if present Sibilant, sonorous
Crepitations Present
Absent
If present Fine, coarse, others
Effect of coughing Disappears,
Remain the same,
Increase
Pleural friction rub Present-absent
Other adventitious
sounds if any Present-absent
Vocal resonance Normal, increased, decreased
Part–I: Internal Medicine
Whispering
Pectoriloquy Absent-present
Special physical findings
Upper border of dullness to percussion if pleural effusion is suspected Front, axilla, back
Shifting dullness Present-absent
Coin sound Present-absent
Local bulge with Present-absent
expansile impulse on
Coughing If present, details-nil
Sputum Normal amount only, increased. If increased, quality and character
Abnormality of sputum Purulent-watery-foul smelling-blood stained others
• There are no added sounds • Movements of the chest are reduced on the left
• Vocal resonance is decreased supra and infraclavicular regions.
Diagnosis: Pleural effusion right side. • Vocal fremitus is increased.
Note: In pneumothorax, all physical findings are • Percussion note is impaired
usually similar to that of pleural effusion except that • Breath sounds are cavernous over the left sup-
the percussion note is hyper-resonant on the affected raclavicular, suprascapular and infraclavicular
side. In pleural thickening mediastinal shift may not regions
be present and the affected side may not be bulging. • Coarse crepitations are present, increasing with
In later stages, the affected side may actually coughing (post-tussive crepitations)
retract due to fibrosis. • Vocal resonance is increased; whispering
pectoriloquy is present
Case 3
Diagnosis: Cavitation associated with fibrosis left
Male 30 years—dyspnea and cough following near upper lobe.
drowning 3 days ago. Physical examination of the chest helps to
• Position of the trachea is shifted to the right side detect gross physical alteration of the lungs and
• There is flattening of the right infraclavicular other intrathoracic structures. For arriving at the
region. Right shoulder is drooping etiological diagnosis, other clinical features help.
• Movements of the chest are diminished in this For example, development of consolidation of the
phony
Contd...
Contd..
13
1 Investigations in Respiratory
Diseases
C Sudheendra Ghosh
Examination of sputum, Radiology of the chest, Computed tomography, Magnetic resonance imaging,
FDG-PET, Bronchoscopy, Lung biopsy, Investigations in pleural diseases, Thoracoscopy and pulmonary
function tests
Fig. 13.1: Consolidation right upper zone. Note: Uniform Fig. 13.3: Fibrocavitary tuberculosis. Note: Bilateral diffuse
opacity with clearcut lower margins. No displacement of the and circumscribed opacities more in the upper zones with
mediastinum and trachea. Note also the air filled trachea and cavitation (central clearing-arrow)
bronchus (air bronchogram) common cause pneumonia
Part–I: Internal Medicine
Fig. 13.2: Middle lobe consolidation right. Note: Uniform Fig. 13.4: Lung abscess left upper zone. Note: The cavitary
haziness right midzone with clearcut margins. Common cause parenchymal lesion with horizontal air fluid level (arrow). Cavity
tuberculosis or pneumonia arrow points to air bronchogram is thick walled. Part of the pus has been coughed out
Fig. 13.5: Bilateral bronchiectasis more affected on the right Fig. 13.7: Collapse right lung. Note the uniform opacity caused
lower zone. Note the dialated ectatic bronchi which are filled by collapsed lung. Trachea (arrow) and mediastinum are
with exudates. Confirmation of the diagnosis is by displaced to the right (arrow)
bronchography or by CT
Fig. 13.6: Emphysema. Note hypertranslucency of the lungs, Fig. 13.8: Interstitial lung disease. Reticular shadows Part–I: Internal Medicine
enlarged lung volume, depressed diaphragm, and the inflated indicating diffuse inter- and intralobular septal thickening. See
appearance of the lungs. Arrow points to an emphysematous also CT scan
bulla with thin walls
Fig. 13.9: Bronchogenic carcinoma. Left upper/zone Fig. 13.11: Pulmonary metastases. Bilateral cannon ball
consolidation due to tumor and collapse. Rib erosion (arrow) shadows—common primaries thyroid, bone and viscera
suggests malignant lesion—bronchogenic carcinoma
Part–I: Internal Medicine
Fig. 13.10: Lymphoma. Note: The bilateral paratracheal lym- Fig. 13.12: Pleural effusion right. Note: Hazy opacity occupying
phadenopathy (arrowheads) is a common cause of mediastinal the right lower part, rising in the axilla (long arrow 1). The costo-
syndrome phrenic (short arrow 2) and cardiophrenic angle (arrowhead 3)
are obliterated in massive effusions, mediastinum is displaced
to the opposite side
Cavities, bullae and cysts: Ring shadows with Thin-walled cavities are seen in emphysematous
thin walls are called cavities. There may or may not bullae and congenital cysts. Bullae and cysts are
be fibrosis. The most common cause for cavities with clear without pulmonary markings within them.
surrounding fibrosis is pulmonary tuberculosis Unlike pneumothorax, they do not cause shift of the
(Fig. 13.3). mediastinum (Fig. 13.6).
Presence of fluid level in a cavity suggests lung
abscess. Abscess commonly results from breaking Coin Shadows
down of pneumonia. Necrosis of the center of a A single regular or irregular circular opacity of the
malignant lesion may also resemble abscess cavity size of a coin is a diagnostic problem. It can be due
(Fig. 13.4). to inflammatory lesions or benign or malignant
Chapter 13: Investigations in Respiratory Diseases 153
Fig. 13.13: Pneumothrax left. Note: 1. The increased trans- Fig. 13.14: Hydropneumothrax left. Note horizontal air fluid
lucency and absence of normal bronchovascular markings level indicating air above and fluid below with the margin in
2. Trachea and mediastinum shifted to opposite sides. between (arrow). This fluid level will shift with the position of
3. Collapsed lung margin (arrow) seen close to the hilum the patient
angle also, with a higher level towards the periphery 1. CT scan-conventional: Sections at 10 mm
and lower level medially. When the fluid is massive, interval are produced while the patients remain
the mediastinum and trachea are shifted to the stationary.
opposite side. When the fluid is small in amount, a 2. High resolution CT (HRCT): In this the sections
lateral view is more helpful to demonstrate fluid are made at 2 mm thickness.
more clearly in the posterior diaphragmatic recess. 3. Volumetric spiral/helical CT.
Even when the pleural fluid collection is only 100 Spiral CT is a recently introduced advancement
mL, the lateral view reveals it, whereas larger in technology. In spiral CT, large volume of the
amount (200 mL, or more) are only clearly visible thorax can be imaged in a single breath hold. In
as blunting of the costophrenic angles in the PA view conventional CT, repeated breath holdings are
(Fig. 13.12). needed. If the patient does not breathe to the same
extent for all pictures, for each section misregis-
Lateral Decubitus Position
tration of sequential events may lead to non-
This view helps to distinguish the presence of fluid recognition of small lesions.
in pleural cavities from fluid in cavities in the lungs
and to differentiate a solid mass from free pleural Indications for Chest CT
fluid. The patient lies on the affected side for 15 CT is used as a second line diagnostic study for
minutes by which time free fluid in the pleural cavity problems that are unresolved by plain X-ray films.
gravitates to the dependent part. PA film taken in
Part–I: Internal Medicine
Fig. 13.15: CT showing bilateral bronchiectasis. Fig. 13.17: CT showing extrinsic allergic alveolitis.
Note: Dilated cystic bronchi on both sides (arrows) Note: Reticulonodular shadows distributed bilaterally
FLUORODEOXYGLUCOSE POSITRON
EMISSION TOMOGRAPHY (FDG-PET)
FDG-PET is a nuclear medicine technique that labels
the glycolytic pathway of tumor cells or other
metabolically active cells to identify glucose-avid
tissues. This has better sensitivity and specificity
for detecting lymph node metastases. This can help
to direct the surgeon toward particular lymph node
groups that show increased activity on PET
scanning. PET scan when combined with CT scan
Fig. 13.16: CT showing honey-comb lung in interstial pul- (PET-CT) can yield better anatomical resolution and
monary fibrosis (IPF). Note: The multiple lesions, more disease activity status.
abundant in the lower zones
for removing foreign bodies. It also provides a better techniques fail. Biopsy is also necessary to institute
airway, especially during bronchoscopy in patients appropriate anticancer therapy which relies a great
with hemoptysis. deal on the histological picture.
The flexible fibreoptic bronchoscope is more Lung biopsy can be done through a bronchoscope
popular. It can be introduced under local anesthesia or percutaneously.
as a bed side procedure and can reach upto peripheral
airways. It can visualize the upper lobe and its Transbronchial Lung Biopsy
segments. Transbronchial biopsies and bronchoal- Through the bronchoscope, the biopsy forceps is
veolar lavage from specific areas can be done with introduced and a piece of tissue is biopsied.
this instrument. A side attachment permits a second
Percutaneous Needle Biopsy
person also to watch the bronchoscopy.
Several instruments are available. Fine needle
Indications for Bronchoscopy aspiration biopsy is done using a thin long needle. It
1. Mass lesions, unresolved pneumonias, suspected is helpful in the diagnosis of lesions situated close
malignancy to the chest wall beyond reach of the bronchoscope.
2. Hemoptysis—both as an emergency or elective The site for biopsy can be determined from PA and
procedure lateral view skiagrams.
3. Diagnosis of endobronchial lesions, strictures and Transthoracic needle aspiration can be done
atelectasis using needles of 18 to 24 gauge size passed through
Part–I: Internal Medicine
4. To obtain specimens by bronchial brushing, the chest wall under ultrasonographic, fluroscopic
bronchoalveolar lavage and biopsies. or CT guidance, after anesthetising the part. The
aspirate is subjected to cytological examination and
Bronchoalveolar Lavage (BAL)
microbiological tests to identify bacterial and fungal
This procedure is done to obtain washings from organisms. Transthoracic needle aspiration is of
a particular region of the bronchial tree. It is great value in the diagnosis of solitary pulmonary
of diagnostic value in infective conditions, neo- nodules and other peripherally-situated lesions.
plasms, pulmonary alveolar proteinosis and Other instruments used for lung biopsy include
sarcoidosis. It is particularly useful to get cytological the screw needle, cutting needles (Trucut and Vim
specimen from peripheral neoplasms. Around 5 to Silvermann’s) and trephines. With simple, unaided
10 ml of normal saline is instilled into the segmental biopsy procedure, the success rate is around only
or lobar bronchus through the suction line of fiber- 10%. Complications include hemorrhage and
optic bronchoscope and immediately aspirated back. pneumothorax.
The specimen is collected in a suitable receptacle
for biochemical, cytological and microbiological INVESTIGATIONS IN PLEURAL DISEASES
studies.
Endobronchial Ultrasound Guided Needle In addition to radiography, other main investigations
Aspiration (EBUS-NA) and Endoscopic Ultra- include study of the pleural fluid, pleural biopsy,
sound Guided Needle Aspiration (EUS-NA) use diagnostic artificial pneumothorax and CT scan. In
bronchoscope/endoscope with an ultrasound probe pleural effusion due to respiratory diseases, pleural
at the end and a working channel through which a aspiration should be done without fail. In pleural
catheter with a needle can be passed. Both tests allow effusion occurring as part of generalized edema,
direct visualization of the lesion being sampled. The pleural aspiration is often avoided, if the fluid clears
CT fluoroscopy and virtual bronchoscopy are other when the edema is treated.
investigations undertaken at times.
Indications for Pleural Aspiration
LUNG BIOPSY Therapeutic
This is done to establish the diagnosis in localized a. As an emergency life-saving procedure: When a
or generalized lesions when other noninvasive massive pleural effusion or bilateral pleural
Chapter 13: Investigations in Respiratory Diseases 157
4. Injury to lung by the aspirating needle gives rise Common causes of exudate effusion: All forms
to hemothorax, pneumothorax or hemoptysis. This of pleurisy—tuberculosis, pyogenic infections, viral
should be avoided by suitable positioning of the infections, dyscollagenoses, malignant lesions.
needle tip and gentle withdrawal of the needle as
Causes of hemorrhagic pleural fluid: Malig-
the pleural space is emptied.
nancy, pulmonary infarction, traumatic lesions,
5. Accidental entry of air into the pleura converts
hemorrhagic diseases, occasionally tuberculous
pleural effusion into hydropneumothorax. This
pleural effusions.
should be avoided by taking proper care during
aspiration. In most of the cases the air gets Chylous Fluid
absorbed even without special measures.
True chylous fluid is caused by the presence of fat
6. Infection of the pleura: This leads to the deve-
globules and it clears on adding fat solvents like
lopment of pyothorax. This should be prevented
ether. This occurs in lymphatic obstruction caused
by following strict asepsis.
by malignant secondaries and filariasis. Pseudochy-
lous appearance is due to the presence of disintegrated
Examination of Pleural Fluid
leukocytes. This does not clear on adding ether.
Gross Appearance Common biochemical tests done on the pleural fluid
The pleural fluid may be clear and watery, straw are the estimation of proteins, LDH, adenosine
colored, turbid, hemorrhagic, milky or purulent. It deaminase and interferon gamma. Adenosine
Part–I: Internal Medicine
may be a transudate or exudate (Table 13.3). deaminase (ADA) and interferon gamma levels in
pleural fluid may help to determine the etiology.
Common causes of transudate effusion: All cause ADA levels > 70 units/L and/or interferon gamma
of gross generalized edema such as congestive heart levels > 200 pg/mL are virtually diagnostic of
failure, nephrotic syndrome, hypoproteinemia and tuberculous infections. These may be required only
cirrhosis of liver may be accompanied by passive in very exceptional circumstances.
pleural effusion, which clears up along with the
generalized edema on treatment. Microbiological Tests
Tests for infective agents reveal the pathogens in
Table 13.3: Differences between transudates and exudates
most of the cases. In simple pleural effusion direct
Characteristics Transudate Exudates smear for AFB is often negative, but in tuberculous
Specific gravity Below 1010 Above 1010 empyema AFB may be numerous.
Appearance Clear and thin Thick and opalascent or opaque
Protein content Below 3g/dL Above 3g /dL Pleural Biopsy
Microscopy Only a few cells Increase in leukocytes and When the diagnosis of pleural disease is still in
presence of malignant cells.
doubt, histological and microbiological studies can
Lymphocytes increase in tuber-
culosis. Neutrophils are increased be undertaken with pleural biopsy specimens. Biopsy
in pyogenic infections. Eosino- is better performed by the specialist. In some centers,
phils are increased in tropical biopsy is done along with the first pleural aspiration
eosinophilia, allergic disorders,
helminthiasis and fungal infections itself.
Microbiology Fluid is sterile Presence of organisms can be
detected in infective conditions THORACOSCOPY
Pleural fluid/ < 0.5 >0.5
serum proteins ratio When pleural lesions have to be visualized in situ,
Pleural fluid /serum < 0.6 > 0.6 the surface of the pleura can be inspected using a
LDH ratio thoracoscope after producing a pneumothorax.
LDH concentration Less than More than 2/3 of upper limit of Biopsy from abnormal areas can be done. This
2/3 of upper normal serum LDH
increases the accuracy of diagnosis. Open lung
limit of normal
serum LDH biopsy is also done at times after doing thoracotomy.
Chapter 13: Investigations in Respiratory Diseases 159
Selection of Respiratory
Function Tests
Studies of Ventilation
Fig. 13.18: Showing lung capacities by spirometry Indications: Obstructive airway disease, bronchial
asthma, chronic bronchitis with emphysema, pleural
diseases, respiratory paralysis and others.
Studies of Arterial Perfusion of the Lungs
Indications: Suspected pulmonary embolism or
multiple infarction, pneumonias, malignancy.
Studies on Diffusion of Gases Across the
Alveolar Membrane
Indications: Alveolocapillary block syndromes such
as pulmonary interstinal fibrosis, diffuse hyaline
membrane disease in newborns, adult respiratory
Fig. 13.19: Spirometry volume-time curve distress syndrome and others.
160 Section 5: Respiratory System
hemoglobin can hold. The SaO 2 value In acute respiratory acidosis, for every 1mm rise
corresponding to PaO2 of 95 ± 5 mm Hg in a normal in PaCO2 the pH falls by 0.008. On the other
young adult is 97%. Arterial carbon dioxide is hand, in chronic respiratory acidosis, for every
expressed only as its tension. Normal PaCO2 is 40 1 mm rise in PaCO2 the pH falls by only 0.003.
± 2 mm Hg. In respiratory failure, PaO2 falls and
Respiratory alkalosis: This is alkalosis developing
PaCO2 rises. The levels of these gases in blood
as a result of excess blowing out of carbon dioxide
depend upon the type of respiratory failure. All
occurring in hyperventilation. In acute respiratory
diseases which lead to hypoventilation, diffusion
alkalosis for every 1mm fall in PaCO2 the pH rises
defects and ventilation perfusion abnormalities
decrease PaO2. The PaO2 may fall to levels as low by 0.008. In chronic respiratory alkalosis, for every
as 40 mm Hg in both obstructive and restrictive lung 1mm fall in PaCO2 the pH rises only by 0.017. For
diseases. Conditions associated with alveolar every 1mEq/L fall in HCO3 the corresponding fall
hypoventilation such as asthma, chronic bronchitis in PaCO2 is 1.2 mmHg.
and emphysema lead to rise in PaCO2 as well. Arterial plasma bicarbonate is 24 ± 2 mEq/L.
Arterial blood pH is 7.40 ± 0.02. Acidosis leads
Major causes of hypoxemia are: to fall in pH and alkalosis to rise in pH (Table 13.5).
1. Reduction in oxygen content of inspired air
2. Generalized hypoventilation Method of Blood Collection for
3. Ventilation perfusion imbalance Arterial Gas Studies
6
Cardiovascular System
CHAPTER
14
1 General Considerations
General considerations, Sequence of cardiac contraction, Arterial supply of heart, Nerve supply, Arterial
blood pressure, Heart failure, Patterns of cardiovascular diseases seen in India
GENERAL CONSIDERATIONS surface area. Normal cardiac index is 3.4 L/m2/ min
(range 2.8–4.2). Cardiac output is governed by
The adult human heart weighs 250 to 350 g. Sixty several factors such as effective venous return,
percent of the weight of the heart is constituted by heart rate, distensibility of the ventricles to receive
the left ventricle. The left ventricle is 1 to 1.5 cm in blood in diastole (i.e. compliance), contractile
thickness, the right ventricle is about 0.5 cm thick. force, obstruction to atrial or ventricular outflow
The intrinsic properties of cardiac muscle include and blood pressure. In health, the cardiac output
excitability, contractility, rhythmicity, conductivity can be increased to 20 L or more during exercise
and distensibility. In normal hearts, increase in fiber or emotional reactions. This is achieved by increa-
length by distension leads to increase in force of sing the heart rate (acceleration) and contractile
contraction. This is Starling’s law. When the heart force (augmentation).
muscle is diseased, this relationship is deranged.
Energy for the myocardium is derived from the Conditions Causing Increased
metabolism of free fatty acids, glucose, lactate, Cardiac Output
pyruvate and ketoacids. Heart uses 8 to 10 mL of Exercise, emotional excitement, fever, thyrotoxi-
oxygen per minute. The myocardial oxygen demand cosis, anemia, pregnancy, beriberi, Paget’s disease
during systole is three times that during diastole. of bone, A-V malformations.
Both systolic contraction and diastolic relaxation are
active energy dependent processes and when the Conditions Causing Decreased
heart muscle is diseased, both these functions may Cardiac Output
be deranged in varying degrees. 1. Reduction in venous return into the atria as in
hypovolemic shock.
Stroke Volume, Cardiac Output and 2. Extreme tachycardia above 150/mt—the diastolic
Cardiac Index interval is shortened so that ventricular filling is
Stroke volume is the amount of blood ejected by reduced.
the ventricles during each cardiac systole. It ranges 3. Extreme bradycardia—heart rate below 40/minute.
from 65 to 75 mL. Cardiac output is the total amount 4. Weakness of myocardial contraction as in
of blood ejected by each ventricle per minute and myocarditis, cardiomyopathy, cardiac failure and
it is the product of heart rate and stroke volume. cardiogenic shock.
In a healthy individual, it is around 5 to 6 liters. 5. Anatomical or functional obstruction to inflow
Cardiac index is the term denoting the output of or outflow from cardiac chambers as in valvular
each ventricle per minute per square meter of body heart diseases.
166 Section 6: Cardiovascular System
6. Arrhythmias such as atrial fibrillation. The booster branches of the aorta. They fill during diastole and
effect of atrial contraction on ventricular filling the coronary blood flow is lesser during systole.
is abolished. Right coronary artery supplies right atrium, right
ventricle, posterior aspect of interventricular septum
SEQUENCE OF CARDIAC CONTRACTION and posterior wall of left ventricle. In addition, it
When the heart rate is 70 to 80/ minute, each cardiac supplies the SA and AV nodes and therefore
cycle lasts for about 0.8 sec. The atria contract for occlusion of this artery leads to arrhythmias. The
0.1 sec preceding ventricular contraction. Atrial coronary artery which supplies the crux of the heart
diastole lasts for 0.7 sec during which time venous posteriorly and gives rise to the posterior descending
blood freely flows into the atria to fill them. Blood artery is the dominant one. In the majority the right
flow from atria to ventricles starts as a passive coronary artery is dominant. Left coronary artery
process beginning with the opening of the A-V valves supplies the left atrium, anterior part of the septum,
in ventricular diastole. Initial phase of ventricular and anterior and lateral parts of left ventricle. Major
filling is rapid, later it slows down. Atrial systole portion of the left ventricle is supplied by the left
helps to pump blood actively into the ventricles and coronary artery and therefore total occlusion of this
this distending force on the ventricles acts as a artery leads to major left ventricular infarction.
booster for ventricular contraction. Atrial systole is The arteries enter from the outer surface of the
not absolutely essential for ventricular filling, but heart and the branches pass inwards. The epicardial
Part–I: Internal Medicine
its absence, as is seen in atrial fibrillation, leads to aspect of the myocardium is better perfused than
fall in cardiac output. This effect is clinically more subendocardial region. Arterial blood flow to the
pronounced in a diseased heart with anatomical or myocardium is 72 to 82 ml/100 g/minute. There is
functional abnormalities. no free communication between the branches of the
Ventricular systole takes 0.3 sec and diastole 0.5 two coronary arteries. Occlusion of a major branch
sec. The first event in ventricular systole is closure leads to irreversible myocardial necrosis within six
of A-V valves and this coincides with the first heart hours. In chronic ischemic heart disease some degree
sound. The initial part of ventricular systole is of collateral circulation develops and protective
isovolumetric contraction, with both A-V and adaptation may occur.
semilunar valves closed. During this period The inside of the heart is lined by endocardium
intraventricular pressures work up and when they which is reflected on to the valves. The A-V valves
reach the diastolic pressures in the aorta and are held on their ventricular aspect by the chordae
pulmonary artery, the semilunar valves open and tendinae of the papillary muscles, which also
ventricular ejection starts. The rate of ejection contract during systole, thereby preventing prolapse
increases during midsystole and when 65 to 75% of of the valve cusps into the atria. Dysfunction of the
ventricular blood is ejected, the rate of ejection papillary muscles results in mitral incompetence.
comes down, and the semilunar valves close a bit The pericardium covers the outer surface of the
later. This coincides with the second heart sound heart. Between the visceral and parietal layers there
which marks the onset of diastole. Initial phase of is just enough fluid for lubricating the surfaces.
relaxation is isovolumetric relaxation with both
A-V valves and semilunar valves remaining closed. NERVE SUPPLY
During this phase, the intraventricular pressure Nerve supply to the heart is derived from the
drops. The A-V valves open when the ventricular autonomic system which supplies the conducting
pressure falls below the atrial pressure to allow rapid system as well as muscle fibers. Vagus is the
ventricular filling. The rate of ventricular filling parasympathetic component. It supplies cholinergic
slows down as the flow proceeds and is augmented parasympathetic fibers mainly to SA and AV nodes
by atrial contraction just before the first heart sound. through M2 muscarinic receptors. It reduces the rate
of SA node and increases the refractory period.
ARTERIAL SUPPLY OF THE HEART
Sympathetic fibers are derived from the cervical
Blood supply to the myocardium is derived from the and upper thoracic ganglia. B1 receptors predominate
right and left coronary arteries, arising as the first in the heart. Both adrenaline and noradrenaline have
Chapter 14: General Considerations 167
pulmonale top the list and they account for most of sinus syndrome and drugs like digoxin account for
the cardiac morbidity. the majority.
The prevalence of ischemic heart disease in India All types of heart diseases described in other
varies from 5 to 7% in the rural areas to 10 to 12% parts of the world are present in India. In addition
in urban population. some cardiovascular problems are more prevalent,
Hypertension is very prevalent. The limited for example, endomyocardial fibrosis, aorto-
surveys give figures as low as 5% among tribal arteritis, thromboangiitis obliterans and poisoning
populations, between 20 to 30% in rural areas and by cardiotoxic vegetable poisons such as Cerbera
as high as 30% in the urban population. Hypertensive odollam, Nerium oleander and Cleistanthus collinus
heart disease and strokes are common. leaf.
Many studies report the prevalence of abnormal
Clinically diagnosed pulmonary embolism is
blood lipid levels (cholesterol, triglyceride, low
less common and the prevalence reported from
density lipoproteins—LDL), lipoprotein-A (LpA)
and others in the rural (20–30%) and urban autopsied cases also seems to be less in India.
(30–40%) population. These predispose to atheroma Infective endocarditis is not uncommon. Very often
and ischemic heart disease. this supervenes on congenital and acquired heart
Diabetes mellitus is another coronary risk factor lesions. Mitral valve prolapse and bicuspid aortic
with increasing prevalence both in urban and rural valve are two common conditions that predispose to
infective endocarditis in apparently healthy persons.
Part–I: Internal Medicine
Examination of the
15
1 Cardiovascular System
Dyspnea, Chest pain of cardiac origin, Palpitation, Hemoptysis, Syncope, Edema, Cyanosis, Fatigue,
Cough, Symptoms related to arteries, Symptoms related to veins, Past history, Physical examination-
general examination, Examination of pulse, Examination of jugular veins, Examination of chest, Palpation
of the precordium, Percussion of precordium, Auscultation of the heart and blood vessels, Recording of
blood pressure
For purposes of uniformity in quantitation, the Dyspnea due to cardiac causes Dyspnea due to respiratory causes
New York Heart Association (NYHA) classification Primary mechanism is Primary mechanism is
of functional status is commonly used to describe pulmonary congestion bronchoconstriction
symptoms such as dyspnea, chest pain, fatigue and Dyspnea often gets relieved Dyspnea often persists even after
palpitation. on assuming the erect posture assuming the erect posture
Past history of cardiac Past history of asthma, COPD and
NYHA Functional Classification illnesses or other cardiac respiratory symptoms such as
symptoms like palpitation or cough or wheeze
Class I Dyspnea occurring at heavy, but accustomed angina
activity Physical examination Physical examination reveals
Class II Dyspnea occurring on moderate exertion reveals cardiomegaly, marked expiratory wheeze
Class III Dyspnea during mild exertion or during daily S3 gallop, cardiac murmurs and rhonchi
routine activities and basal crepitations
Class IV Dyspnea even at rest.
Note: At times the distinction between cardiac and respiratory causes for acute
dyspnea may not be clear cut. Rarely these conditions may also coexist
Paroxysmal Nocturnal Dyspnea
Paroxysmal nocturnal dyspnea (PND) term refers
to the sudden onset of severe dyspnea occurring in a Orthopnea
cardiac patient during sleep at night. Though This is the condition in which the patient has dyspnea
classically described as nocturnal, it can also occur on lying supine, but gets relief in the sitting or
during day if the circumstances permit. The patient propped up position. Increased venous return from
Part–I: Internal Medicine
who goes to sleep comfortably is awakened suddenly the lower limbs in the supine posture precipitates
within 1 to 2 hours by acute shortness of breath and cardiac decompensation and pulmonary venous
cough with frothy blood stained sputum. He is congestion in the presence of left ventricular failure.
apprehensive and distressed. He gets relief by sitting Moreover the pressure of the abdominal viscera on
up, reclining in a chair or even walking to an open the diaphragm in the supine posture contributes to
window to get fresh air. These attacks are highly the dyspnea. However, patients with respiratory
suggestive of severe pulmonary venous congestion ailments such as bronchial asthma and emphysema
secondary to left ventricular failure or mitral stenosis. also prefer the sitting position since the ventilatory
mechanics are more efficient in the upright or sitting
Mechanisms of PND
position.
• When the patient assumes recumbency, the
increase in venous return from the lower limbs
CHEST PAIN OF CARDIAC ORIGIN
combined with the reabsorption of the edema fluid
leads to increased central blood volume. In the Chest pain is an important symptom of cardiac
failing heart, the left sided chambers cannot cope diseases especially in ischemic heart disease, which
up with this increased inflow and this leads to is more common above the age of 45 years but no
pulmonary congestion. age is exempt. Chest pain occurring in age groups
• Diurnal variations in the secretion of ADH cause below 30 years is less likely to be of ischemic heart
fluid retention nocturnally during sleep, disease. Chest pain due to cardiac causes has
worsening the pulmonary congestion. to be differentiated from noncardiac chest pain.
• Diminished sympathetic nervous system activity Endocardium is not pain sensitive, but diseases
during sleep leading to diminution of the affecting the myocardium, especially ischemia and
catecholamine support to the failing myocardium pericarditis present with chest pain. In myocardial
at night is another mechanism. ischemia, accumulation of metabolic products
• Association with the REM phase of sleep and stimulates the local nerve endings. Afferent
proneness for arrhythmias is this period may impulses are carried to the lower cervical and first
contribute to pulmonary congestion and PND. thoracic ganglia through the cardiac sympathetic
These are some of the reasons for worsening of nerves. Referred pain is felt diffusely over the
dyspnea at night. dermatomes supplied by these ganglia.
PND has to be distinguished from acute attacks Primary reduction in coronary arterial blood flow
of bronchial asthma. occurs when the coronary arteries are narrowed,
Chapter 15: Examination of the Cardiovascular System 171
most frequently due to atherosclerosis. Critical Typical effort angina is precipitated by exertion
obstruction (> 70% of the lumen) of the major and relieved promptly by rest within seconds or
coronary arteries leads to myocardial ischemia. minutes and usually it does not last more than 10
Often in addition to the major arteries distal branches minutes. It is also relieved by the administration of
may also be occluded. vasodilators such as nitrates, within 3 to 5 minutes.
Less commonly primary non-atherosclerotic The classical description of angina holds good only
involvement of the coronary arteries may occur in 30 to 50% of cases. In the others, the pain is
in various forms of vasculitis such as polyarteritis atypical, and in many, myocardial ischemia may be
nodosa and Kawasaki’s disease and also in totally silent (silent myocardial ischemia, e.g.
thromboangiitis obliterans. diabetes, old age).
In addition to the primary lesions in the blood Prinzmetal’s Angina (Syn: Variant Angina)
vessels, other precipitating factors worsen ischemia.
In this variant of angina, coronary artery spasm plays
These include exertion, emotional disturbances,
the major role in precipitating angina. Spasm may
tachycardia, anemia, high altitude and others.
occur de novo, but it supervenes most frequently on
Angina may also result from primary reduction diseased coronary vessels. The pain is similar to
of coronary blood flow without any increase in effort angina, but the clinical picture differs in the
myocardial oxygen demand, as is seen in coronary following points.
artery spasm. Rarely under exceptional circumstances 1. Also common in women.
Patients presenting with new onset angina of less of heart attack among the general population, several
than two months duration or progressive aggravation patients come to hospital early, often within a few
of symptoms in the recent past (within two months), hours. But rarely the patient may present much later
or angina following an acute myocardial infarction with pain of longer duration, because of its atypical
are considered to have “unstable angina”. Prognosis nature or lack of awareness of the condition.
of unstable angina is worse since the majority of Acute myocardial infarction is due to the total
such patients have severe and progressive coronary occlusion of blood flow through a major epicardial
artery disease which may lead to acute myocardial coronary artery and this, in over 90% of instances
infarction or fatal arrhythmias. The Braunwald’s is due to thrombus.
classification of unstable angina helps in under- Patients presenting with myocardial infarction
standing the different types of unstable angina. on the basis of the findings in the initial electro-
A patient with chronic stable angina should be cardiogram are described as having STEMI (ST
considered to have gone into the unstable phase when elevation myocardial infarction) and NSTEMI
he develops any of the following features within the (Non ST elevation myocardial infarction). This is
preceding two months: important for deciding on the mode of therapy and
1. Increased frequency, severity, or duration of pain. for triaging patients accordingly. Patients having
2. Angina occurring with decreasing levels of STEMI should be channeled into the appropriate
exertion. reperfusion strategy viz, thrombolytic treatment or
3. Pain occurring even at rest.
Part–I: Internal Medicine
arrhythmias such as atrial fibrillation, ectopic beats may be the distended pulmonary artery or it may be
and lesser degrees of heart block. due to right ventricular myocardial ischemia.
It should be remembered that the classical Pulmonary embolism is another condition
description of the onset of myocardial infarction causing chest pain, often associated with severe
occurs only in one-third of the patients. In 30%, dyspnea and hypoxia with clear lung fileds. Chest
the pain may be atypical or may even be absent. pain occurs due to the moderate sized pulmonary
It is therefore a golden rule in all cases of chest infarcts which involve the pleura and the pain is often
pain, however typical or atypical it may be, to due to the pleurisy.
record the electrocardiogram (ECG) to confirm Other frequent causes of chest pain which mimic
or exclude the presence of myocardial ischemia. cardiac pain include anxiety neurosis, (cardiac
The ECG gives valuable information in over 80% neurosis or Dacosta syndrome, costochondritis,
of cases straight away. preherpetic neuralgia and pain referred from
Ischemic heart disease is rare among normal abdominal organs). Also refer Table 12.3 in Chapter
women who have not attained menopause. Smoking, 12 for further details.
diabetes mellitus and menopause abolish this Pain which is fairly localized, superficial,
gender protection females have. Diabetic women, inframammary and in which the patient can often
particularly smokers have a much higher risk of point to the site of pain often tends to be of non-
developing ischemic heart disease. Women attain the cardiac origin. Such pain may also be variable in
neck and eyes, or drinking ice cold water, it is cerebral hypoxia. Since brain is the largest consumer
indicative of paroxysmal atrial tachycardia. Cessation of oxygen, and its oxygen need is the highest,
of paroxysmal atrial tachycardia, intermittent atrial reduction in arterial blood flow promptly manifests
fibrillation and atrial flutter are often accompanied as syncope within seconds to minutes. Prolongation
by diuresis. of ischemia beyond a few minutes results in
Bradyarrhythmias also can manifest as irreversible neuronal damage—the syndrome of
palpitation. In complete heart block since the heart brain death.
rate is very slow, and diastolic interval is long, The clinical picture is characterized by rapid
increased filling of the ventricle leads to increase in onset of dizziness, dimness of vision, loss of tone
stroke volume and forceful contraction. This gives and slumping to the ground in an unconscious state.
rise to palpitation. The patient may complain of This may be accompanied by vasomotor phenom-
regular forceful heart beats. In sick sinus syndrome ena such as coldness of limbs and profuse sweating.
brady and tachycardias produce palpitation. The pulse may be rapid, slow or absent. Blood
Volume overload of the ventricles can cause pressure is often very low. On assuming the
palpitation due to the forceful contraction. Aortic or recumbent posture cerebral flow improves and the
mitral regurgitation in which left ventricular stroke patient recovers. If restoration of cerebral flow is
volume is increased and atrial septal defect in which delayed due to any reason, convulsions may develop.
right ventricular stroke volume is increased may Syncope may result from several cardiac and
present with palpitation as the main symptom. vascular disorders (Table 15.1). Cardiac syncope is
Part–I: Internal Medicine
cause syncope on exertion. In these conditions, the Table 15.2: Points to distinguish syncope from epilepsy
cardiac output remains fixed and the increased blood Clinical feature Syncope Epilepsy
flow to the exercising muscles causes a transient
Loss of consciousness Occurs within Occurs within a split
relative diminution of cerebral blood flow leading seconds to minutes second
to syncope. Postural hypotension, and hypovolemia Dizziness
resulting from dehydration, blood loss or shock can Premonition Blurring of vision, Aura may be present
also cause syncope. Vasovagal attacks usually occur sweating
in response to emotional or painful stimuli. It is Posture Occurs during erect Not related to
posture and is relieved posture
characterized by fall of blood pressure and an in recumbent posture
inappropriately low heart rate, and is accompanied Fall Often slumps to the Falls heavily
by profound vasodilatation. ground
Assumption of supine posture may abort a Recovery of Rapid, on adopting Passes through the
vasovagal attack. Syncope resulting from leaning, consciousness flat position classical stages
postictal, unconsci-
bending or other postural variations should make ousness may persist
one suspect a left atrial myxoma which obstructs Injuries Usually absent Injuries may be
the mitral orifice in these positions. Syncope caused by fall, biting
associated with micturition or following prolonged of tongue, etc.
coughing-referred to as micturition syncope or post- Recall Can recall history on Has no recall of what
recovery happened
tussive syncope respectively, is due to a reduction
fibrosis, chronic venous congestion of the liver leads in hoarseness of voice and cough. Persons receiving
to cardiac cirrhosis. In these conditions ascites tends angiotensin converting enzyme inhibitors may
to be more prominent than peripheral edema (See develop troublesome cough as an adverse side effect.
also Chapter 2 General Examination). Patients with chronic venous congestion of lungs are
prone to develop recurrent pulmonary infections
CYANOSIS which also contribute to the cough (See also
Cyanosis is bluish discoloration of lips, finger tips Table 12.1 in Chpater 12).
and mucous membranes due to increased levels of
deoxygenated hemoglobin in the capillary blood SYMPTOMS RELATED TO ARTERIES
above 5 g/dL. In congenital heart disease, cyanosis Gradual occlusion of arteries leads to intermittent
develops when the right to left shunt exceeds 25% claudication. This is the occurrence of cramp like
of left ventricular output. Cyanosis is manifested pain over the muscles brought on by exertion and
from birth in conditions like transposition of great relieved by rest. As the occlusion becomes more
vessels and tricuspid atresia. Cyanosis setting in after severe, rest pain occurs. This is excruciating pain
six months of age is the picture in tetralogy of Fallot disturbing sleep. Infection in the limb worsens the
(TOF). Onset of cyanosis between 5 and 20 years is pain. A common cause of occlusion of peripheral
suggestive of Eisenmenger’s reaction. When patent arteries is atheroma. This is often associated with
ductus arteriosus (PDA) goes in for Eisenmenger’s atheroma of coronary and cerebral arteries as well.
reaction, differential cyanosis occurs, the lower
Part–I: Internal Medicine
Table 15.3:
Somatic abnormalities and congenital cardiac Cyanotic spells are attacks of intense cyanosis
defects accompanied by marked breathlessness and
Condition Chromosomal/ Cardiac Associated disappearance of cardiac murmurs. These occur
Genetic defect defects abnormalities
commonly in tetralogy of Fallot. These are often
Down Trisomy 21 AV canal Epicanthal fold, precipitated by feeding, crying or exertion.
syndrome defects, upslanted eyes,
VSD, ASD flat face, brachy Central cyanosis gives rise to secondary
cephaly polycythemia and the increased viscosity of blood
Turner’s 45XO- Bicuspid Short stature, low
syndrome Monosomy aortic valve, ears, nuchal skin
predisposes to thrombotic accidents, especially in
Coarctation excess, wide set cerebral veins.
nipples Clubbing of the fingers and toes is of severe
William’s Deletion 7q Supravalvular Mental retardation,
syndrome 11.23 AS face and teeth
degree (grade 4) in cyanotic congenital heart disease.
abnormalities Clubbing is also a feature of infective endocarditis.
Holt Oram Mutations on ASD, VSD Hand abnormalities In infective endocarditis clubbing may develop over
syndrome gene 12q24 especially of the normal nails within weeks or months and these are
radius, phocomelia
Ellis Van Mutations on ASD,Common Short limbs, short
of lower grades. They are painful. Painful clubbing
Creveld gene 4p16.1 atrium ribs,polydactyly, may also be a feature of hypertrophic osteoarthopathy,
syndrome dysplastic nails, associated often with malignant lesions such as
teeth
bronchogenic carcinoma and this has to be borne in
Noonan Mutations in PS, HCM Mental retardation,
Part–I: Internal Medicine
syndrome gene 12q22 facial dysmorpism mind. Splinter hemorrhages may develop under the
Leopard Mutations PS, HCM Lentigens, ocular distal third of the nails (Refer Fig. 2.21). Osler’s
syndrome in gene 12q22 hypertelorism nodes are painful red macules over the palms and
abnormal genitals,
retarded growth, soles. Janeway lesions are small painless macules,
deafness a few mm in diameter found on the palms and soles.
Long QT Autosomal Long QT With or without Roth’s spots are seen in the retina.
syndrome dominant/ interval, deafness
recessive sudden cardiac
death (SCD) Temperature of the Extremities and Color
Brugada Mutations in ECG variation SCD, VT, When the arterial circulation is adequate the
syndrome SCN5A SCD Syncope
extremities are warm and normal in colour. Presence
be demonstrable only after several liters of edema of warm extremities point to normal cardiac output
fluid have accumulated in the system. or high output states. Vasoconstriction leads to pallor.
Coldness of extremities points to reduction in the
Cyanosis and Clubbing arterial blood flow. In low output states the extremities
Central cyanosis occurs in cyanotic congenital heart are cold.
diseases, such as tetralogy of Fallot, transposition Extreme coldness of one limb or a part should
of great vessels, truncus arteriosus, total anomalous suggest the occurrence of arterial occlusion.
pulmonary venous drainage, tricuspid atresia,
pulmonary atresia, Ebstein’s anomaly, double outlet Edema
ventricles etc. In most of them cyanosis is present
at birth or develop a few months later. Peripheral edema occurs in right sided heart failure.
Look for pitting edema by pressure below the medial
Conditions where there is left to right shunt such
malleoli in ambulant subjects and over the sacrum
as uncomplicated ventricular septal defect (VSD),
atrial septal defect (ASD) and patent ductus in bedridden patients (Refer Figs 2.28A and B).
arteriosus (PDA) are acyanotic for considerable Pulmonary edema is a complication of left
periods of time, often up to 3 or 4 decades or more. sided heart failure. Pulmonary edema leds to cough
With the development of secondary pulmonary and dyspnea. Auscultation reveals persistent
hypertension the shunt reverses and entry of right crepitations over the dependent regions of the lung.
sided blood into left side gives rise to cyanosis. This The sputum is watery and may show fresh blood
phenomenon is called Eisenmenger’s syndrome. streaking.
Chapter 15: Examination of the Cardiovascular System 179
EXAMINATION OF PULSE
Pulse represents the expansile impulse produced by
ventricular ejection and transmitted along
the arteries. Examination of the pulse is a very
important and rewarding method in the diagnosis of
cardiovascular disease. This art should be practised
by all students of medicine meticulously. In
Ayurveda, examination of the pulse “Naadi” has
been described in great detail. Fig. 15.1: Palpation of radial pulse
180 Section 6: Cardiovascular System
palpated with the right hand while examining the radial pulse
pericarditis, pericardial effusion and cardiac
tamponade. This exaggeration of the normal
fluctuation is termed pulsus paradoxus and is defined
as a pulse in which the systolic BP falls by more Method
than 10 mm Hg during quiet inspiration. Palpate the radial artery with the middle three
Pulsus alternans: This is the phenomenon in which fingers. Occlude the artery proximally and using the
every alternate pulse is weak. This phenomenon can distal finger empty the artery by pressing out the
be objectively confirmed by recording the blood blood peripherally. While applying pressure on either
pressure. While recording the blood pressure, when side to keep the arterial segment empty the middle
the initial systolic blood pressure is recorded only finger rolls the artery over the underlying bone to
the stronger beats are transmitted. When the mercury assess its thickness and consistency.
column is further lowered, there is an abrupt Normally, the artery is just palpable as a soft
doubling of Korotkoffs sounds, at which stage all collapsible tube. Thickening, irregularity and cord-
the beats are transmitted to the pulse. It will be seen like feel suggest arteriosclerosis which affects the
that the difference in systolic blood pressure between medium sized arteries—Monckeberg’s sclerosis.
alternate beats may be even as high as 40 mm Hg. This is a change occurring with age, but in some
Pulsus alternans is often a feature of left ventricular cases it is more pronounced. The main abnormality
failure. is in the medial coat of the arteries and this change
does not reflect atherosclerosis. Atherosclerosis
Detection of Pulse Delay
takes place in the intima and is associated with
The two radial pulses come synchronously. When occlusive arterial disease.
the radial pulse and ipsilateral femoral pulse are
palpated simultaneously, the femoral pulse is felt a Auscultation over Arteries
bit before the radial pulse (5 msec). Delay in the Before concluding the examination of the arteries,
femoral pulse suggests obstruction to the aorta as is some of the major arteries should be auscultated to
seen in coarctation (Fig. 15.6). elicit diagnostic findings. These include the carotid,
vertebral and femoral arteries, abdominal aorta,
Arterial Wall Thickness renal arteries and iliac arteries.
This is done to assess the state of the medium sized Normal blood flow through the arteries does not
arteries which are palpable. give rise to bruit. Bruit occurs when there is
Chapter 15: Examination of the Cardiovascular System 183
increased blood flow through normal arteries or 45° incline is selected due to the following
normal or reduced blood flow through narrowed reasons: In supine position, the internal jugular veins
and roughened arterial lumen. Auscultation is are full even in normal persons. At 45° incline
helpful to assess the state of blood flow in arteries if the sternal angle (angle of Louis) and the sterno-
abnormalities are detectable. clavicular joint are at the same level. Therefore, the
top of blood column in the internal jugular vein can
Method
be measured from the sternal angle as shown in
The stethoscope is applied with sufficient pressure (Figs 15.7 and 15.8).
to reach the artery, taking care not to compress it, The center of the right atrium is 5 cm below
and the events are noted. and behind the sternal angle. Normal right atrial
Bruits in the neck may be detected in a small pressure is 5 to 7 cm of blood column and at this
proportion of apparently normal persons without level the top of blood column is seen just behind
disease. the right sternoclavicular joint. Any rise in right atrial
Pistol shot sounds: These are sharp sounds heard pressure will be reflected as elevation of blood
over major arteries like the femorals and brachials column in the jugular vein. The jugular venous pulse
in the presence of aortic regurgitation. is best seen when a light is held tangentially over
While auscultating over the femoral artery, apply the neck. In most of the patients, 45° incline is
pressure on the artery proximal to the chest piece of
adequate to identify the upper level of jugular venous The abdominojugular reflux is tested by
column, but if the venous pressure is unusually high, applying firm pressure over the upper abdomen for
the angle of incline should be reduced and some 10 to 30 seconds with the patient breathing normally.
patients may have to be examined even sitting up. In a normal subject the jugular venous pressure rises
Sometimes difficulties may be experienced in transiently and falls to normal even when the
differentiating the carotid arterial pulsation from the pressure is continued. In presence of cardiac failure
jugular venous pulse. The points of distinction are the elevation of the jugular venous pressure is
given in Table 15.4. prominent and sustained. Positive abdominojugular
Examine the JVP to elicit the following reflux also indicates that the inferior and superior
information: vena cava are patent (Fig. 15.9).
1. Height of venous column, expressed as the Alteration in Diseases
vertical height above the level of sternal angle.
2. Venous pulsations. Jugular venous pressure (JVP): Elevation of the
3. Hepatojugular reflux (abdominojugular reflux). jugular venous pressure reflects increase in right
atrial pressure and this occurs commonly in right
The jugular venous pulse has 3 positive waves,
heart failure. Other less common causes include
a, c and v and 2 negative waves x and y. The “a”
the reduction in compliance of right ventricle
wave is caused by atrial systole. The “c” wave is
as is seen in severe right ventricular hypertrophy,
due to bulging of the A-V valve apparatus into the
pericardial diseases, and right ventricular
Part–I: Internal Medicine
endomyocardial fibrosis. Tricuspid valve disease “X” descent: This is prominent in cardiac
also causes a raised JVP. In superior venacaval tamponade, and it disappears in atrial fibrillation.
obstruction the jugular veins are engorged and “y” descent This is prominent (sharp and deep) in
nonpulsatile. Conditions of increased blood volume constrictive pericarditis and tricuspid regurgitation.
like pregnancy and acute glomerulonephritis are It is sharp, but not deep in restrictive cardiomyo-
associated with raised JVP. pathy. “y” descent is shallow and gradual in tricuspid
Normally during inspiration the JVP falls. A stenosis in which atrial emptying is delayed.
paradoxic inspiratory rise in the height of the jugular
EXAMINATION OF THE CHEST—DILATED
venous column is known as Kussmaul’s sign. This
VEINS ON THE CHEST
is seen in constrictive pericarditis, pericardial
effusion, cardiac tamponade, congestive cardiac These are seen in vena caval obstruction. In
failure and tricuspid stenosis. obstruction to superior vena cava caused by
mediastinal obstruction, dilated and tortuous veins
Alterations in the Pattern of Jugular may be seen over the neck and upper part of chest,
Venous Pulsation with blood flow directed towards the abdomen.
Giant “a” waves: The “a” wave is particularly It is rare for cardiovascular lesions to produce
prominent in conditions where the right atrium mediastinal obstruction, but it may occur in
contracts with greater force as in atrial outflow aneurysm of the arch of the aorta. In inferior vena
caval obstruction dilated veins from the upper
Apex beat: In the majority of normal persons the when the heart alone is on the right side and all other
impulse produced by the apex of the left ventricle viscera are in their normal positions, i.e. isolated
which impinges on the chest wall is seen as a dextrocardia with “situs solitus”, the chances for
localized pulsation in the fifth left intercostal space. major anatomical and functional cardiac defects are
For convenience the apex beat is described in great.
relation to the left midclavicular line. The apex beat
is 1 to 1.5 cm medial to it. Apex beat is better seen Precordial Pulsation
and felt when the breath is held in expiration. In In normal adults with moderate build the precordium
obese subjects with normal hearts the apex beat may does not pulsate visibly as a whole, except during
not be visible. In emphysema and pericardial
physiological increases in cardiac output caused by
effusion, the apex beat is not visible and if at all
exertion or emotional stress. Presence of prominent
palpable, it may be faint. Displacement of the apex
precordial pulsations at rest should suggest the
may occur in several conditions. If the apex beat is
not readily visible inspection from the side with presence of ventricular enlargement or aortic
tangential lighting may reveal the pulsation. aneurysm. Since the right ventricle occupies the
diaphragmatic surface and medial part of the anterior
Cardiomegaly: When the heart enlarges, the apex
surface of the heart, enlargement of the right ventricle
beat is displaced laterally. Position of apex beat
gives rise to left parasternal pulsations. In gross
should be examined when the patient is lying supine
and maybe fallacious if left lateral position is enlargement of the right ventricle, as in atrial septal
Part–I: Internal Medicine
assumed. However feeling the apex beat in the left defects or mitral stenosis the right ventricle may
lateral position may help in assessing the character occupy almost the whole of the anterior surface and
of apex beat or other palpable events over the the pulsations may be more widespread.
apex beat. In right ventricular enlargement the Left ventricular enlargement associated with
displacement is more horizontally outwards, whereas increased stroke volume, as is seen in aortic
in left ventricular enlargement the displacement is incompetence leads to visible precordial pulsations
both downwards and outwards. In extreme cases the occupying part or whole of the precordium.
apex beat may be seen as low as the seventh left Another rare cause of precordial pulsations is
intercostal space and as far out as the midaxillary aortic aneurysm. Aneurysm of ascending aorta
line or even beyond. causes expansile pulsation to the right of the sternum
Displacement of the heart: Conditions which better felt with the patient sitting up and holding the
encroach upon the volume of the thoracic cavity and breath in expiration. Aneurysm of the arch of the
diseases affecting the pleural cavities and lungs lead aorta erodes the upper part of sternum and may
to displacement of mediastinal structures. In pleural present as a localized bulge. Widening of upper
effusion and pneumothorax, the heart is pushed to
mediastinum can be made out by percussion.
the opposite side. In collapse and fibrosis of the
Aneurysm of the descending thoracic aorta
lungs, the heart is pulled towards the side of lesion.
is usually silent, but expansile pulsation felt at the
Dextrocardia is a developmental anomaly in
back on the side of the vertebrae may offer tell-
which the heart occupies the right hemithorax and
tale evidence. Aneurysm of abdominal aorta can be
the apex beat is seen on the right fifth intercostal
space. This anomaly resulting from the malrotation easily seen and palpated per abdomen.
of the heart during embryogenesis may occur in Epigastric Pulsation
several forms.
When dextrocardia is associated with corres- The epigastrium shows only faint pulsations when
ponding anomalous position of the abdominal and a normal adult rests in the supine or 45° incline
other thoracic viscera it is called “dextrocardia with position. This pulsation is transmitted from the right
situs inversus totalis”, i.e. heart is on the right ventricle across the diaphragm and left lobe of the
side and liver is on the left. In this combination, the liver. In children, thin subjects and in tachycardia,
heart per se often does not show any serious more prominent epigastric pulsation may be seen
anatomical or functional abnormalities. However even in the absence of disease.
Chapter 15: Examination of the Cardiovascular System 187
Fig. 15.11: Palpation of the epigastrium for right Fig. 15.12: Palpation of expansile palpation of the liver
Apex Beat
It is the outermost and lowermost position on the
Fig. 15.13: Locating the apex beat with tip of the fingers of
chest wall where a distinct lift caused by cardiac
the right hand. The left hand palpates the intercostal spaces contraction is felt. This is often appreciated by the
palm of the hand, but exact localization may require
in the usual position, it should be looked for in other palpation by the finger tips. In obese individuals and
positions as far as the back of the chest, to detect those with thick chest wall, the apex beat may not
displacement. Particularly palpate on the right side, be easily identifiable. When the apex beat is behind
so that dextrocardia is not missed. Having identified a rib it may not be readily felt. In a small proportion
the apex beat, localization and description of the of normal individuals the apex beat may not be
palpable. In them other methods have to be employed
Part–I: Internal Medicine
Thrills
These are palpable murmurs. Loud murmurs (grade
IV or more) are palpable as thrills. Increased flow
across a normal valve or turbulent flow across
diseased valves gives rise to murmurs. Congenital
and acquired defects which lead to abnormal blood
flow also give rise to thrills.
Thrills arising from the mitral valve are mostly
diastolic. The mid-diastolic murmur with presystolic
accentuation occurring in mitral stenosis is felt
as a thrill, comparable to the purring of a cat.
Systolic thrill over the mitral area indicates mitral
incompetence (Fig. 15.17). From the tricuspid valve
systolic murmurs and diastolic murmurs give rise to
thrills, the former being more common. They indicate
tricuspid incompetence and stenosis respectively.
Tricuspid events accentuate during inspiration.
Fig. 15.15: Palpating the left parasternal region for From the pulmonary and aortic valves, systolic
Part–I: Internal Medicine
Fig. 15.17: Palpation over apex beats with patient in the left
Fig. 15.16: Palpation of the second left intercostal space for lateral position to detect particularly mitral diastolic thrill in mitral
pulsations, valve closure sound and thrills stenosis
Chapter 15: Examination of the Cardiovascular System 191
Fig. 15.18: Palpation over third and fourth Fig. 15.19: Palpation for aortic and pulmonary thrills
intercostal space for systolic thrills Note: Patient holds his breath in expiration
commonly. Continuous thrill may occur, occupying precordium is less resonant than the rest of the chest,
both systole and diastole when the murmurs are since the left lung does not fully cover the precordium
continuous as in patent ductus arteriosus (PDA) or under normal conditions. By gentle percussion, the
rupture of the aneurysm of the sinus of valsalva. transition from resonance to dullness can be made
Percussion helps to distinguish between Tricuspid area: Fifth left intercostal space close to
cardiomegaly and cardiac displacement. In the sternum.
pericardial effusion, the left border extending beyond Pulmonary area: Second left intercostal space close
the apex beat is very suggestive clinical sign. to the sternum.
Percussion is also useful for the detection or aortic Aortic area: Second right intercostal space close to
aneurysms, pulmonary artery enlargement, right the sternum.
atrial enlargement and ventricular aneurysms.
Second aortic area: Third left intercostal space
Note: Wherever more reliable methods to assess
close to the sternum (Figs 15.24 A to H).
cardiac size such as chest X-ray and echocardio-
graphy are freely available, they should be Procedure
employed. When these facilities are not available,
With the patient lying supine or sitting up, auscultate
percussion has to be relied upon, though it is not a
all the areas systematically. Try to identify the
sensitive method.
auscultatory events—normal and abnormal. Once
AUSCULTATION OF THE HEART AND they have been identified, assess the quality and
BLOOD VESSELS intensity. If abnormal events such as murmurs are
present identify the direction and extent of
Sounds which are produced by closure of heart conduction. Conclude auscultation by noting the
valves, movement of the myocardium and great changes produced during the different phases of
A B
Part–I: Internal Medicine
C D
E F
G H
Figs 15.24A to H: Auscultatory areas: (A) mitral, (B) tricuspid, (C) pulmonary, (D) aortic, (E) second aortic area,
(F) conduction of mitral systolic murmur (arrow), (G) conduction of aortic systolic murmur (arrow), (H) conduction of aortic
diastolic murmur
Chapter 15: Examination of the Cardiovascular System 195
Third heart sound: This is heard during the early rates and marked sinus arrhythmia. Autonomic
part of diastole and is produced by rapid inflow of neuropathy occurring in diabetes mellitus tends to
blood from the atria into the ventricles. It is a low abolish sinus arrhythmia. Arrhythmias may be
pitched soft sound heard at the mitral area and also regular or irregular.
medial to it.
Types of Arrhythmias
In childhood and hyperdynamic states such as
pregnancy and anemia, third heart sound may be • Physiological—sinus arrhythmia.
well-heard. In disease states such as cardiac failure • Pathological—may be regular or irregular.
and cardiomyopathy, presence of abnormal third Regular Arrhythmias: There is a basic regularity
heart sound may denote diastolic dysfunction of the in the pattern of arrhythmia, e.g. regular extrasystole,
ventricular myocardium. as in ectopic bigeminal or trigeminal rhythms, partial
Fourth heart sound: This is caused by atrial heart block (second degree) in which a beat will be
contraction and occurs in late diastole. It is soft and missed at regular intervals.
low pitched and considerable training is needed to Irregular arrhythmias: For example, atrial
appreciate it. Fourth heart sound becomes prominent fibrillation. The rhythm is irregularly irregular. The
in conditions in which forceful atrial contractions time interval between beats, strength of contraction
are necessary for proper ventricular filling such as and the intensity of heart sounds vary. All these
ventricular hypertrophy due to hypertension, outflow features are reflected in the pulse also as irregularity
obstruction or cardiomyopathy. in rhythm and force.
block with a 3:2 conduction ratio. Yet another cause Third heart sound is accentuated in conditions
is sick sinus syndrome where a junctional escape of increased ventricular filling such as mitral
followed by a sinus capture produces an escape- incompetence and tricuspid incompetence. In cardiac
capture bigeminal rhythm. failure the third and fourth sound may become
prominent. The fourth heart sound may be audible
Effects of Exercise
when atrial contraction becomes forceful as a result
Once an arrhythmia is detected, if the patient’s of reduced ventricular compliance.
condition will permit, he is made to exercise by When the third or fourth heart sound becomes
sitting up in bed and lying flat 3 to 5 times. Atrial prominent and audible, the cadence of three heart
fibrillation becomes more irregular while benign sounds for each cardiac cycle is called triple rhythm.
ventricular extrasystoles tend to disappear. Heart Triple rhythm may be physiological as is seen in
block is generally unaltered by exercise. children and pregnant women in whom the third heart
Occurrence of ventricular or supraventricular sound is audible, or it may be abnormal as in cardiac
extrasystoles in runs gives rise to paroxysmal failure. When triple rhythm is associated with
tachycardias. In these, the rates generally vary from tachycardia and other abnormalities of the heart, it
120 to 180/minute. If these episodes last longer than is called gallop rhythm. Gallop rhythm may be due
30 seconds they are called sustained tachycardias, to the presence of S3. This is called early diastolic or
while shorter ones are referred to as non-sustained protodiastolic gallop.
tachycardias. Prominence of S4 gives rises to a late diastolic,
Part–I: Internal Medicine
and arterial lumen are sufficient to allow smooth 3. What is its quality? Murmurs may be high
flow. Moreover the endothelial surfaces are regular pitched and blowing in type, or low pitched and
and smooth so that abnormal eddies or vibrations rough. Blowing murmurs are characteristic of
do not occur. When valve orifices are narrowed, abnormal blood flow from high pressure areas to
surfaces are roughened, or the flow of blood through
them is excessive, abnormal vibrations occur and
these lead to murmurs. When valves become
incompetent, the blood leaks back through them and
this abnormal blood flow also leads to murmurs.
Though the normal flow of blood is inaudible to the
unaided human ear, the vibrations can be made
audible by Doppler echography.
Murmurs may be organic or functional: Organic Fig. 15.26: Ejection systolic murmur of aortic stenosis:
S1–First heart sound, S2– Second heart sound, P2– Pulmonary
murmurs are caused by anatomical abnormalities component, A2– Aortic component, M–Murmur
of valves or arteries, whereas functional murmurs
are caused by purely hemodynamic factors.
When a murmur is detected, try to ascertain the
following points by auscultation.
Part–I: Internal Medicine
low pressure areas with high velocity and force, Method: Once the murmur is identified, move the
e.g. (1) Mitral incompetence and tricuspid stethoscope along the classic directions of
incompetence in which blood flows from conduction. If the murmur is heard with the same or
ventricles into atria during systole. (2) Blood from even increasing intensity as one proceeds away from
the aorta or pulmonary artery leaking into the the site of production it is said to be conducted in
ventricles in diastole in incompetence of the that direction.
corresponding valves. Mid-diastolic murmurs occurring in mitral
In ventricular septal defect the high pitched stenosis and tricuspid stenosis are not conducted.
pansystolic murmur is produced by blood flowing Pansystolic murmur of mitral incompetence is
from the left ventricle to the right ventricle across conducted laterally to the axilla and even as far
the defect, under high pressure. behind as the scapular angle or back. Tricuspid
The smaller the orifice, greater is the intensity systolic murmur may also be conducted to the angle
and pitch of the murmur. Murmurs tend to be low of the scapula or back. The ejection systolic murmur
pitched and rough if they are produced by blood flow of aortic stenosis is conducted up along the carotids.
across roughened surfaces or if the pressure gradient At times it may be conducted to all other areas as
is small. The murmurs of mitral and tricuspid well. Early diastolic murmur of aortic incompetence
stenosis are typically low pitched and rumbling, is conducted down to the epigastrium along the left
since the pressure gradient is small. In aortic and and right borders of the sternum.
pulmonary stenosis the systolic murmur tends to be Pulmonary systolic murmur may be conducted
his fist strongly or clench his teeth. The systolic Pericardial Rub
murmur of hypertrophic cardiomyo pathy and This is heard over the precordium as a leather
mitral valve prolapse decreases with exercise creaking sound, during all phases of the cardiac
(Tables 15.5 and 15.6). cycle. The rub is better heard towards the upper part
of the precordium and when the patient leans
Direction of blood flow and the murmurs
Table 15.5:
produced in the common cardiac lesions forward. The rub may be coarse or fine and squeaky.
Pressure with the stethoscope enhances the rub.
Acquired valves Direction of blood-flow Murmur produced
lesions normal or abnormal and optimum site for When pericardial effusion occurs, it disappears.
auscultation Pleuropericardial rub: It is heard when the breath
Mitral stenosis Normal Mitral mid-diastolic is held in inspiration. It disappears when the breath
murmur—Apex
Mitral Abnormal from LV Mitral pansystolic
is held in expiration.
incompetence to LA murmur—Apex and
back Arterial Bruits
Tricuspid stenosis Normal Tricuspid mid-diastolic Auscultation over normal arteries in which blood
murmur—Tricuspid
area TA flow is considerably increased (thyroid arteries in
Tricuspid Abnormal from Tricuspid pansystolic primary thyrotoxicosis) or where the lumen is
incompetence RV to RA murmur—Tricuspid narrowed (e.g. carotid stenosis), may reveal systolic
area TA
bruit. Common sites for auscultation include the
Part–I: Internal Medicine
Table 15.6: Diagnostic features of the common valvular and congenital anomalies of the heart
monitoring equipment available in cardiac intensive pressure in adults is below120 mm Hg and normal
care units. diastolic blood pressure is below 80 mm of Hg.
For clinical use the routine is to record the blood Systolic BP values above 140 mm Hg diastolic
pressure in the right arm unless there is any readings above 90 mm Hg indicate hypertension.
contraindication. If the arm is paralysed, the Values in the range of 120 to 139 systolic and 80 to
recording should be done on the normal limb, since 89 diastolic indicate prehypertension, whose lifetime
values are likely to be lower on the paralysed side. risk of developing hypertension is estimated to be
Separate cuffs are available for adults and children 90%. Finally as per the JNC-VII, systolic BP above
and the appropriate cuff should be used to avoid 160 mm Hg and diastolic BP above 100 mm Hg
errors. The rubber bag of the ordinary cuff used for indicates stage II hypertension very often needing
adults is 12 cm wide and 25 cm long. combination drug therapy for optimal control. Most
patients with hypertension have an elevation of both
Procedure systolic and diastolic pressures. If systolic pressure
The cuff should be tied tight around the arm over alone is elevated, it is called isolated systolic
the brachial artery, leaving the cubital fossa free for hypertension (ISH). ISH is common in the elderly
auscultation. The cuff is inflated while palpating the and the wide pulse pressure seen in this form of
radial pulse (or brachial pulse), till the pulse is hypertension carries a very poor prognosis. If
obliterated. The point at which the pulse reappears diastolic pressure alone is elevated it is called
diastolic hypertension. This is the least common form
Part–I: Internal Medicine
systolic pressure recorded at the thigh tends to Abnormally low blood pressure: This occurs in
exceed that in the upper limb by 20 mm Hg or more. shock. Often the Korotkoff’s sounds may not be
This is termed Hill’s sign. audible or they may be audible only over a very
narrow range and hence likely to be missed. In such
Fallacies in Recording Blood Pressure
cases the palpatory method over the bronchial artery
Auscultatory gap: In some individuals with high may help.
systolic pressures, when the pressure in the cuff is
lowered, the sounds appear at the systolic level Paroxysmal hypertension: The fluctuation in blood
disappear over a segment and reappear again, to pressure may be paroxysmal, as is seen in the early
disappear finally at the diastolic pressure. This gap phases of pheochromocytoma. This can be identified
of silence in the systolic pressure is called the only by repeated recordings or by 24 hr ambulatory
auscultatory gap. If the pressure in the cuff is not blood pressure recording.
elevated above the level of auscultatory gap, the Postural variations: The blood pressure values
lower level of the auscultatory gap may be recorded with the patient lying in bed are accepted
mistakenly taken as the systolic pressure. This is for routine use. In the erect posture the systolic
avoided by doing the palpatory method first. pressure may remain the same or fall by up to 10
Looseness of the cuff: If the cuff is tied loose, the mm Hg, the diastolic remaining the same. If on
pressure recorded tends to be slightly higher. standing, the pressures drop more than 10 mm Hg
with symptoms, or by more than 20 mm Hg, this is
2. Left sided heart failure: Venous occlusion and inflammation: Look for
a. Tachypnea, cheynes stokes respiration distal oedema and tender and palpable veins. In the
b. Pulsus alternans legs look for Homans sign, i.e. passive dorsiflexion
of the foot with legs straight, causes pain over the
c. Gallop rhythm calf. This suggests deep vein thrombosis in the calf.
d. Basal crepitations in the lungs.
Arterial occlusion: By palpating over the major Ophthalmoscopy
arteries and looking for the temperature and color Look for signs of hypertension, infective endocarditis,
of the limbs. hyperviscosity states and others (See Chapter 48).
Part–I: Internal Medicine
CHAPTER
16
1 Investigations in Cardiology
free entry of sodium into the cell. The cell interior Specialized cells of the myocardium in the
becomes slightly positive (+30 mv) at the peak of sinoatrial (SA) node and other parts of the conducting
phase-0 and this reversal of polarity leads to closure system of the heart are capable of generating
of the Na+ channels. Depolarization is a passive spontaneous electrical activity. This property is
process. referred to as automaticity. Generation of the
pacemaker potential by spontaneous phase 4 diastolic
Repolarization
depolarization is the mechanism responsible for
Restoration of the resting membrane potential is a automaticity. Regions of the myocardium, designed
much longer process. It is an active, energy dependent for faster conduction of impulses form the specialized
process, consisting of four phases: conduction system of the heart.
Phase 1: (Overshoot phase) is the reversal of the
overshoot and return of the membrane ANATOMY OF THE CONDUCTION
potential to 0 mv. This initial sharp early SYSTEM OF THE HEART
repolarization is achieved by an increase
in the entry of chloride ions into the cell Sinoatrial Node
(Figs 16.1A and B). The Sinoatrial node (SA) node, 10 to 20 mm long,
Phase 2: (Plateau phase) of the action potential is located subpericardially at the junction of the
the time when calcium channels open up superior vena cava and right atrium, is the seat of
Part–I: Internal Medicine
allowing influx of calcium ions (Ca++) into impulse formation. It is supplied by an arterial
the cell. This influx of Ca++ is neutralized branch which may arise from the right coronary
by an outward efflux of K+ so that the artery in 55% of individuals or the left circumflex
membrane potential remains at a plateau. artery in 45%. The property of automaticity resides
Phase 3: (Cascade phase) is the phase of repolari- in the pacemaker cells (P cells) of the SA node.
zation mediated by continuing K+ efflux Under physiological conditions the SA node serves
which re-establishes the intracellular as the pacemaker for the heart, because it has the
negativity to resting levels. fastest rate of automaticity. All the subsidiary centers
Phase 4: (Resting phase) For each action potential, of automaticity such as the AV node, conduction
some Na + ions enter the cell during pathways and heart muscle are suppressed by the
depolarization and some K+ ions are lost SA node.
during repolarisation. Restoration of the
appropriate intracellular and extracellular Internodal Pathways
concentrations of Na+ and K+ is achieved The impulse from the SA node is conducted to
by an energy dependent ionic pump during the AV node through three specialized tracts—the
phase 4. The excess Na+ ions are pumped anterior, middle and posterior internodal tracts.
out in exchange for K+ ions. These tracts consist of cells anatomically indistin-
guishable, but functionally distinct from ordinary
myocardial cells. A branch of the anterior tract, the
Bachman’s bundle, conducts the impulse to the left
atrium. Atrial depolarization is achieved by radial
spread of the impulse across the atrial musculature.
Atrioventricular Node
Atrioventricular node (AV) is an elliptical structure
3 to 5 mm long, located on the endocardial surface
A B of the right side of the interatrial septum just above
the septal leaflet of the tricuspid valve. It is supplied
Figs 16.1A and B: Schematic representation of action potential
in (A) Working myocardial cell, (B) Specialized pacemaker by the AV nodal artery which arises from the right
cell coronary artery in 90% of individuals.
Chapter 16: Investigations in Cardiology 207
His Purkinje System bundles form the anatomic basis for the various
The bundle of His arises as a continuation of the ventricular pre-excitation syndromes.
AV node and divides into the right and left bundle Principles of Surface Electrocardiography
branches. The right bundle branch, which is a thin
stalk runs down on the right side of the inter- Routine electrocardiographic recording is done by
ventricular septum and arborizes in the Purkinje vacuum tube amplification equipment with a
system which is an extensive subendocardial heated stylus that melts the wax on specially
network capable of swift transmission of the impulse designed heat sensitive paper. More sophisticated
to all portions of the ventricular myocardium. It electrocardiographs use chemical or ink writers and
supplies the free wall of the right ventricle and the digitized storage and retrieval systems. They also
right side of the interventricular septum. provide online computer interaction for inter-
pretation and diagnosis.
The left bundle branches into the left anterior
(superior) fascicle and the left posterior fascicle. The The human torso acts as a volume conductor
anterior fascicle terminates at the base of the anterior transmitting about 20% of the electrical activity
papillary muscle. It supplies the anterior, superior generated by the heart. The potential differences
and lateral portions of left ventricle. The posterior across the chest are picked up by the various lead
fascicle ends at the base of the posterior papillary systems and these produce deflections of the stylus.
muscle. It supplies the posterior and inferior portions Current flowing towards the recording electrode
instantaneous recording of the electrical activity deflection is called R wave. A negative deflection
of the heart along the three planes, frontal, sagittal after the R wave is called S wave. A positive
and horizontal, during atrial and ventricular deflection which follows the S wave is called R
depolarization and also ventricular repolarization. wave.
The magnitude and direction of electrical activity
PR lnterval
are recorded. The Frank lead system using leads
X, Y and Z in the three planes is used for vector This interval denotes the time from the onset of the
cardiography. This is different from the leads used P wave to the beginning of the QRS complex. It
for scalar ECG. represents the time taken by the impulse to traverse
Indications for electrocardiogram: the atrium (P wave), the AV node, bundle of His,
1. As the first investigation in any patient with bundle branches and the proximal 1/3rd of the
chest pain to rule out ischemic heart disease. interventricular septum (PR segment). The PR
2. As the gold standard for the analysis and segment is isoelectric because of electrical silence
identification of the various arrhythmias. after completion of atrial depolarization and entry
3. To detect abnormalities in conduction of the of impulse into the AV node. Normal PR interval is
cardiac impulse such as bundle branch blocks, 0.12 to 0.20 sec.
hemiblocks, accessory pathways and pre- QRS Complex
excitation syndromes.
Depolarization of the ventricles produce the QRS
Normally leads oriented to the right ventricle Note: All values are in milliseconds.
(V1) record a small initial positive deflection and The QT interval may be prolonged in myo-
then a deep negative deflection referred to as the rS cardial ischemia, electrolyte imbalance, drug effects
morphology. Leads oriented to the left ventricle or as a congenital anomaly. Prolongation of the QT
record a qR pattern, viz. a small initial negative interval is an important predisposing factor for the
deflection, followed by a tall positive wave. This development of serious arrhythmias.
transition from the rS morphology to the qR pattern
normally occurs in V4 or V5. If, however, the right U Wave
ventricular (rS) morphology persists in the left chest The U wave is an after-potential related to
leads (V5–V6), this is called clockwise rotation of repolarization of either the papillary muscles or the
the heart. Likewise if the left ventricular qR pattern Purkinje network. Generally this has the same
is seen from right chest leads (V2 or V3), it is referred direction as the T wave. It is best identified in leads
to as counterclockwise rotation of the heart. This, V3 and V4.
however, refers only to the position of the heart in The ventricular activation time (VAT) denotes
relation to the horizontal plane. the time taken from the onset of the QRS complex
J Point to the occurrence of the intrinsicoid deflection (peak
of the R wave). It represents the time taken by the
This is the point where the distal limb of the S wave
impulse to spread from the endocardium to the
merges with the ST segment.
Part–I: Internal Medicine
Holter study is particularly useful in arrhy-thmia fall in blood pressure and ischemic symptoms
evaluation because it not only documents and associated with ECG changes.
quantitates the arrhythmia, but also provides Standard contraindications to exercise testing
correlation of symptoms to the arrhythmia and also include acute myocardial infarction, high risk
permits evaluation of the efficacy of specific anti- unstable angina pectoris, severe aortic stenosis,
arrhythmic therapy. The precipitating factors, the congestive cardiac failure, acute pulmonary
number and duration of ischemic episodes, and embolism or infarction, acute myocarditis or
response to antianginal therapy can be documented. pericarditis, aortic dissection, uncontrolled severe
It is with the routine use of Holter monitoring that systemic hypertension > 200/100 mm Hg, high grade
the concepts of “silent myocardial ischemia” and heart blocks, uncontrolled symptomatic cardiac
“total ischemic burden” evolved. arrhythmias, any acute systemic illness or an
unwilling patient.
Exercise Electrocardiography (Syn: Stress
The indications to terminate exercise testing
Tests, Treadmill Test)
includes inappropriate drop in blood pressure or
This refers to the recording of the electrical activity deceleration of the heart rate with increasing
of the heart while the individual is subjected to the workload and exercise, moderate to severe angina,
stress of graded exercises. The bicycle ergometer sustained VT, ST depression more than 3 mm or ST
or the treadmill is currently used for most exercise elevation in non Q leads, hypertensive response
testing programs. There are various exercise
Part–I: Internal Medicine
for surgical ablation or radiofrequency ablation of books in ECG. A full list of ECG abnormalities is
these abnormal pathways, which forms the definitive not attempted.
treatment for pre-excitation syndromes and intract- The standard 12-lead ECG consists of 3 standard
able arrhythmias. limb leads, 3 augmented unipolar limb leads and 6
augmented unipolar chest leads.
ECG Patterns in Health and Disease
Some of the common abnormalities seen in day to Normal ECG (Fig. 16.5)
day practice and the various conditions for which 1. In sinus rhythm all QRS complexes are preceded
the ECG is useful, are given in Figs 16.6 to 16.24. by P waves.
Detailed description of the findings is not attempted. 2. PR intervals, QRS complexes, ST segments and
The student can appreciate the range of conditions T waves are normal in shape and duration.
in which ECG provides valuable information for 3. Normal voltages, i.e. QRS exceeds 5 mm in
patient care. For individual analysis of the patterns standard leads and 10 mm in some of the precordial
and further description, the student may refer to text leads.
Fig. 16.9: Atrial premature Beats—ECG Fig. 16.11: Paroxysmal atrial tachycardia—ECG
Part–I: Internal Medicine
Fig. 16.16: Sinoatrial block—ECG Fig. 16.18: Second degree A-V block Mobitz type1—ECG
Fig. 16.17: First degree A-V block—ECG Fig. 16.19: Second degree A-V block Mobitz type 2—ECG
216 Section 6: Cardiovascular System
Fig. 16.23: Inferior wall myocardial infarction (IWMI). ST segment elevation in leads II, III and aVF, T wave inversion in leads
III and aVF, pathologic Q waves in lead L III and reciprocal ST depression in L1, aVL, V3,V4,V5
A B
Risk stratification of patients presenting with days. They are therefore useful even later in the
unstable angina or acute coronary syndromes. course of illness for diagnosis.
The commonly used markers of myocardial Normal values of troponin T is < 0.01 ng/mL,
damage are aspartate transaminase (AST) or SOT), levels above 0.1 ng/mL are diagnostic. Values
Creatine kinase (CK), CK isoenzymes (CK–MB), between 0.01 and 0.09 ng/mL are doubtful. In such
myoglobin, lactic dehydrogenase (LDH) and the cases the troponin T level should be repeated serially.
cardiac specific troponins Elevation of troponins is more specific and reliable
Aspartate transaminase: Serum glutamic oxaloacetic in the diagnosis of myocardial infarction.
transaminase (SGOT) levels start rising in 8 to Serial estimations to document the rise and
12 hours, peak at 18 to 36 hours and come down in fall of enzymes are more important than single
3-4 days. Re-infarction causes further rise in SGOT measurements in the follow-up of cases. Intramus-
levels. Normal value is up to 40U/L. cular injections may cause rise in enzyme levels and
Creatine kinase (CK): Levels start to rise within 6 therefore blood should be collected before giving
hours of onset of infarction, peak at about 24 hours IM injections.
and come to normal within 48 to 72 hours. Peak
levels occur much earlier in patients who have had Serological Tests (See also Chapter 20)
successful reperfusion. Although very sensitive and Antistreptolysin-O (ASO) titer is increased in acute
widely used, its important limitations are, false rheumatic fever and rheumatic reactivation. About
Part–I: Internal Medicine
positive elevations in patients with skeletal muscle 2 ml of blood has to be sent without anticoagulant
trauma, convulsions, intramuscular injections, for this test. ASO titres above 200 Todd units in
diabetes mellitus, alcohol intoxication and others. adults and above 333 Todd units in children are
Normal value is 25 to 195 u/L. suggestive, if other criteria for rheumatic fever are
CK isoenzymes—CKMB subfraction: It is a more also present. ASO titre can be followed up to assess
specific marker for myocardial necrosis. Elevated the progress of the disease.
levels of CKMB, for all practical purposes, indicate C-Reactive protein (CRP) is an acute phase
myocardial necrosis, usually due to AMI, but also reactant derived from the liver. Its role as a minor
can occur due to myocarditis, DC cardioversion criterion in the diagnosis of rheumatic fever is well
cardiac surgery and others. Normal values is 0.25 known.
u/L. Hs-CRP—High sensitivity C-reactive protein is
When levels of the CK and CKMB are twice now being increasingly touted as an independent
the upper limit of normal, they are diagnostic of predictor more reliable than even the LDL-cholesterol
myocardial infarction. levels for future adverse cardiac events. As a marker
Myoglobin estimation: It is less specific, but levels of inflammation, this helps to identify those patients
start rising at (2-4) hours and peak at (6-8) hours, at higher risk for development of acute coronary
much earlier than CK, and returns to normal within syndromes. Hs-CRP levels are increased in patients
24 hours. Normal value is 25 to 72 ng/mL. with diabetes, hypertension, dyslipidemia, obesity,
Cardiac specific troponins: The troponin complex, smoking and infections. Hs-CRP levels are reduced
troponin C, troponin 1 (Tn-I) and troponin T (Tn-T) by exercise, weight loss, statins, angiotensin
are normal constituents which regulate the calcium blockers and thiozolidinediones. Based on the levels
mediated contractile process. Quantitative and of Hs-CRP low risk is identified as levels below
qualitative methods of assay of cardiac troponins 1 mg/L, high risk as levels above 3 mg/L and
help in the early diagnosis of acute myocardial intermediate risk at levels between 1 to 3 mg/L.
infarction, especially in those with atypical present- Hs-CRP measurement is recommended for risk
ations and doubtful electrocardiograms. They are prediction and adoption of lifestyle interventions and
also useful to detect minor myocardial damage in appropriate therapeutic strategies in the contexts of
patients with acute coro-nary syndromes. Cardiac both primary and secondary prevention of CAD.
troponins begin to rise within 3 to 6 hours of onset B type or brain natriuretic peptide (BNP) is
of pain and remain elevated much longer; 7 to 14 secreted by the heart and its levels are raised in left
Chapter 16: Investigations in Cardiology 219
ventricular hypertrophy with or without dysfunction. Despite all these limitations, radiography of
BNP levels are particularly raised in patients with the chest is a very reliable investigation which
heart failure and has emerged as a emergency room is almost universally undertaken. It is available
tool for the quick diagnosis of heart failure in patients for Rs. 100 to 200 in almost all parts of India
presenting with dyspnea. BNP levels are also raised (Figs 16.25A to D).
in many conditions which include acute myocardial Posteroanterior (PA) view: Patient’s chest held in
infarction, high risk unstable angina, acute pulmonary full inspiration is in contact with the X-ray film and
embolism and even in renal failure. A cut off value the X-ray source is behind by 2 m (Figs 16.25A
of BNP below 100 pg/mL (picogram/mL) has a and B).
high negative predictive value and a value of over
400 pg/mL has a high positive predictive value for Right lateral view: Patient’s right axilla is in contact
diagnosis of heart failure in patients presenting with with the X-ray film with the arm held up. X-ray
dyspnea. tube is held on the left.
Plasma D-dimer testing is another potential tool Left lateral view: Patient’s left axilla is in contact
and is commonly used in the diagnostic evaluation with the X-ray film, with the hands raised and the
of deep vein thrombosis and pulmonary embolism. X-ray tube is on the right.
It also is elevated in patients who have acute aortic Right anterior oblique: 50° to 60° rotation of the
dissection. It has a great negative predictive value patient with the right side of the chest close to the
with normal values ruling out the diagnosis. film (Fig. 16.25C).
Fig. 16.25A: Normal chest X-ray—PA view diagram Fig. 16.25B: PA view of the chest diagram
(Note 1 + 2 is less than 50% of 3) cardiothoracic ratio (1+2)/
3 is less than 50%
Part–I: Internal Medicine
Fig. 16.25C: Right oblique view diagram Fig. 16.25D: Left oblique view diagrams
(1) Aorta, (2) Pulmonary artery behind left bronchus,
(3) Left artrial appendage, (4) Right ventricle, (5) Left ventricle,
(6) Right atrium, (7) Left atrium, (8) Pulmonary conus,
(9) Superior vena cava, and (10) inferior vena cava
ment and calcification of aorta and valves. Exami- In acute and chronic pulmonary edema caused
nation under the fluorescent screen gives information by left sided heart failure diagnostic information can
about the movements of the heart chambers and be obtained. In chronic pulmonary venous
great vessels. hypertension (e.g. mitral stenosis) the presence of
Ventricular enlargement can be demonstrated in dilated lymphatics (Kerley B lines) can be seen.
lateral chest films. The retrocardiac shadow in front
of the vertebral column is obliterated in left Contrast Radiography
ventricular enlargement. In right ventricular Right anterior oblique view with barium swallow
enlargement the retrosternal space is encroached shows the dilated left atrium indenting the eso-
upon. phagus.
Chapter 16: Investigations in Cardiology 221
Fig. 16.27: Dextrocardia with situs inversus. The left ventricle Fig. 16.29: Left atrial enlargement with pulmonary hypertension.
is on the right, the liver is on the left causing the left dome on Pulmonary artery dilatation in advanced mitral stenosis. Note: Left
the diaphragm to be at a higher level. Trachea is central atrial appendage enlargement showing shadow on the left cardiac
border (arrow) known as pulmonary conus and also note the contour
of the left border in right ventricular enlargement (arrowhead)
222 Section 6: Cardiovascular System
Fig. 16.30: Gross right atrial enlargement. Note: the shift of Fig. 16.31: Pericardial effusion. Note: gross cardiomegaly,
the entire right border laterally – indicating right atrial flask-shaped heart, clear lung fields
enlargement (arrow) Ebstein’s anomaly
CARDIAC ULTRASONOGRAPHY
Part–I: Internal Medicine
In contrast-echocardiography: Ultrasound
(SYN: ECHOCARDIOGRAPHY) procedures are done after introducing echogenic
materials like agitated saline or glucose solution
Introduction containing echogenic microbubbles which reflect
sound. Contrast-echocardiography can be employed
The term ultrasound refers to sound waves with to detect shunts and other abnormalities in congenital
frequency above the audible range for human ear, heart disease. Newer contrast agents for advanced
usually greater than 20,000 cycles/second (Hertz— applications help in the delineation of the endo-
Hz). For medical diagnostic work ultrasound in the myocardial border, and assessment of wall motion.
mega Hertz range, i.e. over million cycles/ second Myocardial contrast echocardiography for the study
are employed. Like light, ultrasound can be directed of myocardial viability is another new development.
in a beam and it follows the rules of refraction and Doppler echocardiography: registers the shift in
reflection. frequency of ultrasound directed on to moving
Time motion mode (M-mode), and brightness objects such as abnormal blood stream. It produces
modulated display mode, (B-mode) are the basic graphic records with a spectral display of velocity
procedures. plotted against time. Doppler echo studies help to
The limitation of M-mode study is that structures assess hemodynamic significance of valvular lesions
are depicted along a single dimensional axis as a and also quantitate shunts.
function of time. In B-mode two-dimensional image Color flow imaging: Entails color coding of the
is formed and dynamic pictures of the contracting Doppler signals to distinguish the velocity and
heart can be produced. This is referred to as real direction of flow. This provides a rapid orientation
time 2D echo. of the presence and location of lesions like atrial
However developments in cardiac ultrasound and ventricular septal defects and valvar insufficiency.
have led to many more new applications. These Stress echocardiographic imaging: During exercise
include doppler echocardiography and color flow stress testing or pharmacologic stress testing is another
imaging, tissue doppler imaging, strain imaging, important application of this technique in the
transesophageal echocardiography, contrast studies, evaluation of coronary artery disease (CAD).
and stress echocardiography. Miniature pocket sized Transesophageal echocardiography (TEE): It is
portable echocardiographic units are also available performed by using transducers mounted on flexible
today and echocardiography has almost become an endoscopes introduced into the esophagus. The
extension of the stethoscope. advantage is that clear images can be obtained from
Chapter 16: Investigations in Cardiology 223
Note: The expertize in ultrasonography and ratories. They are all invasive investigations
availability of newer generations of sophisticated associated with definite, but acceptable risks to
machines are opening up newer areas of investig- health and life.
ations at a rapid pace.
Figs 16.32 to 16.39 show a few of the common Coronary Angiography
findings obtained by ultrasonography of the heart. Coronary angiography (CAG) is used to establish
the presence or absence of coronary stenosis, define
SPECIALIZED INVESTIGATIONS therapeutic options and determine prognosis in
These are the domain of the cardiologist and these patient with symptoms or signs of ischemic heart
tests have to be undertaken in specialized labo- disease. (Figs 16.40 and 16.41)
Part–I: Internal Medicine
Fig. 16.32: 2D echo—short axis view of the mitral valve level Fig. 16.34: Parasternal short axis view at the outflow level
showing the right ventricle anteriorly (RV) mitral orifice (MV) showing aortic valve (Ao) with three cusps, right ventricle (RV)
inside the left ventricular (LV) cavity, the interventricular septum anteriorly and the left atrium (LA) posteriorly
(IVS) and posterior wall of LV
Fig. 16.33: Parasternal long axis view of the heart showing Fig. 16.35: Apical four chamber view of the heart showing the
the right ventricle anteriorly (RV), the left ventricle (LV) right and left ventricles (RV, LV), right and left atria (RA, LA),
posteriorly, the left atrium (LA) and the Aorta (Ao) interatrial septum (IAS) and the interventricular septum (IVS)
Chapter 16: Investigations in Cardiology 225
Fig. 16.36: Color flow imaging across the mitral valve. Fig. 16.39: US pictures are reliable to detect morphological
Note the normal diastolic laminar flow into the left ventricle abnormalities in cardiac chambers. Arrows delineate aneurysm
of the left ventricle (LV)
Fig. 16.38: US image detect intracavitary masses reliably. Fig. 16.41: A normal right coronary angiogram showing the
Arrowheads point to mass in the left ventricle entire length of the right coronary artery, its right ventricular
branches, posterior descending artery, AV nodal artery and
the posterior left ventricular branches
226 Section 6: Cardiovascular System
The procedure consists of introducing special 1. In patients above the age of 35, scheduled
catheters through the femoral or radial artery and for valve surgery, to rule out CAD especially
guiding it up to enter the right or left coronary ostia if multiple coronary risk factors are present.
and in this position injecting radio-opaque dye to 2. If non-invasive testing is equivocal in
obtain imaging of the arteries by rapid sequence assessing hemodynamic significance of
photography. The abnormalities of arterial lumen can lesions.
be demonstrated by this procedure in patients with E. Patients before and after noncardiac surgery
coronary artery disease. The radial artery approach 1. High risk criteria on noninvasive testing.
allows early ambulation after the procedure and less 2. Urgent noncardiac surgery needed after
of local complications. AMI.
Common indications for coronary angiography 3. Persistent symptoms despite medical
(CAG) in different patient groups: therapy.
A. Patients with stable angina: F. Patients with congenital heart disease
1. With class III/IV angina despite symptoms, 1. Assessment of hemodynamic impact of
high risk criteria on non-invasive testing or congenital coronary lesions
resuscitated from sudden cardiac arrest. 2. Assess presence of coronary anomalies that
2. High risk occupations endangering safety could influence surgery
of others, e.g. drivers, pilots. 3. Assess CAD if symptoms or risk factors
Part–I: Internal Medicine
diabetes, uncontrolled systemic hypertension, after angioplasty to study the apposition of stent
and general debility also increase the risk to the vessel wall. It is also of value in tissue
2. Exposure to ionizing radiation to the patient and characterization in the vessel wall (See also page
the doctor. This is considerably less in modern 219).
machines.
3. Myocardial infarction may develop in 0.07 COMPUTED TOMOGRAPHY
to 0.6% of cases. Cerebrovascular accidents
Computed tomography of the heart usually requires
may develop in 0.03 to 0.2%. Brady or tachy-
modification of the standard CT techniques.
arrhythmias, especially heart blocks, asystole,
Currently spiral and multi-array CT scanners with
ventricular tachycardia, and fibrillation may
exposure times of less than 1 second are available
develop in 0.56 to 1.3%.
for evaluation of lesions of the thoracic aorta,
4. Local vascular complications at the site of
pericardial disease, paracardiac and intracardiac
introduction of the catheter may occur in 0.4% of
tumors and patency of coronary arterial bypass
cases. These include vascular occlusion requiring
grafts. For the assessment of cardiac dimensions and
arterial repair, thrombosis, haemorrhage,
function in addition to morphology, millisecond CT
retroperitoneal bleeding, hematoma formation,
scanners are required. Electron beam CT scanner
pseudoaneurysm, development of arteriovenus
(EBCT, Ultrafast CT) employs a focused X-ray
fistula and infection.
beam that provides complete cardiac imaging in 50
5. Contrast allergy, anaphylaxis, contrast induced
Fig. 16.42: Segment division of left ventricle and the associated coronary artery distribution
230 Section 6: Cardiovascular System
centres. Through the venous system the right sided demonstrated. Digital subtraction angiography
chambers can be entered, and the catheter tip can improves the quality of the pictures and the safety
be further advanced into the small pulmonary arteries of the procedure.
and wedged. Events in the right atrium, right ventricle Cardiac catheterization is no longer just an
and pulmonary arterial circulation can be studied. investigatory tool. Several modifications and
Through the arterial system the left ventricle can improvements in this basic technique have taken
be entered. Events in the aorta and left sided place. These include interventions such as mitral and
chambers can be studied. The studies undertaken aortic valvotomy, septostomies (puncturing the
by catheterization include recording of pressure in interatrial septum to make an artificial comm-
individual chambers and major vessels, pulmonary unication), coronary artery angiography, coronary
wedge pressure (which represents the pulmonary artery dilatation and scaning (angioplasty),
venous pressure), sampling blood for its oxygen atherectomies and others. Using suitable bioptomes,
content (oxymetry) and injection of dye into different biopsies can be taken from different portions of the
areas in the heart and vessels to study its anatomy endocardium and subjacent muscle. Defects can be
angiography. By suitable manipulation of the closed by catheter based techniques using various
catheter tip, presence of shunt lesions can be kinds of coils or other devices (See also page 223).
Part–I: Internal Medicine
CHAPTER
Basic life support measures, Advanced life support care, External defribrillation
Procedure: Pinch the nose, and with your mouth Cardiac Resuscitation
applied to the patient’s mouth, breath forcibly out Monitoring of the cardiac rhythm (to distinguish
into the patients mouth, using the force generated between ventricular fibrillation and asystole) is
by your cheek muscles, expiration occurs passively. established by connecting the patient to cardiac
10 to 15 respirations should be given every minute monitor defibrillator and observing the electrical
by one member of the team. activity on the monitor (Fig. 17.3). Definitive manage-
For adults attended to by two rescuers, a ment for the specific cardiac rhythm abnormality is
compression-ventilation ratio of 30:2 is now then planned.
recommended. For two-rescuer CPR for infants and
Procedure
children, the recommended compression-ventilation
ratio is 15:2. Once ventilation and effective cardiac Rhythm is ventricular fibrillation (VF) or ventricular
massage are established, arrange for the ambulance tachycardia (VT)
to transport the patient to a cardiac intensive care 1. An initial shock of 360 J should be delivered by
room in a hospital. Further steps in cardiopulmonary devices delivering monophasic waveforms and
resuscitation will depend upon rapid transportation 120 to 200 J using biphasic devices. Failure of
of the patient to a hospital for advanced life support the initial shock to provide an effective rhythm
care. is a poor prognostic sign. Failure of a single
adequate shock to restore a pulse should be
ADVANCED LIFE SUPPORT CARE followed by continued CPR and a second shock
delivered after five cycles of CPR.
The basic life support activities are continued 2. Establish an intravenous drip with normal saline.
till the patient is moved on to more efficient and 3. If VT or VF still persists, epinephrine 1mg IV
organized line of management. Advanced life support is administered and followed by repeated
care in the resuscitative sequence is designed to defibrillation attempts at 360 J (monophasic) or
achieve definitive stabilization of the patient. 200 J or more (biphasic). Epinephrine may be
Chapter 17: Cardiac Arrest and its Management 233
7
Musculoskeletal and
Locomotor System
CHAPTER
18
1 Rheumatology
In a synovial joint, the bone ends are capped by In India, rheumatic fever merits a special mention
hyaline cartilage. At the osseochondrous junction, since it is common in children and adolescents and
synovium is attached to bone reflected from it to it leads to lifelong crippling cardiac sequelae. In
line the joint cavity. Outside the synovium is the recent years, postviral arthritis secondary to
tough fibrous capsule which is thickened in some chikungunya infection is a major cause of joint
areas to form ligaments. The capsule and ligaments problems in south Indian states like Kerala,
prevent excess movement at the joint. In joints like Karnataka, Andhra Pradesh and Tamil Nadu.
the knee, there are fibrocartilaginous pads or menisci Osseoarticular tuberculosis is also common in
which serve to appose the articulating surfaces children and adults, the osseous focus being in the
properly. The synovial fluid and synovium reduce metaphysis in children and in the epiphysis in adults.
friction during movement. Bursae prevent friction Tuberculosis can also cause an allergic reactive
between tissues around a moving joint. These are arthritis resembling rheumatoid arthritis called
similar to synovium in structure, function and Poncet’s disease. Many systemic diseases may
disease susceptibility. Synovium is highly vascular. present with arthritis; these include hypothyroidism,
Structurally, the synovium presents an ideal stage diabetes mellitus, acromegaly, bleeding disorders,
for humoral and cellular immune reactions. myeloproliferative disorders, AIDS, drug reactions
Synovium has only very few nerve endings and and other conditions.
cartilage has none. Articular cartilage is avascular. The inflammatory group of arthritis constitute
Part–I: Internal Medicine
It derives its nutrition from materials passing into it only around 10 to 12% of all musculoskeletal
from bone or synovial fluid. Articular branches of diseases in India.The major causes of inflammatory
blood vessels enter at the joint margin. arthritis are the seronegative spondyloarthritis, and
The points of attachment of tendons and diffuse connective tissue diseases (DCTDs).
ligaments to bone are called entheses. The joint Seronegative spondyloarthropathies constitute
capsule, entheses, ligaments and tendons are rich in seronegative spondyloarthropathies around 7% of
nerve endings that perceive pain and proprioception. musculoskeletal problems in India. The important
When a joint is inflamed, reflexogenic nerve endings subtypes of spondyloarthropathies are ankylosing
cause reflex contractions of neighboring muscles spondylitis, Reiters syndrome or reactive arthritis,
leading to painful stiffness. psoriatic arthritis, arthropathy of inflammatory
bowel diseases and undifferentiated spondy-
The main function of all synovial joints is to
loarthopathy.
allow stable, controlled movements. Muscles of the
locomotor system are all striated muscles. They are The most important DCTD is rheumatoid
all under voluntary control. arthritis with a prevalence of around 0.5 to 2%
among the general population. The other major
DISEASE PATTERN AFFECTING members of DCTDs are systemic lupus
THE LOCOMOTOR SYSTEM IN INDIA erythematosus, progressive systemic sclerosis, and
inflammatory muscle diseases. Any of the DCTD
Numerically, traumatic fractures, dislocations and may be associated with Sjögren’s syndrome which
other lesions head the list. These fall into the realm is common. Each of the DCTDs can overlap with
of orthopedics. each other as in mixed connective tissue disease and
Rheumatological disorders contribute to the rest progress on to other forms. Other causes of
of the diseases of the musculoskeletal system and inflammatory arthritis are crystal induced synovitis
connective tissues. Osteoarthritis accounts for 30% like gout, and primary vasculitic syndromes.
of the musculoskeletal morbidity Soft tissue The pattern of rheumatological disorders differ
rheumatism constitutes around 20% of musculo- in different age groups. In children, the common
skeletal problems. Low backache, sciatica problems seen are growing pains, hypermobility,
osteoporosis, and problems related to defective hip pain due to several causes, traumatic lesions
posture and lack of exercise are common in clinical of knees, rheumatic fever, osteomyelitis, septic
practice. arthritis, juvenile rheumatoid arthritis (JRA), rickets
Chapter 18: Rheumatology 239
and others. In the young adult male, seronegative occupational trauma during work develop osteo-
spondyloarthritides and postviral arthritides are arthritic changes of particular joints early.
common. During the sexually active periods of life, Occupation and environment can modify joint
arthritic complication of sexually transmitted diseases, particularly osteoarthritis, e.g. goal-
diseases are more common. keeper’s fingers, bass player ’s thumb, Zulu
In pregnancy and the puerperium low back pain dancer’s hip, and others. Tenosynovitis like the
is nearly universal and sciatica is common enough. Achilles tendonitis of long distance runners and
The postmenopausal age is associated with bone and prepatellar bursitis in housemaid’s knee are other
joint symptoms. Osteoporosis proceeds rapidly after examples of occupation-related rheumatism.
menopause. Hypothyroidism, depressive illness and Enthesopathies like lateral and medial epicondylitis
osteoarthritis are common causes of rheumatic of elbow (syn: tennis elbow and golfer’s elbow) are
symptoms in this group. Degenerative joint diseases common in Indian housewives who do clothes
such as osteoarthritis of several joints, cervical washing, grain grinding, pounding, etc. Factory
spondylosis, sciatica and lumbar canal stenosis are workers inhaling metal or polymer fumes can get
more common in elderly. Those exposed to repeated fever associated with arthralgias.
Examination of the
19
1 Musculoskeletal System
Vascular Pain
This takes the form of intermittent claudication in
the early stages, when the main arteries are occluded.
Cramp-like pain is felt during activity over the
exercising muscles. It is relieved by resting, to
reappear when activity is resumed. As the vascular
occlusion extends to the smaller arteries, excruciating
pain develops over the distal parts of the extremities,
felt even while resting. The part is cold with absence
Fig. 19.1: Site of pain (marked red) in polyarthritis of pulsation in arteries. Later bluish discoloration
develops suggesting the onset of gangrene.
Other Painful Conditions
In many instances, the same lesion may cause pain
by several mechanisms. For example, cervical
spondylosis causes joint pains, periarticular pain,
pain of reflex muscle spasm in the neck, pain of nerve
root compression as well as vascular insufficiency.
Painful limitation of movement of shoulders is
common in diabetes and impaired glucose tolerance.
Stiffness of the back may occur due to inflammatory
diseases of the spine or secondary to irritation of
nerve root by other causes. Irregular fever, weight
loss with focal pain and spasm must alert one to the
possibility of tuberculosis of the spine. Local
tenderness and pain over the vertebrae developing
in an elderly person should suggest malignant
secondaries.
An acute backache with limitation of movement
Fig. 19.2: Sites of claudication Fig. 19.3: Pain of sciatica occurring in a postmenopausal woman or elderly
Chapter 19: Examination of the Musculoskeletal System 243
person is commonly due to compression fracture of bow legs in rickets. Gradual shortening of vertebral
osteoporotic vertebrae. A stiff hip in a child or young column and thoracic kyphosis in osteoporosis
adult with flexor spasm could be due to conditions (Dowager’s hump), progressive kyphosis with
as diverse as appendicitis, cold abscess in the groin, flexion of cervical spine in ankylosing spondylitis,
Perthe’s disease or tuberculosis hip. Stiffness of the Heberden’s nodes over terminal phalanges in
knee with difficulty in squatting, occurring in later osteoarthritis, nodules of varying sizes in rheumatoid
life is commonly due to osteoarthritis. In addition to arthritis and tophaceous gout may be painless or can
rheumatological disorders, several neurological become painful. Increase in the size of the head
disorders such as parkinsonism, upper motor neuron is seen in Paget’s disease. Neuropathic joint
lesions, mytonias and dystonias increase muscle tone deformities seen in diabetes mellitus, tabes dorsalis
and ache. These have to be identified by proper and syringomyelia are all totally painless.
examination. Progressive painful deformities of joints with
loss of function occur in rheumatoid arthritis, gout,
Deformities osteoarthritis and psoriatic arthritis (Figs 19.6 to
Many patients complain of progressive or acute 19.9). Extra-articular features are also common
deformities of skeletal structures. These lesions may (Figs 19.10 to 19.21). Tuberculosis, myeloma,
be painful or painless. The common painless malignant secondaries, fluorosis and osteoarthritis,
deformities include rickety rosary, pigeon chest and are common to produce vertebral deformities.
Fig. 19.7: Flexion at DIP joint with hyperextension at Fig. 19.9: Z-deformity of thumb with ulnar deviation in RA
PIP joint in RA (Swan neck deformity)
244 Section 7: Musculoskeletal and Locomotor System
Fig. 19.10: Multiple oral ulcers in Behcet’s syndrome Fig. 19.13: Henoch Schonlein purpura
Part–I: Internal Medicine
Fig. 19.11: Large scrotal ulcer in Behcet’s syndrome Fig. 19.15: Butterfly rash in the malar area
sparing nasolabial fold in SLE
Fig. 19.12: Uveitis in ankylosing spondylitis Fig. 19.16: Osteoarthritis hand. Arrows point to
Heberden’s nodes
Chapter 19: Examination of the Musculoskeletal System 245
Fig. 19.17: Symmetrical arthritis of PIP and Fig. 19.20: Psoriatic arthritis—DIP joint involvement
MCP joints and wrist in RA with pitting of nails
in early stages. Pain in acute gout typically starts at redness may be present. Gut symptoms commonly
night and peaks in a few hours. The first metatarso- encountered are dysphagia occurring in progressive
phalangeal joint is affected most frequently. The term systemic sclerosis, dyspepsia caused by reflux
“podagra” refers to the severe pain in the instep. esophagitis or drug induced gastritis, and melena
Chronic tophaceous gout involves larger joints— usually secondary to drug induced gastroduodenitis.
tophi are common. Respiratory, cardiovascular and nervous systems
Pseudogout (acute synovitis due to calcium may be affected in many instances. Several systemic
pyrophosphate deposition): Knees, wrists, elbows, diseases may present with rheumatological symptoms
shoulders and hands are involved, more common in and signs.
elderly women.
PHYSICAL EXAMINATION
Rheumatic arthritis: Acute arthritis of large joints
with effusion. The joints are affected one after General Examination
another with clearance of the affected joints and Rheumatological examination begins the moment the
affection of newer ones. Complete resolution of patient enters the doctor’s room. Watch his gait. A
arthritis is the rule. Occasionally a chronic deforming slow painful gait and deformities may be apparent
arthropathy may develop especially in the hands at first sight itself. Always ask the patient to strip
(Jaccoud’s arthritis). before examination. Patients with frozen shoulders
Systemic lupus erythematosus: Butterfly shaped have difficulty in removing their clothes and those
rash in the malar area with arthritis is classical with hand problems find it difficult to manipulate
(Fig.19.15). Systemic involvement like fever, renal the buttons (Figs 19.22 and 19.23).
disease, pleurisy or effusions are common. Joint General examination has to be done as in any
deformities are caused commonly by subluxation and other medical case. However, as one scans the
not destruction of tissue and they are reversible. patient from head to toe, the following points require
emphasis:
Acute Arthritis Hair loss in SLE, skin and nail changes of
Common causes include trauma, pyogenic arthritis, psoriasis, prominence of the superficial temporal
rheumatic fever, rheumatoid arthritis, gout, Henoch- arteries and scalp tenderness in giant cell arteritis
Schonlein syndrome, reactive arthritis in Reiter’s and eye lesions such as conjunctivitis in Reiters
syndrome, gonococcal arthritis, syphilitic arthritis, syndrome, episcleritis and scleritis in rheumatoid
hemophilia, serumsickness, allergic disorders. disease.
Chapter 19: Examination of the Musculoskeletal System 247
3. Swelling and deformities. when inflamed. Therefore great care should be taken
4. Wasting of muscles. to avoid hurting the patient.
Posture of the affected part: When a joint becomes Temperature: Skin over normal joint is slightly
painful, muscle spasm develops and the part is held colder than the rest of the body. Elevation of
in a position of maximum relief from pain and all temperature occurs in inflammatory joint disease.
movements are avoided. In general, the position Tenderness
adopted is the one in which joint space is maximal,
e.g. 10° flexion of the knees, flexion of the elbow, Elicit tenderness by gentle pressure. Identify the site
of maximum tenderness with a view to decide
neutral position of the wrists. Any attempt to move
whether the joint space, bony points, capsule,
the part or even tap on the bed is strongly resented.
ligaments, entheses, tendons or bursae are the sites
Color: Look for redness or other changes in color. of maximal affection. Severe tenderness suggests
In acute arthritis, the skin is red and often edematous. acute lesions such as septic arthritis, gout, rheumatic
Bruising may be seen over hemar-throsis (bleeding fever or hemarthrosis. In chronic arthritis, tenderness
into joints) and in traumatic arthritis. may be less marked. Tenderness can be graded by
Swelling and deformities: Most of the superficial quantitating the pressure required to cause pain.
joints have hollows around them, e.g. anterior and Absence of tenderness suggests degenerative
posterior aspects of the outstretched elbow, hollows arthritis. Neuropathic joints are painless and are not
on either side of the patella in the extended knee, tender even in the presence of obvious deformity.
and anatomical snuffbox in the wrist. These hollows Even gross manipulations do not elicit pain from
are filled either due to effusion or edema of articular them.
and periarticular structures early during joint Identification of Anatomical Landmarks
diseases. When the lesion becomes more advanced, Around the Joint
the joint is swollen as a whole.
Look for the anatomical bony landmarks with a view
Wasting of muscles: Long-term disuse of the joint to identify displacements, if any. In fractures and
results in wasting of the muscles which move the dislocations the anatomical landmarks are altered.
joint. Wasting is partly due to involvement of the Determine whether the deformities are correctable
muscle also by the same disease process, e.g. by manipulation. Deformities caused by muscle
rheumatoid disease. Wasting is assessed by spasm or inflammatory lesions can be identified from
comparison of the bulk of the muscle on either side those caused by ankylosis, fractures and dislocations.
Chapter 19: Examination of the Musculoskeletal System 249
Palpate the hollows to determine whether they ankylosis whereas none is possible in bony
are filled and if so, for fluctuation. Fluctuation is ankylosis. Exostoses are bony growths which may
obtained when the joint or bursa are filled with fluid. restrict joint movements if they arise near joints.
Ruptured menisci and cartilages, and loose bodies
Synovial membrane: Thickening of the synovial
within joints (joint mice) can be identified. Range
membrane can be identified in many of the
of movements in any joint can be measured by a
superficial joints as boggy swellings along the line
goniometer. Appendix-1 gives the normal range of
of synovial reflection. Synovial thickening is more
movements of various joints.
marked in proliferative lesions like RA.
Muscle power is tested by asking the patient to
Fluctuation: Palpate with the index fingers of both contract his muscles against resistance. Con-
hands and elicit fluctuation. Fluctuation in all ventionally, for neurological examination muscle
directions suggests the presence of fluid underneath. power is graded as given below:
Cross fluctuation can also be elicited between joints Grade 0: No movement
and bursae communicating with them, e.g. knee joint Grade 1: Only a flicker of movement
and suprapatellar bursa. Grade 2: Movement is possible if gravity is
Periarticular structures: Palpate carefully the joint eliminated
capsule for thickening and irregularity. Ligaments, Grade 3: Movement against gravity is possible
tendons, bursae, and muscles should be examined Grade 4: Movement against partial resistance is
Fig. 19.24: Tennis elbow—site of tenderness (arrow) Fig. 19.27: Palpation of wrist joint
252 Section 7: Musculoskeletal and Locomotor System
joint is possible, it suggests that the earlier flexion causing pain and numbness in the hand with or
at the PIP joint was due to tendon involvement and without muscle wasting must be looked for. In
not joint disease. On the other hand, if flexion of Carpal tunnel syndrome (Figs 19.31A and B),
PIP joint is due to joint disease, no further extension percussion over the flexor retinaculum may lead to
of the joint will be possible even after relaxing the shooting pain along the distribution of the median
flexor tendon. nerve in the hand (Tinel’s sign). The same effect
To assess the health of extensor tendons and their can be reproduced by keeping the hand in full flexion
sheaths check whether finger extension is full and for a minute (Phalen’s sign). Check the arm muscle
pain-free and if any swellings are present on the bulk also. These muscles may be wasted in carpal
dorsum. Inability to extend a finger points to tendon tunnel syndrome.
rupture (Fig. 19.18). Partial loss of extension may Ulnar nerve compression causes pain in the
be due to a slipped tendon . little finger and medial half of the ring finger and
medial margin of the palm. When the site of
Common Tendon Sheath of the Thumb compression is near the elbow both dorsal and volar
Examine for pain and tenderness over the radial aspects of the hand are affected and percussion at
styloid and enquire about its radiation into the hand the elbow reproduces the symptoms (Tinel’s sign).
or forearm, aggravated by movements of the wrist When the nerve is caught distally in the wrist,
and thumb. This occurs in inflammation of the symptoms are limited to the volar aspect of the palm.
common tendon sheath of the abductor pollicis Another example of entrapment neuropathy is
Fig. 19.31A: Carpal tunnel syndrome—sensory Fig. 19.31B: Carpal tunnel syndrome—sensory
loss over the palmar aspect loss over dorsum of hand
254 Section 7: Musculoskeletal and Locomotor System
scleroderma and myxoedema. Dip the hand in ice- Shortness of the neck (total body height divided by
cold water to detect Raynaud’s phenomenon. This neck length more than 13.86), low hair line (posterior
is the occurrence of severe tingling, numbness and hair line coming below C4 spine), and facial
burning pain in the hands and forearm when exposed asymmetry are commonly associated with such
to cold. congenital lesions.
Compression of the subclavian artery by a Cervical spondylosis is a common cause for pain
cervical rib may lead to dusky cyanosis of the hand in the neck and referred pain to the shoulders and
and gangrene of finger tips. The radial pulse may be hands in middle aged and elderly persons.
detected to be weaker on the affected side, especially
when the hands are raised above the head. Thoracic and Lumbosacral Spine
Causalgia: Causalgia is the severe burning pain Look for gibbous, kyphoscoliosis of thoracic spine,
occurring spontaneously over the limb following crowding of ribs and muscle wasting. Note
injuries to the nerve. The other associated features paraspinal muscle spasm if any. Tenderness and pain
are shiny atrophic skin and abnormalities of over insertions of intercostal muscles occurs in
sweating. ankylosing spondylitis (AS). Tenderness of upper
Examination of the vertebral column part of the back, shoulder and anterior chest muscles
Normally aligned vertebral column (spine) has the may be due to nonarticular rheumatism, masked
cervical and lumbar lordosis and thoracic and depression, or hypothyroid state. With the patient
Part–I: Internal Medicine
sacrococcygeal kyphosis. This smooth contour is seated, check movements of the thoracic spine and
altered in diseases affecting the vertebrae, rib cage-flexion, extension, lateral flexion and
intervertebral discs or the paraspinal muscles. The rotation. Severe limitation of rotation occurs in
movements of the spine are flexion, extension, ankylosing spondylitis (AS) due to apophyseal joint
rotation and lateral flexion. involvement. Pain on deep breathing may occur in
tendonitis of intercostal muscles in AS and this may
The vertebral column should be examined with
mimic pleuritic pain. The manubriosternal and
the patient sitting in bed and also standing up,
costovertebral articulations are also affected in AS.
whenever possible. Gibbous (Gibbus) is an angular
Measure chest expansion is grossly reduced in AS.
deformity of the spine, visible and palpable. It is
often the result of fractures, dislocation or diseases Lumbosacral spine is better examined with the
such as spinal tuberculosis. Kyphosis is exaggeration patient standing up. Note the contour of the spine.
of the normal posterior curvature of the spine. Lumbar lordosis is lost in AS. Check forward
Generalized kyphosis occurs in congenital lesions, flexion, side flexion and extension. Flexion is
osteoporosis, osteoarthritis, myeloma and others. markedly limited in disc prolapse. Both flexion and
Lateral curvature of the spine is termed scoliosis. extension are limited in AS. In active AS, the
This may be congenital due to defective development progression of disability can be assessed by the
of the vertebral column or acquired as in paralytic Schober’s test.
poliomyelitis. Schober’s test: Mark the midpoint of a line
Cervical spine: This part of the vertebral column connecting the two posterior superior iliac spines,
has the maximal range of multiple movements and indicated by the dimple of Venus. Draw another
it is a common site for degenerative changes horizontal line 10 cm above the previous line which
(cervical spondylosis). Look for flexion, extension, crosses the spine. Make the patient bend forwards
rotation and lateral flexion of the cervical spine. Note fully and measure distance between the line again.
the range of movement and presence of pain and The skin gets stretched and normally the lower
tenderness. Congenital abnormalities in the cervical point remains fixed and the skin between the
spine are not uncommon. These include atlantoaxial lines stretches by 5 cm or more (Fig. 19.32). With
dislocation, fusion of vertebrae hemivertebrae and progressive limitation of flexion of lumbar spine,
others. The craniovertebral junction may be the seat the lengthening is restricted to less than 5 cm.
of several abnormalities such as platybasia, basilar In apophyseal joint disease, extension is
impression, occipitalisation of the atlas and others. restricted. Put the patient in the prone position
Chapter 19: Examination of the Musculoskeletal System 255
Fig. 19.32: Schober’s test in ankylosing spondylitis Fig. 19.34: Femoral strech. Flexing the knee and extending
(See the lines drawn at 10 cm apart) the hip to stretch the femoral nerve
detect rotational deformities. Note if there is muscle rotated. Normally only after 30° to 40° of lateral
wasting particularly of the quadriceps and glutei. rotation and 70° abduction is resistance felt. If before
Palpate all the bony landmarks around. Note if abduction of 70° a click is felt, Ortolanis sign is
there is pain mimicking sciatica associated with positive. This test should not be done repeatedly as
swelling and tenderness over the ischiogluteal bursa, it can damage the articular cartilage on the femoral
which should suggest ischiogluteal bursitis. It is head.
best detected with the hip flexed. Galeazzi’s sign helps detect unilateral conge-
Pain vaguely felt over the lateral aspect of the nital dislocation of the hip in children below 18
hip with tenderness anteriorly below the mid-point months of age. The child lies supine with hips and
of the inguinal ligament should suggest hip joint knees flexed at 90°. Normally both knees are at the
disease. same level; if one is higher than the other the test is
Pain located anteriorly and tenderness along positive.
lateral border of femoral triangle made worse on Tendonitis causes pain on resisted movement
forced flexion and extension of the hip occurs in involving the specific muscle. Anteromedial pain
iliopectineal bursitis. worsening on exercise and tenderness over adductor
Movements are tested with the patient lying flat. region which worsens on resisted adduction points
Flex the knees and hips to 90° and assess the degree to adductor tendonitis. Lateral pain worsened by
of movement and pain produced by rotation. resisted abduction points to gluteal tendonitis.
Part–I: Internal Medicine
Internal rotation is often affected first. In patients Neurological causes of pain must be looked for.
with external rotation deformity internal rotation is Note if coughing exacerbates the pain on the anterior
virtually impossible. Always compare both sides. aspect of thigh and movement of the back worsens
If dislocation is suspected flex the hip and knee to this pain. Presence of these features should suggest
90°, fix the pelvis with one hand touching the greater nerve root compression. The femoral nerve is put to
trochanter. With the other hand grasp the knee stretch by flexing the knee with patient lying prone.
and push the thigh downwards towards the bed. This leads to pain in the L2, L3 distribution if these
Normally the femur and pelvis move as one unit and segments are affected. Likewise stretch on the sciatic
hence the trochanter is not felt to move relative to nerve elicited by straight leg raising test leads to
the pelvis by the hand which fixes the pelvis as well pain posteriorly in the thigh and leg in lesions of
as touches the trochanter. If however, there is a L4, L5 and 51 segments. Pain over the lateral and
dislocation of the hip, a non-union of an intracapsular anterior aspects of the thigh which tenderness over
fracture or total destruction of femoral head, then the medial aspect of anterior superior iliac spine
the trochanter moves with the thigh relative to the occurs in meralgia paresthetica caused by
pelvis, i.e. it “telescopes”. compression of the lateral cutaneous nerve of thigh.
Patrick’s sign is a simple test to screen for hip Before leaving the thigh, check femoral artery
disease. The patient lies supine. The examiner flexes, pulsation. Look for varicose veins, with the patient
abducts and externally rotates the leg being tested in the standing position.
such that the foot of the tested leg is on the top of
the opposite knee. Next the leg being tested is slowly Knee Joint
lowered towards the examining table. If the test leg This joint is examined to give the following
falls at least parallel to the opposite leg the test is information:
negative—no disease. If the leg remains abducted 1. Assessment of tibiofemoral and femoropatellar
the test is positive indicating hip disease, ileopsoas joints movements.
spasm or sacroiliac disease. 2. Detection of deformities
The Ortolani’s sign detects congenital hip 3. Detection of bursitis
dislocation in infants. The supine infant’s hip are 4. Assessment of the condition of the entheses,
flexed and the examiner grasps the legs of the infant ligaments and menisci, and
so that the examiner’s thumbs are against the inner 5. Ruling out any cause for referred pain.
thighs and the fingers cover the lateral side of the Inspect the areas around the knee for scars,
thighs. Gently the hips are abducted and laterally sinuses and deformities. Note if swellings obliterate
Chapter 19: Examination of the Musculoskeletal System 257
the normal hollows around the knee. Palpate and To test if cruciate ligaments have been injured,
check for warmth and tenderness. Localized pain check by passive movement if there is an increased
and swelling with tenderness confined to the antero- anterior or posterior mobility of the leg with the knee
inferior part of the patella indicates prepatellar kept in 90° flexion. Try to bend the knee outwards
bursitis. Tenderness and swelling at the insertion of and rotate externally keeping the joint 90° flexed.
quadriceps tendon occurs in infrapatellar bursitis. This brings the medial meniscus between femur and
Check tenderness over femoral and tibial condyles, tibia. If it is torn, it causes a click or sharp pain.
anterior surface of patella, medial and lateral joint Likewise the condition of the lateral meniscus is
lines, fibular head and tibial tuberosity. Note if there checked by inward bending and internal rotation of
is tenderness over entheses. Joint effusion presents the knee.
a horse-shoe-shaped swelling situated anteriorly. In knee joint disease, flexion deformities develop
Presence of fluid can be confirmed by pushing fluid early. Genu recurvatum is hyperexten-sion of the
from the suprapatellar bursa into the joint and knee. In genu valgum or knock knee, the knee joints
tapping on patella. It hits the femur and springs back. are displaced medially, the thigh and the leg form
This phenomenon is called patellar tap (Fig. 19.35). an obtuse angle laterally. In genu varum or bow
If the amount of fluid in the knee is small, patellar legs, the knee joint is displaced laterally, the thigh
“tap” can be elicited only in the standing position. and leg are bent like a bow with the convexity
Now make the patient lie prone. A vague ill- pointing outwards. All these defects are usually
defined tender swelling behind the knee occurs in developmental or acquired in diseases such as
several tissues in the foot and chronic discharging Fix the hindfoot and twist the forefoot, if there
sinuses occur in Madura foot—maduramycosis. is pain, it suggests midtarsal joint disease. Swelling
The term talipes (club foot) denotes deformity may also be present (Figs 19.37A and B).
of the foot, usually congenital, or at times acquired. Note if the toes have been pushed apart by
Talipes equinus is extension of the foot in which swelling near metatarsal heads (day light sign).
the person has to walk on his toes. Talipes valgus Compress the metatarsal arch transversely and
is the condition in which the heel is turned out- squeeze individual joints. Pain caused by these
wards. In talipes varus, the heel is turned inwards. maneuvers suggests metatarsal joint disease. Check
Arthritis of the ankle causes diffuse pain on the toes for tenderness over the interphalangeal
standing, worsened by plantar and dorsiflexion of joints.
the foot.
Tendonitis: Note, if the there are swellings related
Talipes valgus may be due to talonavicular to the peroneal, tibialis posterior and Achilles
disease. Affection of midtarsal joints causes collapse tendons. Pain localized behind the lateral malleolus
of the longitudinal arch. In rheumatoid disease, with linear swelling along the tendon sheath occurs
hammer toes occur in which the proximal phalanx in inflammation related to the peroneal tendon.
subluxes upwards displacing the fibrofatty cushion Plantar flexion causes pain and inversion worsens
that normally protects the metatarsal head. This it. Likewise linear swelling behind the medial
increases load on the metatarsal head and painful malleolus with pain exacerbated by plantar flexion
Part–I: Internal Medicine
A B
Figs 19.36A and B: Rocking the heel from side to side to elicit subtalar joint tenderness
Chapter 19: Examination of the Musculoskeletal System 259
Fig. 19.39: Sensory loss from compression Fig. 19.40: Sensory loss from compression
of common peroneal nerve at knee of tibial nerve at ankle
Part–I: Internal Medicine
APPENDIX-1
Range of Movement of Normal Joints
APPENDIX-2
Scheme for Rapid Clinical Examination of Locomotor System and Recording
History taking: Points to ponder
Investigations in
1
20 Rheumatology
Laboratory investigations, Blood, Synovial fluid examination, Determination of HLA status, X-ray examination,
Other imaging techniques, Arthroscopy, Synovial biopsy
A B
Part–I: Internal Medicine
C D
Figs 20.1A to D: Fluorescent antinuclear antibody patterns: (A) Homogeneous pattern—dsDNA; (B) Speckled
pattern—Sm, SnRNP, Ro,La; (C) Rim pattern—dsDNA; (D) Nucleolar pattern—scl-70, SnRNP
patients also progress to develop rheumatoid arthritis individuals tests for these antibodies may be
or scleroderma. Antibodies to SS-A (anti-Ro) are weakly positive in a small proportion. Therefore,
seen in SLE and Sjögren’s syndrome. Antibodies to the significance of the tests has to be correlated
an antigen named Scl-70 are seen in scleroderma with the clinical presentation.
and antibodies to JO-1 are seen in polymyositis. It
Serum Complement Levels
must be remembered that overlap does occur and
therefore, a firm diagnosis should take into account Components of the complement system such as C3
the clinical features, immunological markers and and C4 are consumed during antigen antibody
other investigations. reactions occurring in collagen vascular diseases.
Elevated titers of anti-dsDNA antibodies are
Antineutrophil Cytoplasmic typically accompanied by hypocomplementemia.
Antibodies Reduction in levels of C3 suggests active SLE.
Antibodies to cytoplasmic antigens which develop
in several forms of vasculitides are employed Demonstration of LE Cell Phenomenon
for diagnosis. The most important ones are anti- Presence of LE cells is suggestive of SLE. The LE
neutrophilic cytoplasmic antibodies (ANCA). These cells can be demonstrated in active SLE. The LE
are IgG antibodies. When they react with proteinase cells are also rarely seen in RA, allergic states, drug
3, present in the cytoplasm of neutrophils they are induced lupus, etc. Due to low sensitivity and low
called cytoplasmic ANCA (c-ANCA). specificity, it is replaced by ANA in modern
Table 20.1:
Antinuclear antibodies in connective tissue The fluid can be examined as a fresh wet
diseases preparation under the microscope after staining with
Antibody Disease Comments methyline blue. Other tests include cell count,
dsDNA SLE High specificity, moderate cytocentrifugation to detect microorganisms and
sensitivity
culture, and polarized microscopy for crystals.
Smb (Smith) SLE High specificity, low sensitivity
Ro (SSA) Skin LE, Sjögren’s Complete heart block in DETERMINATION OF HLA STATUS
newborn
La (SSB) Sjögren’s, lupus Minor salivary gland biopsy In humans, the short arm of chromosome 6 contains
snRNP MCTD Also seen in SLE, the genes that regulate immunological processes
scleroderma, RA and these are called the major histocompatibility
Scl -70 Diffuse scleroderma Lung involvement in complex (MHC). It extends over about four million
scleroderma
base pairs. These code for the HLA proteins which
Centromere CREST syndrome Also seen in limited
scleroderma are of two types, i.e. HLA class I antigens and HLA
Histone Drug induced SLE Positive in 100% cases class II antigens. HLA class I molecules are
Jo-1 Dermatomyositis Low sensitivity distributed widely among most somatic cells of the
body with the exception of erythrocytes. HLA
Each laboratory should standardize its results and class II molecules are seen mainly in the cells of the
give its normal values for comparison. Administration immune system such as B-lymphocytes, macro-
Part–I: Internal Medicine
of NSAID reduces serum uric acid level. Therefore phages, dendritic cells and a groups of T-cells. One
false negative values may be seen even in gouty of their main functions is concerned with the
subjects receiving NSAIDs. In chronic tophaceous presentation of antigens to CD4 positive T-cells
gout, serum uric acid is elevated, often above 8 mg/ which activate further immunological processes.
dL but in acute gout, the serum uric acid may be Certain HLA types have strong association with
normal. Moreover all cases of hyperuricemia different rheumatological diseases. HLA-B27 is often
may not present with gouty arthritis. Table 20.1 positive in ankylosing spondylitis and other
summarizes the diagnostic relevance of antinuclear seronegative spondyloarthritis. HLA-DR4 may be
antibodies in connective tissue diseases. positive in RA and DR2 or DR3 in SLE.
In routine clinical rheumatological practice
SYNOVIAL FLUID EXAMINATION
only detection of HLA-B27 become a standard
Examination of the synovial fluid is a very reliable investigation, due to its very strong association with
and cost effective test for diagnosis of joint disease. ankylosing spondylitis. It is not needed in a definite
When the diagnosis is in doubt, this should be done case of ankylosing spondylitis. But HLA-B27 is
early. It can be done as a bedside procedure. Normal useful in suspected spondyloarthritis, acute uveitis
synovial fluid is a thick viscous yellow liquid. Fluid with low back pain and normal X-ray, asymmetrical
from inflamed joints is thin, watery and opalescent oligoarthritis or recurrent enthesitis, and in woman
(Table 20.2). with inflammatory back ache and normal radiology.
Table 20.2: Synovial fluid analysis
Feature Normal Noninflammatory arthritis Inflammatory (noninfectious) arthritis Infective arthritis
Volume < 1 mL > 1 mL > 1mL > 1 mL
Viscosity High High Low Variable
Color Colorless Straw to yellow Yellow Variable
Clarity Transparent Transparent Translucent Opaque
WBC count < 200/cmm 50-1000/cmm 1000-75000/cmm >100000/cmm
Neutrophils < 25% < 25% Often> 50% > 85%
Culture Sterile Sterile Sterile +
Mucin clot Firm Firm Friable Friable
Glucose Nearly equal to Nearly equal to Low (<50 mg%) Very low (< 20 mg%)
blood glucose blood glucose
Crystals - ± ± -
Chapter 20: Investigations in Rheumatology 269
X-RAY EXAMINATION
This is a very simple, reliable easily available and
cheap investigation giving diagnostic information
in most of the diseases associated with structural
changes in bones and joints. X-ray examination is
routinely done in almost all rheumatic diseases for
the following purposes:
1. To exclude bony and joint lesions.
2. To establish the diagnosis by the presence of
typical changes.
3. To confirm the clinical diagnosis and the stage
Fig. 20.3: Osteomalacia showing pseudofracture pelvis of disease.
(arrow) 4. For follow-up.
Characteristic abnormalities which are them-
selves diagnostic occur in osteoarthritis, cervical
spondylosis, ankylosing spondylitis, rheumatoid
arthritis, gout, tuberculous arthritis, osteomalacia,
fluorosis and others. Serial X-rays form the most
A B
Figs 20.6A and B: X-ray lumbosacral spine—ankylosing spondylitis. Note: Calcified ligaments,
Part–I: Internal Medicine
useful to detect bony erosions early in RA. MRI Radionucleotide scanning of bone shows
clearly delineates soft tissue changes like thickening areas of increased or decreased activity related to
or rupture of tendons, meniscial tear inside the vascularity, metabolism or inflammation of bone
knee joint and others. Changes in the spine and and joints. It is very sensitive to changes in tissue
intervertebral disk are also better imaged with MRI. activity but highly nonspecific. 99mTc scintigraphy
It is also considered as the gold standard imaging of commonly employed in our country is very useful
brain in neuropsyciatric lupus and vasculitis. MRI to detect bone metastasis, occult infections like septic
can detect infarcts, hemorrhage, demyelination and disciitis and stress fractures.
vasculitic brain damage.
Bone Densitometry
Early inflammatory changes are picked up
on MRI scans before they become evident in This is the measurement of bone mass or bone
conventional X-rays or CT scans. Dynamic contrast mineral density (BMD) which is the most reliable
enhanced MRI is even more efficient in this respect. parameter to diagnose osteoporosis and to predict
Inflammatory changes reflecting active sacroilitis the chances for fragility fractures in future. Several
include: types of bone densitometers are available world-
1. Bone marrow edema. wide. In India, the two types available are ultrasound
2. Synovitis. densitometers and dual energy. X-ray absorption
3. Enthesitis. densitometers (DEXA). The latter is more reliable
4. Capsulitis. and results are more reproducible, though it is more
Diffusion weighted imaging (DWI) can quantify expensive.
the diffusion coefficients of lesions which can The results of DEXA are quantitative values,
discriminate between normal and affected sub- expressed in two forms T-scores and Z-scores.
chondral bone. T-scores compare the BMD of the patient with
Ultrasonography with high frequency linear the mean peak BMD of the normal young adult
probe is useful in diagnosing synovitis, erosions population using standard deviation (SO).
tenosynovitis, tendon rupture or minimal effusion Z-score compares the BMD of the patient with
Joint aspiration or injection under ultrasound the mean BMD of patients of the same age. The
guidance in sacroiliac joint, hips or shoulders sites commonly measured are the lumbar spines (Ll-
markedly increase the accuracy of the procedure. L4) including the intervertebral disks, hips and
Chapter 20: Investigations in Rheumatology 271
Table 20.3: WHO criteria for osteoporosis in adult women using T-scores by DEXA
Normal BMD is within 1.0 SD of the young adult reference mean
Osteopenia BMD 1 to 2.5 SD below the young adult mean
Osteoporosis BMD more than 2.5 SD below the young adult mean
Severe osteoporosis Osteoporosis with the presence of one of the fragility fractures
forearm. BMD of any other part of the skeleton or best results in osteoarthritis. Removal of loose bodies
that of the whole skeleton can also be determined and debridement have given significant improvement
(Table 20.3). in joint function and pain reduction. In skilled hands
ARTHROSCOPY and well chosen cases arthroscopic treatment is very
useful to give relief.
This is endoscopic visualization of joints though
an arthroscope. Arthroscopy is done for biopsy, SYNOVIAL BIOPSY
therapeutic debridement of diseased joint structures,
synovectomy and arthroscopic fixation of intra- It is a useful procedure to make a definite diagnosis
articular structures following injury, etc. knees and of undiagnosed chronic monoarthritis. In conditions
shoulders are the most frequently arthroscoped like synovial malignancies and tuberculosis it gives
joints. As a therapeutic measure, it has given the a definite diagnosis.
8
Hematological System
CHAPTER
21
1 Hematology: General
Considerations
The cellular components of the bone marrow are: of the cells. These include predominantly erythro-
Mean values poietin for the erythroid cell lines, colony stimulating
Myeloid precursors and 57% factors G-CSF and GM-CSF for leukocytes and
thrombopoietin for platelet precursors. Cytokines of
granulocytes
lesser role are IL7, stem cell factor (SCF), FLT3
Erythroid precursors 25% ligand, IL3 and IL5.
Lymphocytes 16% Hemoglobin serves the function of oxygen
Monocytes 3% transport. The leukocytes form an important defense
Plasma cells 1.3% against microbial infections particularly the
Reticulum cells 0.3% neutrophils against bacteria. Eosinophils play a
Megakaryocytes 0.1% defensive role against helminthic parasites and in
allergic reactions. Though all the functions of the
In addition, the microenvironment of the
marrow where the HSCs are produced and mature basophils are not yet clear it is known that basophils
and tissue mast cells which contain granules rich in
is becoming clinically very important. This micro-
environment consists of: histamine play a major role in anaphylactic
reactions.
1. Stromal cells—fibroblasts (most studied),
marrow endothelial cells, osteoclasts The circulating lymphocyte population consists
2. Cytokines—stem cell factor (steel factor, c-kit of T-lymphocytes (80%) B-lymphocytes (15%) and
Part–I: Internal Medicine
ligand), Flt 3 ligand, thrombopoietin null lymphocytes (5%), T-lymphocytes can further
3. Matrix proteins—fibronectin, hyaluronan, be classified into various subtypes. These take part
heparan sulphate, tenascin, laminins, collagen. in cellular immunity. The B-lymphocytes are the
main cells concerned with antibody production and
The effects of the contents of this microen-
vironment are profound and are being studied in humoral immunity. Plasma cells are derived from
B-lymphocytes and they actively secrete immuno
depth. This information is crucial in areas like
transplantation, gene therapy and regenerative globulins.
medicine. Circulating monocytes have phagocytic activity.
Lymphoreticular organs consist of organized In addition, they present the antigens to lymphocytes
for further processing. Platelets take part in the initial
tissues such as lymph nodes, the liver and the spleen.
In addition almost all organs contain lymphoid tissue steps of hemostasis (primary hemostasis), augment
the process of coagulation (platelet procoagulant
either organized (e.g. thymus, tonsils, adenoids,
Peyer’s patches in the small intestine and others) or activity) and also help in the final disposal of the
clot. In addition to hemostatic activity, platelets are
more loosely arranged.
known to have several other functions as well.
Hematopoiesis and its Regulation
PATTERN OF THE COMMON
Active production of the formed elements of blood
occurs in the cancellous bones and the ends of the HEMATOLOGICAL DISORDERS IN INDIA
long bones. The cells are formed extravascularly in Hematological problems are widely prevalent.
the marrow and they are released into the vascular Almost all the known hematological disorders have
compartment depending on the demand. been described from India.
The cells originate from the totipotential
hematopoietic stem cells (HSCs). Multipotent Anemias
progenitors like common lymphoid progenitors and Most frequent hematological disorder seen in all
common myeloid progenitors are formed from these communities is iron deficiency anemia (IDA). It is
cells. Erythroid, myeloid, megakaryocytic and more prevalent in women and children. The average
lymphoid precursors are formed by successive prevalence in the general apparently healthy
differentiation of these multipotent progenitor stem population is 7.2% but in particularly vulnerable
cells. At each stage of differentiation cytokines groups such as agricultural workers and slum-
influence the proliferation and differentiation dwellers it may be even over 80%.
Chapter 21: Hematology: General Considerations 277
Nutritional macrocytic anemia caused by dietary a range of symptoms such as anemia, infections, bone
inadequacy of folates and malabsorption states is pains or fractures.
prevalent more among pregnant women and children.
Unlike in the west, pernicious anemia is rare. Vitamin Lymphomas
B12 deficiency occurs less commonly. When it does All types of lymphomas are common. Non-
so, it is due to dietary causes. Over 30% of anemias Hodgkin’s lymphoma (NHL) is more frequent than
show deficiency of two or more haematinic factors. Hodgkin’s lymphoma (HL). Many of them are seen
Hemolytic anemia is common. Sickle cell in advanced stages with prominent lymphadeno-
disease, thalassemias and hemoglobinopathies pathy and systemic manifestations.
E and D are widely prevalent. Other hemoglo-
binopathies occur sporadically. Among the Hemorrhagic Disorders
congenital red cell abnormalities, spherocytosis is Purpuras constitute 2/3 of cases and coagulation
most common. G6PD deficiency is prevalent widely disorders the rest. Among the purpuras immune
and this predisposes to hemolysis. thrombocytopenic purpura (ITP) is the most
The common acquired hemolytic anemias are common. Secondary purpuras follow next in
malaria, autoimmune hemolytic anemia, transfusion frequency.
reactions, Rh and ABO incompatibility and
secondary to several toxic substances and drugs. Henoch-Schönlein Purpura
Hypoplastic anemias are also frequently seen. Many
22
1 Examination of Hematological
System
History, Physical examination, Involvement of other systems in hematological cases, Systemic complications
caused by drugs
HISTORY 1. Hemorrhoids.
2. Excessive menstrual bleeding: Menstrual
Most of the points in history and physical examination bleeding occurring for more than four days and
which are relevant to diseases of the hematopoietic more frequently than once a month may be
system have been described in this book under taken as excessive. Normal blood loss during
different sections. a menstrual period ranges around 60 mL.
The following points in history are particularly Anemia produced by excessive menstrual
important: bleeding is more common in peripubertal age
group in which the adolescent girl gets excess
Nutrition
blood loss without adequate nutritional supple-
Dietary history should be taken in detail. Iron mentation.
deficiency anemia and nutritional macrocytic anemia 3. Repeated pregnancies at intervals shorter than
caused by deficiency of folate and/or vitamin B12 three years.
are largely due to inadequate dietary intake of these 4. Ulcerating lesions of the gastrointestinal tract,
nutrients. Severe protein deficiency may also give e.g. gastric and colonic carcinoma, ulcerative
rise to anemia. Dietary articles rich in iron are liver, colitis, intestinal tuberculosis, peptic ulcer-
meat, fresh green vegetables, onions, grapes and ation. Extensive use of antiplatelet drugs, and
jaggery. Rich sources of folic acid include liver, drugs which cause upper gastrointestinal
meat, green vegetables and fruits. Food articles rich bleeding such as NSAIDs may lead to minor
in B12 are liver, meat and other animal products. degrees of GI bleeding over prolonged periods
Dairy products (especially yoghurt and butter milk) and this can lead to anemia.
supply small amounts of this vitamin. Vegetable 5. Heavy infestation by hookworms or whip-
sources do not contain vitamin B12. Vitamin C worms. In many parts of India with improved
deficiency leads to scurvy in which bleeding is a sanitation the prevalence of soil transmitted
prominent clinical manifestation. Rich sources of helminths have come down. Hookworms
vitamin C include citrus fruits, gooseberries (amla), especially Ancylostoma duodenale, Necator
guava, and sprouting pulses. americanus and the whipworm Trichuris
trichiura which are the main causes of
Sources of Blood Loss gastrointestinal blood loss have come down.
Nutritional deficiency is often complicated by blood In addition, lesions such as carcinoma of the
loss. Common sources of blood loss are given below: stomach, colon and uterus may lead to occult blood
Chapter 22: Examination of Hematological System 279
loss and present for the first time as anemia even by fever and rigor. Recurrent infections associated
when the underlying condition remains silent. with fever should suggest the possibility of neutropenia,
In all cases of anaemia, source of blood loss if dysfunction of neutrophils or immunosuppressed
any, should be identified and corrected to get full states. Lymphoma (HD) may present with PUO.
relief. Occasionally fever is seen in myelofibrosis and CLL.
Night sweats suggest low grade fever and may
History of Drug Intake
be observed in lymphoma and leukemia.
Drug intake Fatigue, malaise and lassitude may be seen in
Several drugs lead to toxic damage to the blood anemia especially iron deficiency and hemato-
components and bone marrow. A few examples are logical malignancies. Emotional disorders also often
given below: give rise to these symptoms.
hematuria, hemetemesis and melena are more lymph nodes may give rise to mediastinal syndrome
suggestive of platelet or vascular abnormalities. In consisting of obstruction to lymphatics, veins and
this group, bleeding from cuts and wounds can be trachea caused by pressure at the thoracic inlet. The
arrested by local pressure. Bleeding into joints and face is congested and suffused. The jugular veins
deep tissue spaces are suggestive of coagulation are prominent and nonpulsatile. Pressure on the
abnormalities. In these, cuts and wounds give rise cervical sympathetic trunk caused by enlarged lymph
to prolonged blood loss, not easily controlled by local nodes may lead to Horner’s syndrome, characterized
pressure. If the extravasated blood tends to clot, this by ptosis (drooping of upper eyelid), miosis (small
may exclude a major coagulation defect. The pupil), enophthalmos (retraction of eyeball) and
bleeding tendency may show periodic waxing and anhydrosis (absence of sweating) on the same side
waning. of the face. In conditions like chronic myeloid
Secondary causes of bleeding tendencies include leukemia, the patient may complain of abdominal
renal failure, antiplatelet drugs, consumption masses, due to enlargement of spleen and liver.
coagulopathy, snake envenomation and scorpion
Bone Pain
bites and several others.
This is caused by increased pressure of the hyper-
Thrombophilia plastic marrow. This is seen in acute leukemias,
This term denotes an accelerated tendency for multiple myeloma, chronic myeloid leukemia, and
thrombosis which leads to venous and arterial hemoglobinopathies.
Part–I: Internal Medicine
Red urine: Acute intravascular hemolysis, myoglo- Nails koilonychia, ridging, flattening of nails: Iron
binuria, porphyria, anthracycline and phenazo- deficiency state.
pyridine drugs. Purpura/ecchymosis: Platelet disorders. Palpable
Amenorrhea: Antimetabolites, alkylating agents. purpura—vasculitis.
Cushingoid features: Long-term corticosteroid
Musculoskeletal System therapy.
Backache Congestion of conjunctiva and plethoric
Acute hemolytic reactions, involvement of vertebrae appearance: Polycythemia.
and spinal cord in acute leukemia and aggressive Generalized pruritis and excoriation of skin:
lymphoma, myeloma. Polycythemia vera, lymphomas, chronic lymphatic
leukemia.
Arthritis and Arthralgia Bronzing of skin: Iron overload states.
Gout secondary to hyperurecemia (hematological Chronic leg ulcers: Hemolytic anemias.
malignancies, MDS, hemolytic anemia, hemochro- Pigmentation of the skin: Megaloblastic anemia.
matosis, hemarthrosis in hemophilia, collagen
Systemic Examination
vascular diseases, ALL.
Shoulder pain: Splenic infarct (left side), gall- Mouth and throat should be examined carefully.
bladder disease (right side) in hemolytic disease. Presence of cheilosis and glossitis suggest nutritional
Part–I: Internal Medicine
observed in anemia. Hemorrhages and exudates are the young with normal coronary arteries. The
seen in aplastic anemia, acute leukemias and cardiovascular features caused by anemia disappear
thrombocytopenic states. Retinal hemorrhage when the hemoglobin level is corrected. Therefore,
may also occur as a complication of sudden it is necessary to re-examine the patient after
exsanguinating hemorrhage and rapidly developing correction of anemia to confirm the presence of
anemia. Leukemic deposits can be made out in the organic cardiovascular disease. Hypertension with
retina as raised areas with pale centre. Many patients polycythemia is called Gaisbock’s syndrome.
with chronic myeloid leukemia, polycythemia and Multiple venous and arterial thrombosis may
hyperviscosity states show engorged and tortuous develop in polycythemia and severe thrombocytosis
retinal veins which disappear when the condition is and thrombophilia.
corrected. Sausage shaped retinal veins are observed
Locomotor System
in Waldenstrom’s macroglobulinemia. Features of
raised intracranial tension including papilledema Arthritis, joint swellings or ankylosis should be
may develop in neuroleukemia. looked for. Acute lymphatic leukemia may present
with joint symptoms resembling rheumatic fever.
INVOLVEMENT OF OTHER SYSTEMS IN Arthropathy may occur as a result of hyperuricemia
HEMATOLOGICAL DISEASES and secondary gout as occurring in leukemias,
myeloma, polycythemia and myelofibrosis. In
Nervous System hemophilia painful swellings of joints develop in
Table 22.2: List of drugs showing complications corresponding to situation in which they are used, respectively
Drug Condition for which used Major toxicity in addition to bone marrow aplasia
Vincristine Acute lymphatic leukemia and lymphoma Peripheral neuropathy, myelopathy
Anthracycline antibiotics, e.g. doxorubicin Leukemias, tumors, lymphomas Myocardial toxicity leading to cardiac failure
Cyclophosphamide Leukemias, tumors, lymphomas Hemorrhagic cystitis
Methotrexate Leukemias, tumors Hepatotoxicity, Pulmonary fibrosis, mucositis
L-asparaginase Acute lymphatic leukemia Pancreatitis
Busulfan Chronic myeloid leukemia Pulmonary fibrosis, skin pigmentation, cataract
Interferon Chronic myeloid leukemia Fever, arthralgia psychosis
All-trans-retinoic acid (ATRA) Acute promyelocytic leukemia ATRA syndrome with leukocytosis
Anti thymocyte globulin (ATG) Aplastic anemia Immunosuppression, anaphylaxis
Part–I: Internal Medicine
CHAPTER
23
1 Investigations in
Hematological Disorders
Complete blood count (CBC) is one of the first India. Hemoglobin level has to be repeated at
hematological investigations to be done. In many of periodic intervals to assess the progress of the
the laboratories this is now done by an automated condition.
analyzer which gives the result in a short time The standard procedure to estimate hemoglobin
as a printout. In addition, cell histograms are also is by cyanmethemoglobin method using international
available. These automated analyzers have gradually standards and reliable equipment. The accuracy of
replaced laborious and time consuming manual the instrument has to be checked regularly.
methods during the past 50 years. Except in one- Normal values of hemoglobin for different age
man clinics or rural laboratories manual methods groups accepted by WHO are:
have gone out of vogue due to the labor involved
Children
and chances for errors.
• 6 months to 6 years 11 g/dL and above
All hematological cases should have the following • 6 years to 14 years 12 g/dL and above
investigations done: • Adult males 13 g/dL and above
• Complete blood count (CBC): This will include
hemoglobin concentration, red cell count, red cell Adult females
indices, (mean corpuscular volume—MCV, mean • Nonpregnant 12 g/dL and above
corpuscular hemoglobin—MCH, mean corpuscular • Pregnant 11 g/dL and above
hemoglobin concentration—MCHC), hematocrit, Increase in hemoglobin above 17.5 g/dL in males
red cell distribution width (RDW), reticulocyte and 15.5 g/dL in females occurs in polycythemia
count, platelet count, platelet distribution width, and hemoconcentration.
mean platelet volume and total and differential
ENUMERATION OF CELLS
leukocyte count.
• ESR and C-reactive protein (CRP). The errors of manual methods of enumeration of the
• Well stained peripheral blood smear. cells (erythrocytes, leukocytes and the platelets) are
minimized by using automated and semiautomated
HEMOGLOBIN ESTIMATION counters. These are now widely used for measuring
This should be done as part of general investigation various blood parameters. Automated counters
in all patients irrespective of the complaint since require only appropriate samples to be fed into them.
anemia is very prevalent in many communities in Newer counters can measure 8 to 20 parameters.
286 Section 8: Hematological System
allow easy recognition of even mild degrees of Normal Blood Smear and Pathological
anisocytosis. Estimation of mean corpuscular Abnormalities of Erythrocytes
volume (MCV) does not give accurate values when (Figs 23.2 to 23.21)
the number of macrocytes or microcytes is small.
RDW is a useful investigation in such situations.
Normal range is 42.5 ± 3.5 fL (standard deviation)
or 12.8 ± 1.2% (as coefficient of variation). RDW
is used for classifying anemias and as an indicator
for morphological analysis in the clinical laboratory.
It is elevated in iron deficiency anemia, but not in
thalassemias or anemia of chronic disease. It is
increased (above 17) in megaloblastic anemia
compared to other causes of macrocytosis.
Shape
Normal RBC is circular. Variation in shape is termed
poikilocytosis. Erythrocytes are oval in elliptocytosis
Fig. 23.2: Normal blood smear
(Fig. 23.8) and spherical in spherocytosis. Unlike
normal RBCs which are biconcave, spherocytes are
Fig. 23.5: Polychromatophilic macrocyte (arrow) Fig. 23.8: Howell-Jolly bodies—nuclear remnants in the
cytoplasm of RBC (arrows)
Part–I: Internal Medicine
Fig. 23.6: Punctate basophilia (arrow). Note basophilic Fig. 23.9: Cabots ring which is remnant of nuclear material
granules in the cytoplasm of RBC (arrow)
Fig. 23.7: Normoblast—normal precursor of RBC. Fig. 23.10: Burr cells—note short spiny margins
Note: the nucleus and hemoglobinized cytoplasm (arrows)
Chapter 23: Investigations in Hematological Disorders 289
Fig. 23.11: Acanthocytes—note the thorn like projections Fig. 23.14: Elliptocyte—note the oval shape (arrows)
Fig. 23.13: Echinocytes—RBC with toothed margins Fig. 23.16: Keratocyte; (syn horn cells), helmet cell or bite
(arrows) cell. Note the defect caused by loss of peripheral cytoplasm
(arrows)
290 Section 8: Hematological System
Fig. 23.17: Schistocyte—note the broken fragments Fig. 23.20: Stomatocyte—mouth like cleft in the RBC (arrows)
of erythrocytes (arrows)
Part–I: Internal Medicine
Fig. 23.18: Sickle cells—note the sickle shape due to the Fig. 23.21: Teardrop cells (arrows)
presence of HbS (arrow)
Occasionally erythroblasts may be seen in peripheral increased in hemolytic states and regenerating
blood (normoblast or megaloblast) in conditions anemias. The count is reduced in aplastic anemia.
where there is an active regeneration. For example, Since the reticulocyte count is expressed as
after acute hemolysis or hemorrhage or even during a percentage of the erythrocytes, errors are likely to
treatment of nutritional anemias. In dyshemat- occur when erythrocyte counts and PCV vary.
opoiesis distorted erythroblasts or their fragments This error is obviated either by doing absolute
may be seen in peripheral blood (Figs 23.2 to 23.21). reticulocyte count or using a correction factor.
Malarial parasites should be looked for in all Correction for anemia:
cases, irrespective of the presenting symptom.
Characteristics to identify malarial parasites are HB PCV
ARC = ORC × or ORC ×
given below: 15 45
1. They are intraerythrocytic.
2. Cytoplasm is blue when stained by Romanowsky Note: ARC—absolute reticulocyte count, ORC
stains. observed RC, PCV—packed cell volume.
3. Chromatin is red.
Parasites in Peripheral Blood Film/Marrow
Shape of the parasites, their number and size
(Figs 23.22 to 23.25)
depend upon their species and the stage of their
development.
RETICULOCYTES
These are the early forms of RBC derived from
erythroblasts. Reticulum is not demonstrable by the
usual Romanowsky stains. A wet preparation is made
by mixing one drop of blood (by finger prick) and
one drop of a supravital stain (brilliant cresyl blue
or methylene blue). After applying a coverslip this
is kept for 2 to 3 minutes, and examined under oil
immersion. An alternate method is to make a smear
after mixing a drop of blood with the vital stain and
counter-stain the slide with Leishman stain. Around
200 to 500 RBCs are examined for reticulocytes. Fig. 23.23: LD bodies within macrophages in the
Normal reticulocyte count is 0.8 to 1.5%. This is marrow (arrow)
292 Section 8: Hematological System
Fig. 23.24: Microfilaria W. bancrofti—note the smooth curves Fig. 23.27: Myeloblast in acute myeloid leukemia. Note the
and the clear speces in front and back nucleoli in the blast (arrow)
Part–I: Internal Medicine
Fig. 23.26: Chronic myeloid leukemia. Peripheral blood— Fig. 23.29: Acute promyelocytic leukemia (M3). Numerous
note myelocyte (arrow) blasts (arrows) and promyelocytes (arrowheads)
Chapter 23: Investigations in Hematological Disorders 293
Fig. 23.30: Acute myeloid leukemia (M1) numerous Fig. 23.33: Hemophagocytosis-of-neutrophil by
myeloblasts (arrow) and arrowheads point to Auer rods macrophage. Note the engulfed neutrophil (arrow)
Fig. 23.32: Macropolycyte—note the excessive number of Fig. 23.35: Peripheral blood film showing rouleauxing (arrows)
nuclear lobes in the neutrophils a finding in macrocytic anemia indicates high ESR
294 Section 8: Hematological System
Fig. 23.36: Plasma cells, in bone marrow in multiple Fig. 23.37: Serum protein electrophoresis multiple
myeloma. Note: The plasma cells (arrows) myeloma. Note: The monoclonal M-band (asterisk)
Part–I: Internal Medicine
subleukemic leukemias the total leukocyte count is myelocytes in chronic myeloid leukemia, mature
not elevated but leukocyte precursors may be seen. lymphocytes in chronic lymphatic leukemia,
In aleukemic leukemia the peripheral blood does not myeloblasts in acute myeloid leukemia,
contain abnormal cells, but bone marrow reveals lymphoblasts in acute lymphatic leukemia.
them. b. Presence of blast cells above 20% is suggestive
Leukemoid reaction is the presence of immature of acute leukemia.
leukocytes in the peripheral blood with moderate c. Suppression of the other normal leukocytes, e.g.
or severe leukocytosis, often secondary to other neutropenia in acute leukemia (Table 23.1).
conditions. Erythrocytes: Generally there is a suppression of
Conditions giving rise to leukemoid reaction. erythropoiesis and therefore various grades of
Myeloid reaction Pneumonia, meningitis, anaemia develop, especially in acute leukemias.
diphtheria, amebic liver Platelets: They are considerably reduced in acute
abscess tumors with leukemias especially so in those associated with
metastasis to the bones bleeding. When the platelet count falls below
Lymphatic reaction Disseminated tuberculosis, 50,000/cmm spontaneous bleeding is common.
pertussis, infectious mono-
Classification of Acute Leukemias
nucleosis, infective hepatitis
It is possible to diagnose 50 to 70% of all Acute leukemias are further subclassified based on
Part–I: Internal Medicine
Fig. 23.38: Normal bone marrow—note the cellularity Fig. 23.39: Normal bone marrow × 1000 (Megakaryocyte)—
(arrow) and the stroma (arrowhead) low power view note the large cell with irregular margins (arrow shows escaping
platelets). Normoblast (short arrow). Plasma cell (arrowhead)
298 Section 8: Hematological System
helpful:
common practice to take biopsy specimen also along
1. Unexplained anemias.
with aspiration since histology gives additional
2. Parasitic infections like leishmaniasis and
information about the cellular and stromal elements.
malaria.
3. Investigation of pyrexia of unknown origin SPECIAL INVESTIGATIONS IN
especially in infection by Salmonella typhi. NUTRITIONAL ANEMIAS
4. Karyotyping in hematological disorders, e.g.
Ph’ chromosome in chronic myeloid leukemia Iron Deficiency Anemia
and nonhematological conditions such as
Serum iron levels are decreased. Total iron binding
Turner’s syndrome and Klinefelter’s syndrome.
capacity (TIBC) is increased. Normal serum iron
5. Secondary malignant deposits in the bone
levels range from 60 to 160 mcg/dL (13–32 P mol/L).
marrow.
Normal iron binding capacity (transferrin level)
6. To demonstrate iron stores and iron deficiency.
ranges from 280 to 400 mcg/dL (45–70 P mol/L).
7. Staging lymphomas.
Normal transferrin saturation is 30 to 35%. Lower
Therapeutic Indications values less than 16% indicate iron deficiency.
Demonstration of iron stores in the bone marrow
1. To collect bone marrow for transplantation from by “Prussian blue staining” is a reliable method to
the donor. assess the iron status of the individual. The serum
2. For infusion of fluids under exceptional ferritin level is a very reliable indicator of the
circumstances in children-site: Tibial marrow iron stores in the body. Normal values range from
cavity. 15 to 200 ng/mL in males (mean 50.4) and
Procedure: Following sites may be employed: from 12 to 125 ng/mL in females (mean 24). In
1. Iliac crest—posterior superior iliac spine being conditions of iron overload such as thalassemia
the commonest site. An alternate site is the and hemochromatosis the values are very high.
anterior iliac spine. Values of serum iron below 80mcg/dL is
2. Manubrium or the first piece of sternum. suggestive of iron deficiency. Transferrin saturation
3. Tibial shaft. below 16% and low ferritin < 15 ng/mL in males
4. Occasionally the ribs and vertebral spine, and<12ng/mL in females) are very reliable indicators
especially when pathological lesions are of iron deficiency except under special situations
detected in them. such as renal failure patients receiving hemodialysis.
Chapter 23: Investigations in Hematological Disorders 299
Serum ferritin, being an acute reactant, is deceptively of RBCs are determined by isotopic studies
high in patients undergoing dialysis procedures. using radioactive chromium.
Serum transferrin receptor (sTFR) estimation
Immunological Studies
is a newer investigatory tool for iron deficiency.
It is increased in iron deficiency and this distinguishes After establishing the presence of an active
iron deficiency anemia from anemia of chronic hemolytic process further investigations are carried
diseases (ACD). out to determine the specific cause.
Preliminary Investigations in a Patient with can be quantitated by measuring the volume of serum
Generalized Bleeding Disorder exuded. In platelet dysfunction and in throm-
bocytopenia clot retraction is defective. Normally
Bleeding Time the separated serum measures around 50%. Clot
This is done by noting the time taken for spon- retraction is defective when the platelet counts fall
taneous arrest of bleeding from a cut in the capillary below 50,000/cumm and in thrombocytopathies.
system. Bleeding time depends upon the adequacy
Fibrinolysis
of platelet number and function, and capillary
integrity. This test is standardized (Ivy) by using a The tube containing the clot is observed at regular
template for incision over the forearm and applying intervals for 24 hours. Early lysis of the clot (within
a pressure of 40 mm of mercury proximally using a 2 hours) should suggest the possibility of excessive
sphygmomanometer cuff. Normal bleeding time is fibrinolysis.
up to 7 minutes. Above 10 minutes is abnormal. Other Tests
Coagulation Time (Syn: Clotting Time) Presence of excessive fibrinolytic activity of the
Principle: The time taken for spontaneous clotting plasma used to be demonstrated by euglobulin lysis
of freshly drawn blood at room temperature is noted. time and lysis of fibrin plates. At present D-dimer
In theory, deficiency of any of the factors in the estimation is preferred.
intrinsic and extrinsic pathways of coagulation
Part–I: Internal Medicine
Prothrombin Time
should prolong the clotting time but in practice mild
or even moderate deficiencies of several factors do This test denotes the integrity of the extrinsic and
not. Normal clotting time is 5 to 10 minutes. Clotting common coagulation pathway. It is a test commonly
time is prolonged only if the defect is moderate or employed to monitor anticoagulant therapy with
severe. In practice prolongation of the coagulation coumarin drugs. This is probably the most frequently
time is almost always caused by hemophilia, done test of coagulation function, since many patients
Christmas disease, disseminated intravascular are at present on long-term anticoagulant therapy.
coagulation, heparin therapy, fibrinogen deficiency The time taken for extrinsic thromboplastin (usually
or circulating anticoagulants. extracts of brain) to form a clot in recalcified platelet
poor plasma at 37°C is noted. In the normal it ranges
Hess’ Test (Capillary Fragility Test) from 12 to 15 seconds and this is the prothrombin
The fragility of the capillaries when submitted to time (PT). The patient’s PT is compared with that
higher pressure is revealed by the appearance of of a normal control (often pooled) plasma of normal
purpura distal to compression of the arm by a persons done simultaneously under the same
sphygmomanometer cuff inflated to 90 mm Hg and conditions. PT can be expressed as the absolute times
kept for five minutes. Platelet and vascular defects obtained or as a ratio of the patient’s PT with the PT
and several other conditions give rise to a positive of the control subjects.
test. Being nonspecific, this test is not of great Previously different laboratories used to employ
diagnostic importance in hematology. different thromboplastins with varying potency and
This test is important in determining the therefore the values showed great variation between
possibility of hemorrhagic complication in dengue different laboratories.
hemorrhagic fever. In order to standardize the test and avoid inter-
laboratory variations, internationally standardized
Clot Retraction thromboplastin is used and the results are expressed
The tube in which the blood is allowed to clot is as international normalized ratio (INR). INR
observed after one hour and two hours at 37°C. In ranging from 1.5 to 3 are maintained to provide
normals the clot retracts and the serum exudes. This anticoagulation for different thromboembolic
function depends on platelet activity. The process conditions.
Chapter 23: Investigations in Hematological Disorders 303
Partial thromboplastin time (PTT) also known When coagulation defects are caused by the
as activated partial thromboplastin time (APTT) deficiency of normal factors the abnormality can be
measures the time required for the formation of corrected by the addition of 10 to 20% of normal
thrombin and fibrin clot by the intrinsic coagulation plasma. In the presence of circulating anticoagulants
pathway. When one or more of the coagulation normal plasma fails to correct the deficiency.
factors, except factor VII, are reduced to levels Rusven (Russel’s viper venom) clotting time is
below 30% of normal, the APTT is prolonged employed to assay factor X and also for the detection
(normal value of APTT for most of the laboratories of lupus anticoagulant.
is 35 seconds). The missing coagulation factor can At present quantitative and qualitative
be identified and quantitated by repeating the test estimations of coagulation factors are undertaken
with the addition of plasma having known defects in several advanced laboratories. These help to
and noting the correction of APTT (modified APTT diagnosis subclinical deficiencies, inheritance pattern
tests). in relatives, detection of hereditary and acquired
The conditions in which prothrombin time (PT) hyper coagulation states such as protein C and
and partial thromboplastin time (PTT) are prolonged protein S deficiencies and qualitative abnormality
are listed below. of prothrombin.
PT Prolonged
TESTS FOR PLATELET FUNCTIONS
1. Deficiency of factor VII.
Large platelets (megathrombocytes) with platelet available in many laboratories in India. D-dimer can
diameter more than 4μ occur in immune throm be estimated by ELISA, latex agglutination or by
bocytopenias, regeneration of platelets and in whole blood agglutination.
thrombocytopathies like Bernard Soulier syndrome. D-dimer is one of the fibrin related markers
Small platelets occur in thrombocytosis. The platelet (FRM). Plasmin cleaves both fibrin and fibrinogen
size may vary. This can be shown by automatic cell at the same site. But when plasmin acts on covalently
counters. Further examination is by electron cross linked fibrin, D-dimers are released. Thus,
microscopy by which the granule content and cellular D-dimers can be measured in the plasma as a relatively
ultrastructure can be studied. specific test of fibrin (rather than fibrinogen). It
indirectly shows prior thrombin and fibrin clot
Tests for Qualitative Function
formation and subsequent degradation by plasmin.
of Platelets Aggregation
D-dimer can be estimated by a variety of methods:
Platelet aggregometry is ideally done by aggregometer semiquantitative vs quantitative, manual vs auto-
and thromboelastograph (which are automated mated, latex agglutination vs ELISA. The normal
instruments) or by manual methods. Aggregation in value is 0.22 to 0.74 mcg/mL.
response to adenosine diphosphate (ADP), collagen,
epinephrine, thrombin, arachidonic acid, ristocetin, Clinical Significance
and other substances can be studied. The D-dimer test provides a measure of fibri-
Part–I: Internal Medicine
Table 23.6: Causes of thrombophilia 100 mm/hr. Examination of the buffy coat may show
• The inherited hypercoagulable states plasma cells which are characterized by deep blue
• Antithrombin III deficiency cytoplasm, eccentric nucleus.
• Protein C and S deficiency Generally myeloma presents with progressive
• Disorders of the fibrinolytic system anaemia and bone pains. The vast majority are
• Disfibrinogenemia persons above the age of 55. ESR is often above
• Factor V Leiden defect 100 mm/hr. Examination of the buffy coat may show
• P 20210 (prothrombin abnormality) plasma cells which are characterised by deep blue
• Hyperhomocysteinemia cytoplasm, eccentric nucleous and perinuclear halo.
• Increased in factors VIII, IX, XI levels Diagnosis is confirmed if two or more of the
• Acquired causes following criteria are fulfilled (See Figs 23.36 and
– hyperhomocysteinemia
– thrombocytosis 23.37)
– hyperviscosity states 1. Bone marrow examination reveals plasma cells
– antiphospholipid antibody syndrome in excess of 30%. Many of them show
abnormalities like vacuolation and multi-
Screening Laboratory Tests nuclearity, such cells are called myeloma cells.
In advanced cases bone marrow aspirated from
Prothrombin time (PT), activated partial throm-
any site will reveal the abnormality. If in doubt,
boplastin time (APTT), and thrombin time (TT), the
aspiration from a site showing radiological
1
24 Hematological Emergencies
and their Management
Severe anemia, Agranulocytosis, Bleeding, DIC, Immune thrombocytopenia, Deep vein and thrombosis,
Disseminated intravascular coagulation, Severe hemolytic crisis, Macrophage activation syndrome, Immune
reconstitution inflammatory syndrome, Transplant rejection syndrome
Disseminated intravascular coagulation (DIC): cytosing hemopoietic cells in the bone marrow.
Identify and remove the cause. Heparin in small The mortality is high ranging from 15 to 60%.
doses and replacement of fibrinogen and clotting Aggressive treatment includes supportive measures
factors (fresh frozen plasma) help to arrest the and immunosuppression with high doses of steroids,
intravascular coagulation and restore coagulability intravemous immunoglobin, cyclosporine, other
of blood. DIC is a hematological emergency with immunosuppresents and plasmapheresis.
high mortality. The basic treatment of DIC is the
treatment of the underlying cause. Supportive IMMUNE RECONSTITUTION INFLAMMATORY
treatment includes control of hemodynamic SYNDROME
parameters, respiratory support and sometimes With the institution of antiretroviral therapy in
invasive surgical procedures. Control of bleeding HIV infection and AIDS, immune status of the
and thrombocytopenia should be undertaken with patient improves and opportunistic infections are
blood component therapy including FFP, cryo- successfully overcome. But a small number of
precipitate and platelet concentrates. Clotting factor patients develop inflammatory disease in response
concentrates are not recommended. to specific opportunistic pathogens within a few
weeks or months of initiating therapy. This exuberant
SEVERE HEMOLYTIC CRISIS inflammatory response is called immune recon-
This may complicate several underlying diseases stitution inflammatory syndrome (IRIS).
Part–I: Internal Medicine
9
Endocrinology
CHAPTER
25
1 General Considerations
Anatomy and functions of endocrine organs, Pattern of endocrine disorders in India, Genetically determined
endocrine abnormalities, Paraneoplastic manifestations of malignancy
• Growth hormone release inhibiting hormone Blood supply is from superior thyroid arteries which
(somatostatin) are branches of the subclavian, and thyroidea ima which
• Prolactin releasing and prolactin inhibiting arises as a branch of the aorta.
(Dopamine) hormones Venous drainage is into superior, middle and
• Melanocyte stimulating hormone releasing factor inferior thyroidal veins which ultimately join the
(MSHRF) internal jugular vein.
• Arginine vasopressin and oxytocin.
Probably the end organ hormones exert their Hormones
feedback effects on the hypothalamus as well as Thyroxine (T4) and triodothyronine (T3) (only 20%
the pituitary gland. of total) are produced by the thyroid follicles.
Thyrocalcitonin is formed in the parafollicular cells.
Pituitary Gland
(C cells) 80% of circulating T3 is derived from
This weighs about 0.5 to 1 g. The blood supply is deiodination of T4 to T3 in the liver and kidneys.
derived from the internal carotid and anterior
cerebral arteries. Venous drainage is into the cavernous Parathyroid Glands
sinuses. The gland is situated in the pituitary fossa. They are four in number together weighing about
Below is the sphenoid air sinuses, on either side, 50 to 120 mg, remaining in close relation to the
the internal carotid arteries and cavernous sinuses. lateral lobes of the thyroid. Sometimes one or
The posterior pituitary is continuous with the more of these glands may remain in the media-
Part–I: Internal Medicine
pituitary stalk of hypothalamus above. stinum in relation to the thymus. Hormone secreted
is parathormone.
Hormones
Anterior Lobe Pancreas
• Thyroid stimulating hormone (TSH or The whole gland weighs about 90 g. It contains
thyrotrophin)—Pulsatile, more at night exocrine and endocrine tissues. The arterial blood
• Adrenocorticotrophic hormone (ACTH)— supply is derived from the splenic artery and
Circadian rhythm pancreaticoduodenal branches of the hepatic and
• Growth hormone (GH)—Circadian rhythm, superior mesenteric arteries. Venous drainage is
more in the morning. into splenic, and superior mesenteric veins and then
• Follicle stimulating hormone (FSH)—Pulsatile into portal vein. The endocrine tissue consists of
• Leutinizing hormone (LH)—Pulsatile the islets of Langerhans which consists of alpha,
• Prolactin—Pulsatile secretion beta, delta, and PP cells. Islets form only 1% of
• Beta lipotrophins (-LPH) pancreas weight, most of the islets are located in
• Alpha,beta and gamma endorphins derived from the tail of the pancreas. Insulin secretion per day
-LPH. is approximately 50 units. Main hormones are
—Insulin produced by beta cells, glucagon from
Intermediate Lobe alpha cells, somatostatin from delta cells and
Alpha and beta melanocyte stimulating hormones pancreatic polypeptide from PP cells.
(MSHs).
Adrenal Glands
Posterior Lobe These are two in number, right and the left, placed
Mainly arginine vasopressin (antidiuretic hormone— in close relation to the upper poles of the kidneys.
ADH) and oxytocin, both synthesized in the supraoptic Each adrenal weighs about 4.5 g. The cortex forms
and paraventricular nuclei of hypothalamus and 90% of the gland. Arterial blood is derived from
migrate as neuroseretory granules to the posterior three suprarenal arteries—superior from inferior
pituitary. phrenic artery, middle from the aorta, and inferior
from renal artery. Venous drainage is by suprarenal
Thyroid Gland vein, the right drains into the inferior vena cava and
Weight: 15 to 25 g the left drains into the left renal vein.
Chapter 25: General Considerations 313
Adrenal Hormones are also formed in neural tissue and such hormones
have action on the central nervous system as well
Adrenal Cortex
as in other tissues.
Cortisol, corticosterone, aldosterone, deoxycor- Their actions are summarized in Table 25.l.
ticosterone, dehydroepiandrosterone (DHEA) and Possibly several other substances with hormonal
androstenedione. activity exist, which are being identified from time
Adrenal Medulla -to-time.
Norepinephrine, epinephrine.
PATTERN OF ENDOCRINE DISORDERS SEEN
Ovaries IN INDIA
These are two in number. In adults their weight Classic diabetes mellitus tops the list in frequency.
varies with the period of menstrual cycle. Arterial Though nationwide surveys are not available,
supply is from ovarian arteries which are branches limited surveys in different population groups have
of the aorta. Venous drainage is into the pampiniform shown that the prevalence may vary from 6 to 7%
plexus from which ovarian veins are formed. The among the general population urban 15 to 16%,
right one drains into the inferior vena cava and the rural 4 to 5%. Undetected cases and those with
left into the left renal vein. impaired glucose tolerance may contribute another
Hormones equal number. Among the diabetics 96% is type 2
secretion
Substance P Central and peripheral nervous system Vasodilatation stimulates muscle contraction,
reduction of rise of plasma glucagons and insulin
are infrequent. They may occur as isolated abnor- affecting the posterior pituitary, diabetes insipidus
malities or as part of a multiple endocrine syndrome is the most frequent.
(MEN II). Hypothalamic syndromes are seen at times.
Parathyroid lesions are seen not uncommonly. These present as classical Froehlich syndrome,
Hypoparathyroidism occurring as a complication of obesity, eating disorders or somnolence. Laurence-
thyroid surgery may present as tetany. Hyper- Biedl-Moon syndrome is also not uncommon with
parathyroidism caused by parathyroid hyperplasia polydactyly and retinitis pigmentosa.
or neoplasms gives rise to hypercalcemia and various Gonadal abnormalities are widely seen. In
skeletal abnormalities. Chronic renal failure leads to males, undescended testes, primary and secondary
secondary hyperparathyroidism and osteodystrophy hypogonadism, azoospermia and impotence are
at times. common. In women, delayed puberty, primary
Vitamin D malnutrition is common in many amenorrhea, other menstrual irregularities, disorders
parts of India, especially in the colder regions in of breast development, sterility and menstrual
the north. This presents as rickets in children and disturbances due to polycystic ovarian disease
osteomalacia in adults, particularly in pregnant and (PCOD) top the list. Postmenopausal osteoporosis
lactating women. In addition to the fully manifest is widespread.
cases several milder forms occur, which usually Except diabetes mellitus, thyroid disorders
go undetected. and gonadal dysfunction, classical presentation of
Anterior pituitary disease may present as primary other endocrine disorders is a clinical curiosity
endocrine abnormalities such as hypopituitarism, seen in all general medical clinics. More than the
gigantism and acromegaly or as intracranial space florid syndromes, milder grades of dysfunction
occupying lesions. Hypopituitarism and diabetes are encountered. This has to be kept in mind and
insipidus due to viperine snake bite are rare, but a high degree of clinical suspicion and careful
specific entities, seen in India. Among diseases investigations are necessary to diagnose them.
Chapter 25: General Considerations 315
26
1 Clinical Examination in
Endocrine Diseases
GENERAL SYMPTOMATOLOGY IN
ENDOCRINE DISEASES
A B
Figs 26.3A and B: Female Addison’s disease. Note: Pigmentation
(pheochromocytoma), obesity
(Cushing’s syndrome)
b. Palpitation Thyrotoxicosis,
hypoglycemia,
Respiratory Symptoms
a. Hoarseness Myxedema, laryngeal nerve
of voice paralysis following thyroid
surgery, retrosternal goiter
Fig. 26.4: Vitiligo-depigmented patches on the shin pressing on recurrent
Froehlich’s syndrome, laryngeal nerve, carcinoma
Laurence-Moon-Biedle thyroid
syndrome b. Stridor Hypoparathyroidism
c. Skin pigmen- Addison’s disease c. Cough when Pressure on the trachea caused
tation over (Figs 26.3A and B), lying down by thyroid and parathyroid
axillary folds, Cushing’s syndrome, tumors.
palm and hypothyroidism,
sole creases, thyrotoxicosis Gastrointestinal Symptoms
pressure points,
a. Increased Diabetes mellitus,
moist surfaces
appetite thyrotoxicosis,
and mucus
pheochromocytoma
membranes
d. Vitiligo (Fig. 26.4) Hypothyroidism, b. Anorexia Hypothyroidism, Addison’s
Addison’s disease, disease
diabetes type I c. Increased thirst Diabetes mellitus, diabetes
e. Increased Hyperthyroidism, insipidus, thyrotoxicosis,
sweating hypoglycemia, hyperparathyroidism,
(hyperhidrosis) pheochromocytoma hypercalcemia
d. Vomiting Diabetic ketoacidosis,
Cardiovascular Symptoms Addison’s disease, pituitary
a. Dyspnea Caused by secondary tumors with raised intracranial
hypertension tension, hyperparathyroidism
318 Section 9: Endocrinology
Fig. 26.6: Dwarf normal—age-matched woman Fig. 26.7: Acromegaly male (45 years) side view. Note
for comparison (30 years) the prognatic mandible
PHYSICAL EXAMINATION
Anthropometry
of the body exceeds the upper segment. If growth
At birth the ratio between the upper and lower hormone excess occurs after fusion of the epi-
segments is approximately 1.7:1. By the age of 10 physis acromegaly develops. There is enlargement
years the ratio becomes 1:1 because the lower limbs of the soft tissues and bones of the hands, feet
increase in length at a higher rate compared to the skull and mandible with separation of the teeth
torso. Hypothyroid dwarfs (cretins) retain infantile (Figs 26.7 and 26.8). In eunuchoidism, the lower
skeletal proportions. In constitutional dwarfs and segment is longer because of delayed epiphyseal
dwarfism due to hypopituitarism the skeletal fusion.
proportions are not altered. Pituitary hyperfunction
producing excess of growth hormone in childhood Skin and Appendages
leads to excessive height and large body size. This Dry, coarse, scaly skin occurs in cretinism and
is known as gigantism. Maximal linear growth myxedema. Striae over the abdomen, back gluteal
occurs in the bones of the extremities, so that the region, thighs and other parts develop in Cushing’s
arm span exceeds the height and lower segment syndrome (Fig. 26.9). In diabetic ketoacidosis the
320 Section 9: Endocrinology
Eyes
Eyebrows
These are scanty or absent in hypothyroidism
(madarosis). This has to be distinguished from
lepromatous leprosy which is a common cause of
loss of eyebrows. Look for conjunctival con-
gestion, or periorbital edema as in Graves’ disease
and myxedema, and watering from the eyes
(epiphora) in exophthalmos. Infrequent blinking
(normal 3–5 times/mt) may be observed in Graves’
disease.
Stare
Widening of the palpebral fissure may be normal,
Fig. 26.9: Cushing’s syndrome: Striae on abdominal
wall (arrow)
familial or congenital. Pathologically it occurs in
Graves’ disease and in conditions of sympathetic
overactivity. Widened palpebral fissure may simulate
skin is dry. In hyperthyroidism the skin is warm
Part–I: Internal Medicine
proptosis.
and moist. Pretibial myxedema occurs as localized
Lid Lag
supple cutaneous nodular masses in front of the
tibia. Thick woody skin over the nape of the neck Normally, the upper eyelids closely follow the
(scleredema) may be seen in type II diabetes. downward movements of the eyeballs, so that
Lesions resembling glazed porcelain with yellow the sclera is not visible above the cornea, when the
or reddish center (necrobiosis lipoidica diabeti- patient looks down. In thyrotoxicosis the upper
corum) and pigmented papules which are usually lid fails to move down fully along with the eyeball,
circumscribed skin spots may be seen in the pretibial so that a rim of sclera is exposed when the patient
region (shin spots) in diabetes mellitus. looks down. This phenomenon is called lid lag and
this indicates thyrotoxicosis. Less commonly this
Hair phenomenon may be due to local abnormalities
in the eye especially if lid lag is unilateral.
a. Look for the presence, nature and distribution
of hair over the face, genitalia, axillae and rest Abridged classification of eye changes in Graves’
of the body. Hirsuitism is excess growth of disease
hair over moustache area, face, chest and rest 1. No signs or symptoms
of the body in females. Virilizing tumors in 2. Only signs limited to upper lid retraction, stare
women lead to the development of the male with or without lid lag and proptosis. No
pattern of hair distribution. symptoms.
b. Absence of body hair in males: This may 3. Soft tissue involvement leading to excessive
be familial at times. Pathologically it occurs lacrimation, edema of conjunctiva and lids
in hypogonadism, hypopituitarism and (chemosis) and photophobia.
hypoadrenal corticism. Recent fall of body 4. Proptosis (Fig. 26.10).
hair occurs in hypothyroidism and hypopara- 5. Extraocular muscle involvement with restriction,
thyroidism. of movements and diplopia.
c. Abnormality of face: Moon face or Cushingoid 6. Corneal–ulceration and perforation-exophthalmic
facies—the face is rounded with ruddy ophthalmopathy.
prominent cheeks. The ears are hidden behind 7. Loss of vision due to involvement of the cornea
them. This occurs in Cushing’s syndrome. and optic nerve.
Chapter 26: Clinical Examination in Endocrine Diseases 321
Myasthenia or periodic paralysis may be (macroglossia) the speech becomes thick and
the thyroid isthmus—Delphian lymph node may in movement of the gland along with the larynx on
be palpated over the thyroid gland. In carcinoma of swallowing. This feature helps to distinguish thyroid
the thyroid with secondaries, cervical lymph nodes from other masses like lymph nodes.
may be enlarged. It is ideal to palpate the thyroid gland with the
palms and fingers, neck being kept semiflexed and
Extremities the examiner standing behind. Relaxation of the
Examine the hands and feet carefully. The following sternomastoid muscle is essential for the examination
abnormalities are of diagnostic importance. to be successful. The gland can be displaced to one
a. Cretinoid hand: Short and blunted fingers, side by pressure on the opposite side and this makes
square palm and short radius seen in cretinism. the lateral lobe more accessible for palpation. Palpate
b. Trident hand: The fingers are pointed and are of symmetrically for the lateral lobes and the isthmus.
equal length seen in achondroplasia. Complete the procedure by palpating the thyroid
c. Spade hand (syn. Paw hand): Very prominent between fingers and thumb during deglutition.
thenar and hypothenar eminences with cylindrical Normal thyroid may be palpable as a soft movable
spatulate blunted fingers are seen in acromegaly. mass and its movements can be readily detected.
d. Eunuchoid palm: The palm is long, narrow, with Except during puberty and pregnancy, the gland is
fine skin and delicate, tapering fingers seen in not prominently visible in normal subjects.
hypogonadism. Ascertain the following points during palpation.
Part–I: Internal Medicine
e. Polydactyly: There are supernumerary digits. If the gland is enlarged, whether the enlargement
This is seen in Turner’s syndrome and is diffuse or nodular. If nodular, is it a single nodule
Laurence-Moon-Beidl syndrome or this may be or are there multiple nodules?
an isolated abnormality without any accom-
Tenderness: This may be present in acute and
panying disease.
subacute thyroiditis. Mild tenderness may occur
Nails in carcinoma and also when the gland is highly
vascular as in thyrotoxicosis.
The color, surface and texture of the nails should
be examined. Various abnormalities like opacities, Consistency: Ascertain whether the thyroid is soft,
discoloration, ridging, furrowing, friability, pitting firm, hard or woody and whether there are calcified
and shedding of the nails may occur in thyroid nodules. Is the consistency uniform or varied?
disorders. Brittle nails are characteristically seen Carcinoma and woody thyroiditis are generally
in thyrotoxicosis and hypoparathyroidism. Clubbing hard. Hashimoto’s thyroiditis may be hard at times.
of the fingers may occur in thyrotoxicosis. Iodine deficiency goiter may be soft or firm and
multinodular goiters have variable consistency.
Generalized Edema Adenomas and tense cysts may be firm. In primary
In myxedema there is non-pitting edema. The skin thyrotoxicosis the gland is soft and warm or may
is coarse and dry with sparse hairs. However in be firm.
secondary hypothyroidism, there is no edema and Pulsation: When the thyroid is highly vascular as
the skin is thin and shiny. in primary thyrotoxicosis it pulsates. Increased
vascularity generally correlates with hyperfunction.
EXAMINATION OF INDIVIDUAL GLANDS
This is associated with thyroid bruit.
Thyroid Gland Lower margin: Palpate the lower margin, particularly
The term goiter refers to enlargement of the thyroid. when the patient swallows, in order to determine
Enlargement of thyroid gland can be noticed in front whether the thyroid mass extends down into the
of the neck. In early cases the gland can be seen only mediastinum. Clnically retrosternal extension can
when the neck is extended. Classic feature of the thyroid be demonstrated by asking the patient to raise both
is movement upwards on swallowing. The arms above the head for 30 seconds when the neck
anatomical relationship of the thyroid gland in veins would distend with plethoric appearance of
between the layers of the cervical deep fascia results face. When retrosternal goiter leads to pressure
Chapter 26: Clinical Examination in Endocrine Diseases 323
effects it may produce signs of mediastinal obstruction. thyroid during thyroid or other neck surgeries also
Percussion over the suprasternal area and manubrium lead to tetany. Presence of tetany can be elicited
sterni may reveal dullness caused by the retrosternal clinically.
mass.
Elicitation of Tetany (Fig. 26.5)
Mobility: Majority of goiters are mobile. Mobility 1. Trousseau’s sign: Apply a sphygmomanometer
is tested by trying to move the gland from side-to- cuff above the elbow, inflate it above systolic
side with the neck kept flexed and turned to pressure and maintain for 3 minutes. The wrist
the ipsilateral side to relax the sternomastoid. gets flexed and fingers and thumb become
The thyroid may get fixed to deeper structures adducted and extended (accoucher’s hand).
in malignancy and thyroiditis. 2. Chvostek’s sign: Tap with a knee hammer on
the side of face 3 to 5 cm below and in front of
Auscultation
the ear. The facial muscles twitch briefly with
With the patient holding the breath, auscultate over each tap. 5% of the normal population may give
the lateral lobes and isthmus. When the thyroid is a positive Chvostek sign.
highly vascular, continuous bruit may be audible. 3. Schultz’s sign: Tapping of the center of the
Thyroid bruit has to be distinguished from aortic tongue with the finger will give rise to local
stenotic murmurs which may be conducted up to depression due to contraction of the muscles.
the neck. So also, bruit may arise from the carotid
vascular occlusion involving the internal iliac and such as diabetes mellitus, cirrhosis of liver and
penile arteries. renal failure.
Priapism: This is defined as an abnormal, painful Menopause or cessation of menstruation
and sustained erection of penis without sexual occurs between the ages of 45 and 50 years.
desire. It is pathological. In most cases the cause Complete cessation of periods follows a brief spell
is not endocrine in nature. of menstrual irregularity. Since the estrogen levels
fall, hot flushes, also called hot flashes, vaginal
Female Reproductive System dryness and atrophy of breasts accompany the
At birth the female baby may have prominence of onset of menopause. Hot flushes may be disabling
the labia and clitoris caused by the maternal at times. They come on as sudden attacks or
estrogens. In some babies perinatal vaginal bleeding warmth all over the body, accompanied by
may also occur as a result of withdrawal of palpitation, sinking feeling, sweating and a desire
maternal estrogens. This subsides in a day or two. to lie down. They pass off spontaneously within
Menarche: In India, the onset of puberty is between minutes to hours.
11 and 16 years. Pubic hairs start appearing by 12 When the menopause sets in before the age of
years and breast development proceeds between 40 years it is called premature menopause. This
12 and 15 years. Pubertal changes and secondary may be due to pituitary failure, (Sheehan’s
sexual characters are determined by estrogens, syndrome), ovarian failure or surgical removal of
Examine the external genitalia. Look for the EXAMINATION OF THE BREASTS
distribution of pubic hair, labia majora and minora,
clitoris, vaginal opening and presence of hymen The breasts should be palpated in both sexes as
(perforate or imperforate). Clitoromegaly denotes part of the general examination. Enlargement of
the enlargement of the clitoris. This is seen when the breast in males is called gynecomastia. The
there is excessive levels of androgenic hormones glandular tissue can be felt as a firm button or
as is seen in tumors of the adrenal cortex, androgen disk underneath and around the areola. True
secreting tumors of the ovaries or therapy with gynecomastia is the occurrence of enlargement of
androgenic hormones. glandular tissue. This is due to endocrine causes.
Pseudogynecomastia is the enlargement of the
Further information is obtained by digital and
breasts caused by deposition of fat without increase
colposcopic examination of the vagina, Changes
in glandular tissue. Often this is a part of general
occurring during pregnancy are given in Chapter 37.
obesity. Breast carcinoma is one of the most
Enlargement of the ovaries and other pelvic
frequent cancers affecting women. Rarely the male
organs can be made out by digital examination of
breast also may be the seat of carcinoma.
the vagina (or rectum in prepubertal girls).
Gentle pressure on the areola and milking action
More information can be obtained by exami-
over the nipples help to squeeze out secretions.
nation under anesthesia with simultaneous palpation
Lactation unassociated with the postpartum state or
over the suprapubic region. Sometimes ovarian
pregnancy is called galactorrhea. It may occur as a
Part–I: Internal Medicine
individual. Male pseudohermaphroditism is the Tumors more than 1cm in diameter are called macro-
condition where the gonad is the testis, but the adenomas.
genitalia are of the female type. Female pseudo-
hermaphroditism is the combination of ovaries and Hormonal Effects
male type genitalia. Overproduction of hormones: Tumors of the
pituitary may lead to overproduction of one or more
LESION OF THE PITUITARY of the trophic hormones. Excess of growth hormone
Endocrine abnormalities involving the pituitary leads to gigantism in children and acromegaly in
include overproduction or underproduction of adults. Prolactinomas lead to impotence,
hormones, tumor formation and vascular lesions impairment of spermatogenesis, gynecomastia and
such as pituitary apoplexy leading to sudden loss galactorrhea in men. In women, it leads to
of function. Lesions characterized by hormonal galactorrhea, amenorrhea and hirsuitism. ACTH
abnormalities manifest as endocrine disturbances, secreting tumors give rise to Cushing’s disease.
whereas tumors give rise to signs and symptoms
of intracranial space occupying lesions as well. In Pituitary Insufficiency
many cases hyperfunction is associated with Growth hormone deficiency in childhood leads to
hyperplasia or neoplasia of the pituitary. Some pituitary dwarfism. In panhypopituitarism all the
tumors do not produce hormones (nonsecretory) target glands show hypofunction. The gonads,
27
1 Investigations in
Endocrine Disorders
General investigations, Estimation of hormone levels, imaging procedures, Fine needle aspiration biopsy,
Diabetes mellitus, Thyroid disorders, Parathyroid disorders, Adrenal glands, Anterior pituitary disorders,
Gonadal disorders, Posterior pituitary disorders, Appendix-1
Table 27.1:
Criteria for diagnosis of diabetes mellitus and Glycosylated Hemoglobin (HbA1c)
impaired glucose toleranceTable 27.1:
In normal individuals a small proportion of
Diabetes Venous plasma glucose Venous blood glucose
hemoglobin combines with the circulating blood
Fasting Above 126 mg/dL Above 112 mg/dL
(>7 mmol/L) (> 6.25 mmol/L) glucose and this fraction is called glycosylated or
2 hrs after Above 200 mg/dL Above 180 mg/dL (> 9.9
glycated Hb. This can be separated into 3 types
glucose load (> 11.1 mmol/L) mmol/L) HbA1a, HbA1b, and HbA1c, more binding is to HbA1c.
*Impaired Below 126 mg/dL Below 112 mg/dL (> 5.6 The proportion of glycosylated hemoglobin
fasting GT > 6.1 mmol/L) mmol/L) increases with increasing levels of blood glucose.
2 hrs after 140-200 mg/dL 128-180 mg/dL (7.1-10 The binding of glucose to Hb is a nonenzymatic
glucose load (7.78-11.1 mmol/L) mmol/L) process that occurs continuously throughout the
(IGT)
lifespan of the red cells. Once glycosylated, the
Note: Fasting plasma glucose above 100 mg/dL but below 126 mg/dL is also abnormal,
*
Table 27.3:
Results of various isotopic tests in thyroid PARATHYROID DISORDERS
disorders
Changes in blood levels of parathormone (PTH), serum calcium, phosphorus and creatinine in various
Table 27.4:
parathyroid disorders
At present a simple screening test is employed in patients exhibiting high plasma norepine-
to exclude Cushing’s syndrome. phrine levels. When 0.3 mg of clonidine is
Plasma cortisol is estimated at 8 AM after given orally, it will suppress norepinephrine to
taking 1 mg of dexamethasone during the the normal range within 3 hours in essential
previous night. If plasma cortisol is less than hypertension. Failure of suppression is suggestive
5 mcg/dL, Cushing’s syndrome is excluded. of a tumor.
e. Corticotropin releasing hormone (CRH) test: Since pheochromocytomas may arise from the
100 mcg CRH given IV leads to an exaggerated adrenal medulla (90%), or other sites of chromaffin
rise in cortisol and ACTH in 95% of patients tissues, they have to be localized prior to surgery.
with pituitary dependent Cushing’s syndrome. This is done by CT scan or imaging with 131I
The term exaggerated rise refers to a rise of metaiodobenzyl guanidine (MIBG).
20% above basal level in cortisol and 50% above
basal level in case of ACTH. GONADAL DISORDERS
f. Inferior petrosal sinus sampling: Bilateral Indications for investigating gonadal functions.
simultaneous inferior petrosal sinus blood I. Delayed puberty and precocious puberty in
sampling with measurement of ACTH levels in boys and girls.
central and peripheral blood in the basal state II. Sterility—in women the ovulatory cycle can
and following IV injection of 100 mcg CRH helps be monitored by clinical and hormonal studies.
Part–I: Internal Medicine
testicular biopsy is done to determine the cause of trophic hormones from the anterior pituitary
azoospermia. and corresponding effects on the target glands.
Histological examination of the endometrium c. Study of the inter-relationship between the target
obtained by cervical dilatation and curettage (D and glands and the pituitary. For example:
C) is a very common investigation employed in i. Dexamethasone suppression test for pitui-
gynecological practice. tary—adrenal relationship.
ii. Hypoglycemia resulting from adminis-
Ultrasonography and Laparoscopy tration of insulin stimulates production of
The production of Graafian follicles and ovum can growth hormone (GH). Rise in blood sugar
be determined by ultrasonography and laparoscopy. inhibits GH secretion. In fact, GH deficiency
The latter is employed also for the collection of is diagnosed when the serum level of GH
ovum for use in assisted pregnancy. is less than 5 mcg/L in response to insulin
induced hypoglycemia.
Surgical Investigations
iii. The antiestrogen drug clomiphene can be
In the investigation of sterility in both sexes, tests used for studying the relationship between
to determine the patency of vas deferens and the pituitary and the gonads. When
fallopian tubes are undertaken routinely. clomiphene is given in a daily dose of
3 mg/kg (maximum 150 mg) for 10 days,
Karyotyping
Nearly all pituitary tumors are benign adenomas, Insulin Tolerance Test
of which 25 to 30% are hormonally silent. Prol- Insulin induced hypoglycemia is a powerful stimulus
actinoma is the most common among the hormone for cortisol and GH secretion. This test is done in
secreting tumors. The following investigations are suspected hypothalamic—pituitary dysfunction.
undertaken to assess the abnormalities of the gland. Take basal blood samples for glucose, cortisol,
ACTH and GH at 9 AM. Soluble insulin is
Hormonal Studies given as an IV bolus at a dose of 0.15 u/kg. Further
a. Estimation of the basal levels of pituitary hormones blood samples are taken at 20, 30, 45, 60, 90 and
and the hormones of the target glands: thyroid, 120 minutes. Blood glucose will fall to 40 mg%
adrenal cortex and gonads. at 45 minutes and patient develops symptoms of
b. Studying the effect of the hypothalamic releasing hypoglycemia. Rise of cortisol above 500 mmol/L
and inhibiting hormones on release of the and GH 720 mu/L indicates normal response.
338 Section 9: Endocrinology
Oral Glucose Tolerance Test in Acromegaly nephrogenic diabetes insipidus (NDI). The
Growth hormone (GH) secretion is pulsatile. Basal corresponding urine specific gravity ranges from
GH concentrations are undetectable most of the 1001 to 1005. To differentiate PDI from NDI, urine
time and hence dynamic tests are preferred. Nor- and serum osmolality are measured after 10 to 25
mally glucose suppresses GH secretion. In mcg of desmopressin intranasally or 1 to 2 µg IM.
acromegaly GH levels are paradoxically increased In PDI the urine osmolality will be raised by more
by glucose. The test is done as follows: than 50% while there is no significant rise in NDI.
Basal plasma sample is taken to estimate GH Water Deprivation Test
and glucose. About 75 g of oral glucose is
Subjects with obsessive compulsive drinking (OCD)
administered. Further blood samples are taken at
pass large volumes of urine with low osmolality
30, 60, 90 and 120 minutes and GH and glucose
(100–200 mOsm/kg). This can be distinguished
are estimated.
from diabetes insipidus by the water deprivation
Suppression of GH to less than 1 mu/L excludes test. Deprivation of fluids for eight hours raises
the diagnosis of acromegaly. urine osmolality in OCD, but not in PDI and NDI.
Triple bolus Injection: Synthetic analogs of three Severe cases of diabetes insipidus may not tolerate
hormones—insulin, GnRH, and TRH are injected water deprivation for this period and in them the
as a bolus to stimulate the anterior pituitary gland. test may have to be interrupted, Both desmopressin
Part–I: Internal Medicine
The response is assessed by measuring cortiosol, injection and water deprivation test can be done
GH, prolactin, TSH, LH and FSH levels in blood. simultaneously.
This test was first introduced in 1973. Blood
Syndrome of Inappropriate Secretion of
glucose levels are also monitored for hypoglycemia.
Antidiuretic Hormone
Imaging Procedures Syndrome of inappropriate secretion of anti-
Demonstration of the enlargement of the pituitary diuretic hormone (SIADH) is a common cause of
by imaging techniques. For example: hyponatremia. It is associated with hypotonic
1. Lateral view radiograph of skull may show plasma < 270 mOsm/kg), urine osmolality more
enlargement of sella turcica and erosion of than 300 mOsm/kg and excessive renal sodium loss
clinoid process. (>50 mmol/L).
2. Calcification above the sella may suggest calcified
Water Load Test
cyst arising from the Rathke’s pouch. CT scanning
and MRI elegantly bring out all. When a water load of 20 mL/kg body weight is
gIven to normal persons, 80% of this volume will
POSTERIOR PITUITARY DISORDERS be excreted within 5 hours and the urine osmolality
falls below 100 mOsm/kg (the specific gravity
Diabetes Insipidus falls below 1005). In SIADH the excretion of the
Urine osmolality remains below 300 mOsm/kg waterload is impaired considerably. There is
in pituitary diabetes insipidus (PDI) as well as in dilutional hyponatremia as well.
Chapter 27: Investigations in Endocrine Disorders 339
APPENDIX-1
Normal Values in Endocrinology
Anterior pituitary
• Growth hormone (basal) GH 4-6 ng/mL
Gonadotrophins (plasma)
• Premenopausal women except at ovulation FSH 5-20 mIU/mL (5-20 u/L)
LH 5-25 mIU/mL
• Ovulatory surge FSH 12-30 mIU/mL
LH 25-100 mIU/mL
• Postmenopausal FSH > 50 mIU/mL
LH > 50 mIU/mL
• Men FSH 6-18 mIU/mL
LH 5-20 mIU/mL
• Children of both sexes (prepubertal) FSH < 5 mIU/mL
LH < 5 mIU/mL
• ACTH at 8 AM < 80 pg/mL
10
Nephrology
CHAPTER
28
1 General Considerations
R Kasi Visweswaran
Applied anatomy, Applied physiology, General patterns of medical disorders affecting the kidneys and
urinary tract in India
front of the vertebral bodies and aorta. The ascent Normal Drainage of Urine
is arrested by the origin of the inferior mesenteric Urine formed in the kidneys is drained into the
artery arising from the abdominal aorta. The lower renal pelvis and it passes down the ureters which
poles may be connected by functioning renal tissue are 20 to 25 cm long and 5 mm wide. The ureters
or fibrous bands. Other common developmental descend along the tips of the transverse processes
anomalies include agenesis of kidneys, variation in of the lumbar vertebrae to enter the bladder at the
the number and branching pattern of renal arteries trigone after a short oblique course through the
and veins, double pelvis and ureters, incompetent detrusor muscle. This oblique intramural course
vesico-ureteric junction, ectopic opening in ureters and sling-like arrangement of the muscles act as a
and the presence of posterior urethral valve. sphincter and prevent the backflow of urine into
The kidney receives its blood supply through the uteters during micturition when the bladder
the renal artery which arises from the aorta. Even pressure increases (vesicoureteric reflux).
in normal persons, there can be more than one
Normal adult urinary bladder can usually hold
renal artery supplying the kidney. Similarly, renal
up to 500 mL of urine. In chronic obstruction, it
veins may be single or multiple and they drain into
may dilate and become more voluminous. When
the inferior vena cava. The lymphatics drain into
distended, it can be seen or felt in the suprapubic
nodes alongside the aorta and inferior vena cava.
region as a globular swelling.
Auto-nomic nerve supply is derived from the renal
In normal persons, infection of the bladder is
Part–I: Internal Medicine
blood flow rate, high oxygen demand of the tubular are regulated by the kidneys depending on the
cells, filtration of the plasma and metabolism of body’s needs. When water intake is restricted, the
drugs and toxins in the kidney make this organ kidneys compensate by reabsorbing more water
highly vulnerable to ischemic and toxic insults. from the tubules resulting in the formation of smaller
Kidneys cannot withstand anoxia for long. quantity of concentrated urine. The reverse happens
when fluid intake is excessive. A healthy adult
Excretion
should produce at least 400 mL urine in 24 hours
The excess water derived by ingestion and to eliminate the metabolic wastes. This is the
metabolism is eliminated by the kidneys and skin. obligatory urine volume.
Urea formed by metabolism of dietary proteins, Urine output below 400 mL in 24 hours is termed
creatinine formed by catabolism of endogenous oliguria. When the intake of water is excessive,
proteins and uric acid formed by metabolism of more dilute urine is formed. Normal kidneys can
nucleic acids are eliminated mainly by the kidneys. eliminate up to 10 liters of water in 24 hours. Under
In addition, the kidneys eliminate many other waste normal circumstances, the fluid intake seldom
products and several drugs. The kidneys perform exceeds 3 liters and it is easily excreted. Urine volume
these functions by glomerular filtration, selective in excess of 3 liters in 24 hours is termed polyuria.
tubular reabsorption of essential substances and Normal kidneys can conserve or eliminate salt within
tubular secretion of waste products. wide ranges and in health the urinary specific gravity
Children Adults
Renal disorders in children are mainly related to Renal failure, both acute and chronic may occur
congenital or developmental anomalies such as at this period and it is usually the result of
phimosis, posterior urethral valve, abnormalities glomerulonephritis, interstitial nephritis acute
of ureter and bladder, incompetence of ureter- tubular necrosis, obstructive nephropathy, urinary
ovesical junction, and agenesis or hypoplasia of the infection or inherited conditions such as polycystic
Part–I: Internal Medicine
kidney. Solid tumors like nephroblastoma are kidney disease and Alport’s syndrome. Several
encountered more in children. Congenital or acquired other systemic disorders which affect kidneys
abnormalities of the urinary tract predispose to manifest with renal complications above the age
urinary tract infection during infancy and childhood. of 40 years. These include diabetic nephropathy,
If left untreated, these may lead to chronic renal hypertensive renal disease, ischemic nephropathy,
failure with stunting of growth and skeletal drug induced nephropathy, tumors, nephrolitiasis,
deformities due to renal osteodystrophy in later life. obstructive nephropathy and persistant infection.
Stone disease is also not uncommon in children. Polycystic kidneys may present as systemic hyper-
Post streptococcal glomerulonephritis is encoun- tension, hematuria, chronic renal failure or
tered more frequently, especially in the lower abdominal masses.
socioeconomic strata. Nephrotic syndrome is not
uncommon. In older children, hypertension, Elderly Subjects
unexplained pallor, bone deformities, nocturia or
enuresis should make the clinician suspect a disorder The most common problem is obstructive uro-
of the kidneys and urinary system. pathy caused by enlargement of the prostate in men
and prolapse of the genital tract in women. Chronic
Young Adults renal failure, persistent urinary infection and tumors
The most common disorder in this age group is contribute to the majority of problems in this age
glomerulonephritis presenting with proteinuria, group. Elderly subjects whose renal function is
hypertension, microscopic hematuria and varying subnormal are very susceptible to toxicity from
degrees of renal failure. IgA nephropathy is now drugs which are eliminated by the kidneys, e.g.
being recognized as the most common glomerular aminoglycosides or radiocontrast agents.
disease in young adults. Reflux nephropathy may The speciality of nephrology has reached a high
also present with renal failure. Hematuria occurring level of development in India with several neph-
in young and middle aged adults is generally due to rology units, offering dialysis services and renal
glomerulonephritis, urinary calculi, urinary infection, transplantation.
CHAPTER
29
1 Clinical Examination in
Renal Diseases
R Kasi Visweswaran
papillary necrosis or chronic noninfective hematuria, the urine is blood stained throughout
tubulointerstitial nephritis. In chyluria the milki- and it indicates that the urine entering the bladder
ness disappears on mixing the urine sample with is already mixed with blood. This signifies renal or
chloroform since lipids are taken up by the ureteric lesions.
Part–I: Internal Medicine
chloroform layer. In acute glomerulonephritis the Painful hematuria is associated with infections,
urine is smoky. This is caused by the presence of stones, tumors and trauma. The hematuria that
erythrocytes and the abnormal urinary sediments. occurs with renal parenchymal diseases like
glomerulonephritis, genitourinary tuberculosis and
Hematuria
with some of the urothelial malignancies are
Presence of blood in urine is a common symptom generally painless. The presence of blood clots in
in urinary disease. Hematuria may be macroscopic the urine helps to rule out the possibility of
or microscopic. It may be painful or painless. glomerular disease. It has to be borne in mind that
Gross hematuria makes the color of urine red or painless hematuria may become painful, if clots
brown. In less severe forms of hematuria urine form and obstruct the lower urinary passages.
appears to be smoky. In microscopic hematuria Hematuria occurring in glomerulonephritis is
urine may appear to be normal. Under the usually associated with the presence of RBC casts
microscope erythrocytes are seen as biconcave in the urine. Since the casts are formed at the distal
disks, singly or in clusters. At times they may be tubules, the red cells travelling through the tubules
embedded in casts. When fresh urine is centrifuged, are entrapped into the cast and are passed in the
erythrocytes settle to the bottom, leaving the urine as RBC casts. Hence, their presence in the
supernatant clear. However, the depth of color is urine is taken to indicate active glomerulonephritis.
not a totally reliable guide to the severity of blood In hematuria the centrifuged urine sample will
loss, since even small quantity of blood in urine show sediment of red cells and clear supernatant.
may give rise to alarming red color. The terms hemoglobinuria and myoglobinuria
If a patient is made to pass urine under obser- denote the presence of hemoglobin or myoglobin
vation or is asked to collect separately the initial, in urine. Since the pigments are free in the solution,
middle and terminal streams of urine in 3 appro- the supernatant is colored in the centrifuged
priately labeled containers, the hematuria can be specimen. When large quantities of hemoglobin or
classified according to the presence of blood in myoglobin are released into the circulation as a
relation to the urinary stream. Initial hematuria result of intravascular hemolysis or crush injuries
occurs only at the beginning of micturition and of muscles, these pigments appear in urine. Microscopy
the urine clears up as micturition proceeds. This reveals no erythrocytes in hemoglobinuria and
occurs if bleeding is distal to the bladder. Terminal myoglobinuria but the chemical test for blood in
hematuria is usually caused by bleeding within the urine will be positive. Special tests can be used to
bladder and in posterior urethral lesions. In uniform identify myoglobin.
Chapter 29: Clinical Examination in Renal Diseases 351
disease. When the capacity of the bladder is prolapse of the uterus or other conditions causing
reduced, frequency of micturition is increased. laxity of the pelvic floor.
Nocturia is the condition where the patient is Enuresis is the term used to denote the involun-
woken up from sleep because of the urge to pass tary voiding of urine during sleep. This is a normal
urine. In health 2/3 of the urine volume is formed phenomenon till the age of 2 to 3 years, by which
during waking hours and only 1/3 during sleep. In time children develop complete control over the
several diseases states which give rise to diuresis, bladder and rectum. In 10% of normal children
this pattern is changed and night urine may equal control over micturition is not full even after three
or exceed the day urine. Nocturia is common in years. In them also, voluntary control is achieved
diabetes mellitus, early stages of chronic renal after varying periods of time. Causes of enuresis
failure, early stages of congestive cardiac failure include psychological factors like anxiety and fear,
and administration of long acting diuretic drugs, organic lesions like urinary obstruction and
towards the latter half of the day. Need to pass infection and neurological disorders like spina bifida
urine while keeping awake at night need not be and paraplegias. Enuresis may be a symptom of
taken as nocturia. polyuria.
The term pneumaturia indicates the presence
Abnormalities of the Act of Micturition
of gas bubbles in the urine. Common causes
The terms urgency and precipitancy refer to sudden include fistulous communications between the gut
Part–I: Internal Medicine
uncontrollable urge to pass urine, with even passage and the urinary tract and infection by gas forming
of accumulated urine before reaching the toilet. The organisms. It may also occur following instrumentation
cause may be local or neurogenic. Common local or surgery of the urinary tract.
causes include trigonitis, vesical stone, urethritis and
prostatic enlargement. Neurological disorders Symptoms of Uremia
leading to bilateral pyramidal tract lesions and The retention of nitrogenous and other toxic waste
dementia lead to urgency and incontinence. products leads to the symptoms of uremia which
Incontinence of urine is the inability to hold is the result of advanced renal failure. Uremic sym-
urine in the bladder. In most cases it results from ptoms are diverse, vague and nonspecific, referable
lesion of the lumbosacral segments of the spinal to almost all systems of the body (Table 29.2).
cord and its distal connections. It may occur as a
postoperative complication of prostatic surgery.
In women, vesicovaginal fistulae may develop as Table 29.2: Symptomatology of uremia
a complication of obstructed labor and this leads
General symptoms Lethargy, mental confusion, loss
to urinary incontinence. of weight
In total incontinence, there is constant dribbling Nervous system Peripheral neuropathy, muscle
of urine through an incompetent or injured urethral cramps, myoclonus , epilept ic
sphincter or through fistulous communications. seizures, coma
Cardiovascular system Hypertension, pericarditis, arrhy-
In overflow incontinence or false incontinence thmias, congestive heart failure
(also called paradoxical incontinence) or retention Respiratory system Kussmaul’s respiration, pleurisy,
with overflow, the bladder fills and emptying is pneumonia, pulmonary edema
difficult due to mechanical obstruction to the Skin and nail Sallow pigmentation, pallor, dry
and scaly skin, uremic frost over
urethra or bladder neck or failure of the urethral the face, pruritus, hyperkeratotic
sphincter to open and start the micturition reflex. papules; half and half nail
As the intravesical pressure rises it leads to inter- Gastrointestinal system Nausea, anorexia, vomiting, hem-
mittent dribbling of urine. atemesis due to gastric ulceration
Stress incontinence is the involuntary passage Hematological Anemia, hemorrhagic tendency
of urine whenever the intra-abdominal pressure Metabolic and endocrine change Osteomalacia, renal osteodystro-
phy, impotence, amenorrhea,
rises due to coughing, sneezing or laughing. This complications during pregnancy
is more common in women. This may occur in
Chapter 29: Clinical Examination in Renal Diseases 353
As a result, the uremic patient may present himself Family history is important since several renal
to different specialities initially. disorders are hereditary with a strong genetic
predisposition, e.g. polycystic kidney, Alport’s
Past History
syndrome and others. In autosomal dominant
History of acute glomerulonephritis, recurrent uri- polycystic kidney disease, there may be other
nary infections, congenital abnormalities of the members in the family with identical problems. A
urinary tract, surgery on the urogenital tract, careful family history for abdominal swelling,
instrumentations including catheterization, and hematuria, hypertension, cerebrovascular acci-
complications during pregnancy such as pre- dents, or cysts in other family members help to
eclampsia should be carefully elicited. In India, strengthen the diagnosis and also detect the disease
scabies with secondary bacterial skin infection is in asymptomatic relatives. In the case of Alport’s
a frequent etiological factor for acute glomerulo- syndrome, history of deafness or myopia due to
nephritis. keratoconus in other family members must be
looked for.
Drug History Several familial diseases like diabetes mellitus,
Several drugs are capable of causing renal damage. hypertension, collagen vascular disorders, and
Important among them are analgesics, non- tuberculosis affect the kidneys. These have to be
steroidal anti-inflammatory drugs, aminoglycoside specially enquired into.
30
1 Investigations in
Nephrology
R Kasi Visweswaran
URINE EXAMINATION ded in the urine so that if floats, freely and the
reading is noted without parallax error. If the room
Volume temperature is higher than that at which the
instrument is calibrated, the actual SPGR is obtained
For measuring 24 hours urine volume, the patient
by adding 0.001 for every 3°C increase above 20°C.
should be instructed to void and empty the bladder
Normal SPGR ranges from 1002 to 1035. Urine
and discard the urine at a specified time say, 8 am.
passed in the morning is maximally concentrated in
The collection time starts now. All the urine
the majority of normal persons. Any SPGR above
passed subsequently, up to and including 8 am,
1018, in the absence of abnormal constituents like
the next day is collected in a bottle containing
glucose is evidence that the renal concentrating
a preservative, usually 10 mL of glacial acetic acid.
power is normal. When excess of liquids are
This is the 24 hours, urine specimen. If the time of
consumed, the SPGR comes down to as low as 1003.
collection of each specimen and its volume are
The SPGR can also be estimated by using a
charted, it helps to determine the volume of urine
refractometer. The refractometer is calibrated for
passed during day and night. Normal adult passes
reading the refractive index and specific gravity
700 to 2500 mL of urine in 24 hours.
of urine directly. Light rays falling on a prism are
If the 24 hours urine is to be collected for
refracted by the intervening test fluid and the extent
special tests or estimation of 17-ketosteroids, VMA
of refraction can be read from the meter. Only
or other metabolites, a large container with an
one drop of urine is needed for this estimation and
appropriate preservative has to be supplied.
it is based on the refractive index of solutions which
Specific Gravity varies with the SPGR (Fig. 30.1).
This is measured using a urinometer. The specific Osmolality
gravity depends upon the concentration of solutes It is a more accurate parameter to express the
present in the urine. Crystalloids like urea, salts and concentration of solutes in urine. This can be
sugars raise specific gravity (SPGR) considerably, measured using an osmometer it correlates roughly
whereas colloids like proteins do so to a lesser extent. with the specific gravity (Table 30.1).
The osmolality of urine may vary from 50 to
Method 1200 mOsm/kg water. The osmolality of plasma
The urine is allowed to cool down to room and the glomerular filtrate is about 285 mOsm/kg.
temperature, since the urinometer is calibrated to In plasma the main substances which contribute
be used at 16 to 20°C. The urinometer is suspen- to osmolality are sodium, glucose and urea and if
Chapter 30: Investigations in Nephrology 355
Isosthenuria
In this condition, the urine SPGR remains constant
around 1010 and the osmolality around 285 mOsm/
kg. This results from the loss of concentrating
and diluting functions of the renal tubules as is
seen in chronic nephritis. 1010 is the SPGR of
glomerular filtrate.
Urine Concentration and Dilution Tests
Normal persons should be able to concentrate
the urine to SPGR 1018 after 8 to 12 hours of
fluid deprivation. Failure to concentrate the urine
to SPGR 1018 (mOsm 600–650) after overnight
water deprivation, may indicate loss of ability to
Fig. 30.1: Refractometer—The sample is placed in the oval concentrate the urine and further investigations are
glass of the refractometer and covered with the lid. The light
rays pass through the prism under the oval glass disk and
required. This is done by continuing the water
the refracted light is seen through the eyepiece. The scale as deprivation test with monitoring of pulse, blood
seen through the eyepiece is shown in the insert, which pressure and body weight till 3% of the body weight
shows the scale of specific gravity or refractive index and the
pigments, urobilinogen, prophobilinogen, other may prevent or delay the progression of diabetic
metabolites, pigments or several drugs. Turbidity nephropathy.
of freshly voided urine may be due to pus, blood or The routine laboratory tests include the detec-
crystals. tion of proteins, glucose, bile pigments and bile
salts, acetone and microscopic examination of the
Smell
centrifuged deposits. Under special circumstances
Fresh normal urine has no offensive odor. On several other substances passed in urine can be
standing it assumes an ammoniacal smell due to looked for e.g. urobilinogen, porphobilinogen, other
splitting of urea to ammonia by the bacteria. Fishy sugars, amino acids, creatinine.
or offensive smell of fresh urine suggests urinary
infection. Several substances like acetone, amino Tests for Proteins
acids, methyl mercaptan in hepatic failure and Heat coagulation test detects all proteins in urine
aromatic substances derived from foods (e.g. garlic) which include albumin, Tamm-Horsfall protein,
may change the odor of freshly passed urine. beta 2 microglobulin, immunoglobulins and other
proteins: “Albustix” detects only albumin. It is
Reaction necessary to differentiate between albumin and
Fresh urine is acidic in reaction with pH below 5.5. other proteins in urine.
In vegetarians and those who take alkalies, the Heat coagulation and acetic acid test: A 15 cm
reaction may be mildly alkaline. The reaction is tested long test tube is filled 2/3 with urine and the top of
Part–I: Internal Medicine
with litmus paper. The pH can be determined by a the column is heated to boiling over a flame, holding
pH paper or pH meter. Pathologically, loss of the the test tube at its bottom. An opalescence develops
capacity of the tubules to eliminate acid leads to the if proteins or phosphates are present. At that stage
production of alkaline urine. This happens in renal two to three drops of 2% acetic acid is added
tubular acidosis. Urinary infection with E. coli through the side of the test tube. Opacity due to
makes the urine strongly acid. Infection by B. proteus coagulated proteins persists whereas the one
makes the urine strongly alkaline. Uric acid stones caused by phosphates disappears promptly. The
occur in acid pH. Stones secondary to chronic density of opacity is generally proportional to the
infections develop in alkaline urine. amount of protein in the urine. Normal urine does
Therapeutic modification of urine pH is a not give a positive heat test.
common practice in the management of urinary Dipstix test: Dipstix filter paper strips impregnated
infection. This gives symptomatic relief and also with chemicals and enzymes which change color
enhances the effectiveness of antibacterial drugs. when exposed to protein and detects the presence
In renal tubular acidosis urine pH is monitored in all proteins except light chains of immunoglobulins.
order to assess therapy. “Albustix” strips are specific for albumin. The
intensity of color gives an approximate idea of the
Chemical Constituents of Urine quantity of albumin present and amount of albumin
The main excretory products in urine are urea, can be read off by comparison with standards.
uric acid, creatinine, several inorganic salts and Several other methods are available for side
organic substances. In addition, normal urine also room detection of urinary protein.
contains minute amounts of proteins and glucose
which are too low to be detected by the ordinary Detection of Specific Proteins, Microalbumin
side room tests. When the amount of urinary and Amino acids in Urine
albumin increases, but is still not detectable by the This can be done by electrophoresis, immuno-
ordinary side room tests, it is called micro- electrophoresis, chromatography and radioimmuno-
albuminuria and this denotes the presence of early assay. These have to be performed in specialized
stages of renal involvement, especially so in diabetic laboratories.
nephropathy. Screening for microalbuminuria is The term microalbuminuria is used when the
done in order to identify early stages of diabetic urinary loss of albumin ranges from 20 to 200 mcg
nephropathy. Appropriate management at this stage per minute or 30 to 300 mg of albumin/day. This
Chapter 30: Investigations in Nephrology 357
can be detected only by tests like radioimm- copper and produce colors ranging from green to
unoassay. Microalbuminuria can be diagnosed from brick red, depending upon their concentration. This
a single random urine sample by estimating the test is nonspecific since several substances like
albumin/ creatinine ratio. Before checking for fructose, lactose, galactose, aspirin, vitamin C, and
microalbuminuria, regular urine test is done to rule many drugs may give a positive test. But in any
out gross proteinuria and urinary tract infection. person in whom the reducing sugar has been
Patient should not be having fever and undertake identified as glucose, this simple test can be
unaccustomed physical activity. In those with performed at home to monitor glycosuria.
diabetes and hypertension, the blood sugar and BP Specific test for glucose is the glucose oxidase
should be well controlled before undertaking the test. Glucostix test strips are available commercially.
test. These tests are based on specific enzyme-mediated
Bence-Jones protein: This consists of the light reactions which can also be quantified. These test
chains of abnormal proteins secreted by neoplastic strips are reliable and easier to perform, but more
plasma cells in multiple myeloma and other plasma expensive. Test strips are unaffected by the other
cell dyscrasias. These can be detected by a simple sugars or drugs. In view of reliability and ease of
heat test. the test, strip tests should be preferred.
Around 10 mL urine is taken in a test tube,
acidified with 1 drop of 2% acetic acid, and heated Acetone
Fig. 30.4: Epithelial cells in fresh urine Fig. 30.6: WBCs and bacteria in fresh urine deposit
Fig. 30.8: RBC cast—urine deposit Fig. 30.10: Uric acid crystals (mostly hexagonal)
—urine deposit
Part–I: Internal Medicine
Fig. 30.9: Granular cast—urine deposit Fig. 30.11: Calcium oxalate crystals
(envelop shaped crystals)—urine deposit
failure and inappropriate secretion of antidiuretic creatinine clearance. Hence, it is not necessary to
hormone. Some laboratories measure only the repeat creatinine clearance test for periodic short
nitrogen content in urea molecule and express it term follow-up. It can be assessed by serial monitoring
as blood urea nitrogen (BUN). For all clinical of serum creatinine alone. When the serum creatinine
purposes it is taken as 50% of the urea level. Blood doubles, the creatinine clearance is reduced by half,
urea of 60 mg = BUN of 28 mg. and so on.
For estimation of blood urea, venous blood is
Serum Uric Acid
collected without anticoagulant or preservative and
sent to the laboratory. Uric acid is an end product of purine metabolism
and is excreted mainly by the kidneys. Hence the
Serum Creatinine blood levels of uric acid may increase in proportion
Creatinine is an end product of endogenous muscle to the degree of renal failure:
breakdown and since the rate of muscle catabolism Normal level: Males 2.5-8 mg/dL
remains steady in health, the levels of serum Females 1.5-6 mg/dL
creatinine do not vary from day-to-day. (Normal However, hyperuricemia may also occur in
0.7–1.2 mg/dL). Creatinine is filtered completely primary disorders of purine metabolism such as
by the glomeruli and is not significantly reabsorbed gout. Hyperuricemia by any cause can also lead to
or secreted by the renal tubule. Unlike blood urea, renal damage. The blood levels of urea, uric acid
its level is unaltered by the degree of hydration, and creatinine are markedly lower in pregnancy.
Part–I: Internal Medicine
protein intake and urine flow rate. Therefore, the The rise of serum uric acid levels during pregnancy
level of serum creatinine remains steady over to the prepregnant level is suggestive of development
prolonged periods. Creatinine clearance is a reliable of pre-eclampsia.
clinical parameter of glomerular filtration rate. Serum Electrolytes
Alteration in serum creatinine is a very reliable indicator
of glomerular filtration rate. Normal serum sodium (135-145 mEq/L)
Serum potassium (3.5-4.5 mEq/L)
Creatinine clearance: Normal creatinine clearance Serum bicarbonate (22-27 mEq/L)
is 110 ± 15 mL/mt. This is obtained by performing The serum sodium, potassium and bicarbonate
the creatinine clearance test. In this test, the amount have to be closely monitored in patients with acute
of creatinine in 24 hours urine is measured. Serum renal failure (ARF), since timely correction of
creatinine value is also determined during this 24 electrolyte imbalances and prevention of further
hours period. A simplified formula for calculating deterioration are important in its successful
creatinine clearance is given below: management. In many cases the sodium and
bicarbonate levels may be lower than normal. This
Creatinine Urinary creatinine (mg/day) × 5
clearance = may be due either to dehydration or dilutional
(mL/mt) Serum creatinine (mg/dL) × 72 hyponatremia. These must be differentiated before
instituting therapy. Normal kidneys have a wide
Creatinine clearance can also be calculated reserve to regulate and compensate for deficiency
using the Cockcroft and Gault formula, from the or excess of various electrolytes. In renal failure,
age, body weight and serum creatinine value. this reserve capacity is grossly impaired. Fatal
hyperkalemia may occur in patients with acute
Creatinine 140-Age in years × Weight in kg
clearance = renal failure.
(in mL/min) 72 × Serum creatinine in mg/dL Therefore the serum potassium levels have to
be closely monitored. If intake of sodium and
The normal value is 15% less for females potassium is within normal range, the kidneys
compared to males. Therefore, the result is maintain normal blood levels even if renal function
multiplied by 0.85 for females. This formula is is grossly impaired. But if the intake is increased
applicable for adults only. or decreased, abnormalities of serum electrolyte
In the same individual there is a fixed rela- levels develop. The body produces acid ions at the
tionship between the serum creatinine level and rate of 1 mEq/kg body weight daily. This is excreted
Chapter 30: Investigations in Nephrology 363
by the kidneys as titrable acid. When excretion is failure are associated with characteristic lipid
defective, the H + ions use up the bicarbonate abnormalities such as elevation of serum chole-
reserve resulting in metabolic acidosis. sterol, triglycerides and alteration in the lipoprotein
profile. Detection of these abnormalities helps in
Calcium, Phosphorus, Magnesium
diagnosis. Since longstanding hyper-lipidemia
Normal Values: accelerates atherosclerosis, proper intervention to
• Calcium 8.8-10.2 mg/dL normalize the lipid profile forms part of therapeutic
• Phosphorus 2.5-4 mg/dL management. However, in steroid responsive neph-
• Magnesium 1.5-2.5 mg/dL rotic syndrome, the lipid abnormalities correct
Estimation of these divalent ions is of importance themselves when the nephrotic syndrome remits.
in the management of chronic renal failure since
Urine to Plasma Ratios (U/P Ratios)
their levels are altered considerably. In untreated
chronic renal failure, there is hyperphosphatemia, Measurement of the ratio of the concentration of
hypocalcemia and hyperparathyroidism. Abnormal- substances between urine and plasma is employed
ities of calcium and phosphorus develop in acute to assess functional defects in the nephron.
renal failure as well. But, being of shorter duration, In an oliguric patient, measurement of these
their clinical impact is less, compared to that in parameters will enable the clinician to decide whether
chronic renal failure. the oliguria is due to prerenal causes or acute tubular
necrosis. In a patient who has dehydration,
tract is obstructed, the back pressure on the High dose infusion pyelogram (double dose
collecting system can be identified as proximal contrast IVU): It was employed previously to
distention of the ureter, dilatation of the pelvis and delineate the urinary system in patients with renal
clubbing of the calyces. Chronic pyelonephritis failure. This is not commonly done now due to
produces distortion of the pelvicalyceal system. risk of complications and the availability of other
Anatomical abnormalities such as double ureters, methods for diagnosis.
hydronephrosis, renal tumor, polycystic kidneys, Retrograde pyelogram (RGP): The urinary
tumors in the collecting system, stones and passages are visualized by introducing contrast dye
indentation in the bladder neck produced by into the ureter by retrograde catheterization.
enlarged prostate can be demonstrated shows a Through a cystoscope, ureteric catheters are
normal IVU (Fig. 30.14). introduced and 4 to 6 mL of iodinated dye is
Complications of IVU include anaphylactic injected into the ureter or renal pelvis and pictures
reaction following dye injection, convulsions, a “hot are taken. This brings out the pelvicalyceal systems
flush” and rarely renal failure following larger doses and ureters clearly.
of the dye. These complications are less common Antegrade pyelogram (AGP): The radiocontrast
with the low osmolar, nonionic contrast media. In dye is injected directly into the renal pelvis through
multiple myeloma the risk of renal failure following percutaneous puncture or nephrostomy tube and
administration of iodinated contrast media is high. X-rays are taken to visualize the level of obstruction
ANGIOGRAPHY
Flush abdominal aortogram: This is done by
injecting dye into the aorta above the renal arteries
through a catheter introduced through the femo-
ral or brachial artery. Films are exposed at the rate
of one film per second for 5 to 6 seconds. This
helps to study the aorta and its branches. Various
abnormalities like position, number, branching
pattern, occlusion, dilatation, stenosis of blood
vessels and collateral circulation to organs can be
identified. These studies are also sometimes
necessary to visualize the vascular pattern of the
kidneys of the donor for transplantation.
Selective renal arteriogram: A special arterio-
Fig. 30.14: Normal IVU. Showing nephrogram on both sides. graphic catheter is positioned in the renal artery
The kidneys, renal pelvis, ureters and part of the bladder
and pictures are taken after dye injection, the
are visualized by the dye-numbered 1–4. The base of the
bladder is not included in this film arterial pattern of the kidney can be studied in detail.
366 Section 10: Nephrology
Part–I: Internal Medicine
Fig. 30.15: Micturating cystourethrogram showing gross reflux of the dye instilled into the
bladder proximally, even during the filling phase
In addition, dilatation of narrowed segments using all morphological abnormalities like enlargement,
balloon catheters (percutaneous transluminal renal contraction, distortion, tumors, cysts, abscesses,
angioplasty), occlusion of vessels which feed stones and other abnormalities can be clearly
tumors or vascular malformations by the injection delineated. So also the ureters, urinary bladder and
of substances like gelfoam and other procedures prostate can be visualized. Amount of residual urine
can be undertaken by selective renal artery in the bladder can be determined. Ultrasound aided
catheterization. procedures such as renal biopsy, and surgical
Digital subtraction angiogram (DSA): This gives operations are employed frequently. Doppler studies
an angiographic picture without interference from help to assess the blood flow and hemodynamics
other structures such as bones, gas and soft in the abdominal aorta and renal arteries and their
tissues. Since the clarity is very good, intravenous branches. These studies are of great value in the
DSA can be performed by giving a smaller volume assessment of several pathological states. Whenever
of the dye into a peripheral vein as a bolus and facilities exist, ultrasound investigation should be
taking the pictures as the bolus travels to the done before undertaking any invasive procedure like
abdominal aorta and renal arteries. IVU or retrograde catheterization.
Renal vein catheterization helps to obtain
samples from either side and estimate renin and COMPUTED TOMOGRAPHY SCAN
other substances. Computed tomography (TC) can reveal the size of
the kidneys, morphological abnormalities, details of
ULTRASONOGRAPHY
vasculature and presence of other abnormalities in
As in the case of all other specialities ultrasono- the abdomen. It is helpful in the detection and staging
graphy has become a very elegant investigatory of malignancies of the urinary tract great strides
modality in the diagnosis of anatomical abnor- are being made in this technique. CT urogram, MR
malities of urinary system. The kidneys and angio, spiral CT and MRI scan are the other recent
adrenals can be clearly visualized. Their size, almost diagnostic investigations.
Chapter 30: Investigations in Nephrology 367
Fig. 30.16: H and E staining of normal Fig. 30.17: Isotope renogram showing retention of DTPA in
glomerulus in light microscopy the collecting system of the left side. There is no retention
on the right side. The bladder is full
ISOTOPIC STUDIES
severe blood loss occurs resulting in hypotension,
blood transfusion may be required. Very rarely Dynamic Renal Scintigraphy
surgical intervention may be needed.
Renal biopsy is an invasive procedure associated The radiopharamaceutical most often used is 99mTc-
with a complication rate of 2 to 5% and a mortality DTPA (diethylene) triaminepenta-acetic acid) or
rate of less than 0.1%. With the advent of ultra-
123
I labeled orthoiodohippuric acid (hippuran). The
sound for marking or guiding biopsy and the use DTPA is excreted by glomerular filtration, whereas
of the biopsy gun, the complication are reduced to hippuran is both filtered and secreted by the tubules.
very low levels in experienced hands. Isotopic investigations are employed to study:
Biopsy specimens are processed for histo- 1. Renal blood flow
pathology, morphology by H and E stain, (Fig. 30.16) 2. Obstructive uropathies (Fig. 30.17)
PAS stain, silver stain, trichome and others special 3. Bladder emptying
stains. Frozen sections are used for immuno- 4. Glomerular filtration rate.
fluoresence. Demonstration of immunoglobulin
IgG, IgM, IgD, IgA, IgE, and complement Static Renal Scintigraphy
components such as C3 Clq and others can be done
This is done using 99mTc DMSA (dimercaptosucecinic
using fluorescein tagged appropriate antibody and
acid) which is taken up by tubular cells, in
fluorescence microscope. The quantitative and
proportion to renal function. The function of each
qualitative information so obtained helps to make
kidney can be estimated separately using citrate
specific diagnosis.
labeled gallium or leukocytes labeled isotopically.
Another method to demonstrate immuno-
globulins is by using immunoperoxidase staining Foci of infection in the urinary tract can also be
identified accurately.
methods.
Chapter 30: Investigations in Nephrology 369
APPENDIX-1
SI Units (International System of Units)
SI units are used by the international scientific community. The use of a single system of measurement
will improve the comparability of test results between countries. Many journals have adopted SI units.
Quantitating a substance in moles (SI units) rather than in grams (traditional unit) allows an easier
understanding of molecular relationships.
Traditional unit Conversion factor SI unit
Urea nitrogen 8-18 mg/dL 0.357 3-6.5 mmol/L
Serum creatinine 0.6-1.2 mg/dL 88.4 50-110 micromol/L
Urinary creatinine Male 20-26 mg/kg/24 hrs 0.0088 0.18-0.23 mmol/kg/24 H
Urinary creatinine Female 14-22 mg/kg24/ hrs 0.0088 0.12-0.19 mmol/kg/24 H
Plasma glucose (fasting) 70-110 mg/dL 0.05551 3.9-6.1 mmol/L
Uric acid—serum 2-7 mg/dL 59.48 120-420 mcmol/L
Serum potassium 13.7-19.5 mg/dL 0.2558 3.5 - 4.988 mmol/L
Serum sodium 135-147 mEq/L 1 135-147 mmol/L
Serum phosphorus 2.5-5 mg/dL 0.3229 0.80-1.60 mmol/L
11
Neurology
CHAPTER
31
1 General Considerations
in Neurology
Arterial supply, Veins of the brain, Spinal cord, Meninges, Cerebrospinal fluid, Symptomatology in
neurological disorders, Motor function, Sensory function, Profile of neurological disorders in India
enters the posterior cranial fossa through the deep white matter drain into internal cerebral vein
foramen magnum, after piercing the atlanto-occipital and great cerebral vein of Galen. These two groups
membrane and the dura mater. The two VAs on of cerebral veins, interconnected through several
either side course upwards on the anterolateral anastomotic channels, pass through the subara-
surface of the medulla and unite with each other at chnoid space to empty into the venous sinuses
the lower border of pons to form the basilar artery. which lie between the meningeal and periosteal
The basilar artery ascends in a groove on the anterior layers of the dura mater.
surface of the pons and at its upper border, divides Knowledge of the venous anatomy and physi-
into the right and left posterior cerebral arteries. ology is essential to comprehend several disease
Knowledge of the arterial supply to the brain mechanisms. Absence of valves in the venous
(Table 31.1) is essential because cerebrovascular system facilitates flow of blood in either direction
accidents caused by thromboembolic occlusions or in the major venous channels depending upon the
hemorrhage occurring in specific arteries give rise level of intracranial, intrathoracic and intra-abdominal
to characteristic neurological deficits, e.g. carotid pressures. Egress of venous blood is a compen-
hemiplegia caused by occlusion of the trunk of the satory mechanism to lower intracranial pressure.
internal carotid artery, lateral medullary syndrome Retrograde flow into intracranial veins makes the
caused by occlusion of posterior inferior cerebellar brain vulnerable to develop malignant metastases
artery and others. Cerebrovascular occlusion may and abscess formation, secondary to lesions in the
Part–I: Internal Medicine
result from arterial disease affecting the intracranial thoracic and abdominal cavities. Since venous flow
arteries, extracranial portions of these arteries, or in the large sinuses tends to be sluggish, cerebral
from emboli arising from the heart as in valvular venous thrombosis is a common complication of
disease and ischemic heart disease. hypercoagulable states such as postpartum
thrombosis, dehydration, polycythemia and others.
VEINS OF THE BRAIN Occlusion of venous drainage leads to rise in
The cerebral veins which have neither muscular intracranial pressure. Thrombosis of the cavernous
tissue nor valves consist of two groups superficial sinus is a dreaded complication of sepsis over the
and deep. Superficial veins drain the cortex and central portion of the face and nose. It leads to facial
subcortical white matter and empty into the and orbital edema, paralysis of ocular nerves and a
superior sagittal, cavernous, petrosal and transverse characteristic clinical picture. Due to intercomm-
venous sinuses. The deep veins from the peri unication, affection of one side soon involves the
ventricular regions, diencephalon, basal ganglia and opposite side too.
Though the vascular territories of the brain are
anatomically distinct, considerable overlap and
Arterial supply to the deeper areas in the brain, variations exist even in health. Moreover the blood
Table 31.1:
brainstem, and cerebellum flow in each territory is also determined by other
Corpus striatum and Medial and lateral striate branches of middle factors such as arterial narrowing, presence of
internal capsule cerebral artery central branches of anterior collaterals and others. Though syndromes of
cerebral artery
Thalamus Branches of posterior cerebral, posterior
vascular occlusion generally run true to type,
communicating and basilar arteries sometimes, the clinical effects may not truly
Hypothalamus striate Anteromedial and posteromedial branches correspond to the anatomical vascular supply.
from the circle of Willis
Midbrain posterior Basilar, superior cerebellar and cerebral SPINAL CORD
arteries
The spinal cord extends from the foramen magnum
Pons Basilar, anterior inferior, and superior cere-
bellar arteries
to the interspace between the first and second
Medulla Vertebral, basilar, anterior and posterior lumbar vertebrae in adults and still lower down in
spinal and posterior inferior cerebellar infants and children. Though the cord stops at this
arteries level the arachnoid mater extends down to the
Cerebellum Posterior inferior, anterior inferior, and second sacral vertebra and the dura mater extends
superior cerebellar arteries a bit further down.
Chapter 31: General Considerations in Neurology 375
31 pairs of spinal nerve roots emerge from the on the lateral surfaces of the spinal cord, ventral
cord. The segments in the cord are: and dorsal to the dorsal nerve roots, forming two
• Cervical 8 posterior longitudinal arterial plexuses on either
• Thoracic 12 side. The anterior midline arterial channel and the
• Lumbar 5 two posterior arterial plexuses are reinforced by
• Sacral 5 anterior and posterior radicular arteries. These
• Coccygeal 1 radicular arteries, which arise at irregular intervals
From each segment the anterior nerve root from the ascending cervical, deep cervical,
emerges and carries motor fibers to the periphery intercostal, lumbar and sacral arteries, pass along
(Fig. 31.3). Posterior sensory root joins at each with the spinal roots to enter the spinal canal.
segment, and this carries sensory information to One such artery (artery of Adamkeiwicz) which
the cord from the peripheral receptors, through the arises from the left side of the descending aorta in
peripheral nerves. The anterior and posterior nerve the lumbar region is particularly large. It is clinically
roots join to form a spinal nerve. The roots emerge more important because it forms a major source of
through the intervertebral foramina. At the cervical blood supply to the lower two-thirds of the spinal
and thoracolumbar regions the cord is wider since cord. The upper thoracic (T1 to T4) and the upper
the roots for the brachial and lumbosacral plexus lumbar (L1 and L2) segments of the spinal cord are
arise at these levels. Since the spinal cord is shorter more vulnerable to ischemia being in the border zones
medulla to pass down as the crossed pyramidal Antomically the site of lesion may be:
tract and arborise at the anterior horn cells of the a. Anterior horn cells
same side. The rest of the fibers descend on the b. Anterior spinal roots
same side (uncrossed pyramidal tract) and at c. Nerve trunks and plexuses
different levels cross over to the opposite side to d. Peripheral nerves
arborise at the spinal anterior horn cells (lower e. Neuromuscular junction, or
motor neuron-LMN). Thus the upper motor neuron f. Muscles (Table 31.5).
exerts influence on the opposite side of the body
at all levels. SENSORY FUNCTION
Paralysis All sensations depend on impulses elicited by
adequate stimulation of the sensory receptors. These
The term “paralysis” denotes abolition of function
impulses are transmitted to the brain by afferent
either motor or sensory, but in common clinical
sensory nerve fibers. All receptors which respond
parlance, this term is used to denote loss of motor
to external stimuli are called exteroreceptors. These
function. The terms “paralysis” “plegia” and
are present in the skin, mucous membranes and the
“palsy” are used to denote total or severe loss of
organs of special senses. The receptors that respond
motor function. “Paresis” denotes slight or partial
to stimuli from within the body are called inter
loss of motor function.
oreceptors. These include proprioceptors in the
Part–I: Internal Medicine
Paralysis of voluntary muscles can occur either muscles, ligaments and joints that respond to
due to a lesion in the upper motor neuron (UMN)
movements and changes in the position of the body
pathways or due to a lesion in the lower motor and visceral receptors. Appreciation of particular
neuron (LMN) pathways. Tables 31.3 and 31.4.
sensations does not depend entirely on the
In lesions of the UMN, only voluntary stimulation of specific sensory nerves, but it is
movements are abolished whereas reflex activity determined by the particular pattern of impulses that
is preserved, or (even exaggerated). Lesion in the are received by the brain. For practical purposes
UMN may affect any part from the cerebral cortex the following types of receptors and their functions
to the terminal ramifications of the pyramidal fibers. are given below:
In lesions of the LMN, both voluntary and
reflex activities are abolished. LMN paralysis may • Touch Free nerve endings, nerve endings
result from lesions occurring anywhere in the lower in the hair follicles, Meissner’s
motor unit, i.e. anterior horn cell, efferent axon, corpuscles, Merkel’s disks
its neuromuscular junction and the muscle. • Pain Free nerve endings
Cerebral cortex Restricted contralateral paralysis, e.g. face, upper limb or lower limb. Focal seizures and cortical type of
sensory loss, i.e. loss of tactile localization, tactile discrimination and steriognosis on the opposite side.
Aphasia, apraxia, agnosia, if dominant hemisphere is affected
Internal capsule Dense contralateral paralysis, e.g. hemiplegia hemianesthesia, contralateral, homonymous hemianopia
Thalamus Impairment of all modalities of sensation, spontaneous pains and choreoathetosis on the opposite side.
Note: These features constitute thalamic syndrome.Thalamic lesion in not associated with motor weakness,
unless the lesion extends to the adjacent internal capsule
Midbrain Paralysis of ipsilateral III and IV cranial nerves and contralateral hemiplegia
Pons Paralysis of ipsilateral V, VI and VII cranial nerves and contralateral hemiplegia
Hemisection of spinal Ipsilateral LMN paralysis involving the damaged segment
cord (Brown-Sequard UMN paralysis below this level.
syndrome) Band of hypoesthesia at the level of lesion. Loss of tactile discrimination, vibration and proprioception below
the level of lesion. Contralateral loss of touch, pain and temperature below the level of lesion.
Complete transection Bilateral LMN type paralysis at the affected segments, if the lesion affects the cord at a distinct level. Bilateral
of spinal cord UMN type paralysis below the level of the lesion. Loss of all modalities of sensations below the level of the
lesion. Bladder and bowel dysfunction
thalamic tract, the fibers from the lower part of In the lateral spinothalamic tract, the fibers from
the body lie laterally and those from the upper part the lower part of the body lie osterolaterally and
of the body, medially. those from the upper part of the body antero-
medially.
Pain and Temperature
These are carried up by the lateral spinothalamic Tactile Localization, Tactile Discrimination and
tract. First order neurons are situated in the posterior Kinesthetic Sensations
root ganglia. Their central axons in the posterior Tactile localization, tactile discrimination and
roots enter the posterior horn and divide into vibration sense, joint sense, position sense and
ascending and descending branches. The ascending sensation of passive movement are carried by the
branches travel one or two segments up and arborise posterior column.
with the second order neurons in the substantia
gelatinosa on the same side. The axons of these Pressure Sensation
second order neurons cross to the opposite side This is carried by the anterior spinothalamic tract.
and ascend up in the lateral white column as the Since different sensations are carried by different
lateral spinothalamic tract. The temperature fibers discrete tracts in the spinal cord some of which
lie dorsally and medially whereas the pain fibers lie are crossed and others uncrossed, localized lesions
anteriorly. In the medulla, pons and midbrain it of the spinal cord give rise to dissociated anesthesia,
ascends up together with the anterior spinothalamic i.e. loss of one modality of sensation, while
tract and terminates in the third order neurons preserving another. For instance, in syringomyelia
present in the VPL nuclues of the thalamus. Axons where the crossing pain and temperature sensory
of these third order neurons pass up through the fibers are affected early and selectively, pain and
posterior limb of the internal capsule and the corona temperature sensations are lost whereas touch and
radiata to reach the sensory cortex. other posterior columns sensations are preserved.
382 Section 11: Neurology
The fibers carrying touch cross over to the Brain tumors, tuberculomas, cysticercosis, cerebral
opposite side more obliquely than those carrying infarcts and head trauma are the causes for
pain and temperature. Due to this fact, in transection symptomatic epilepsy. The common causes for
or hemisection of the spinal cord, the level of dizziness or vertigo are diseases of the peripheral
sensory loss may be different for touch, pain and vestibular apparatus, postural hypotension or
temperature. lesions of the cervical spine. Anemia and drug
induced giddiness should be kept in mind while
PROFILE OF NEUROLOGICAL DISORDERS analyzing the problem of giddiness. Of all the pains
IN INDIA that affect either the neck, low back or limbs, those
Clinical neurology is a chimera. It encompasses a due to musculoskeletal disorders top the list.
great variety of neurological disorders, which may Spondylosis and prolapsed intervertebral disc in
be congenital, hereditary, nutritional, vascular, the cervical or lumbar region are common among
inflammatory, infective, toxic metabolic, demye- the demonstrable causes.
linating, degenerative, traumatic or neoplastic. The The second group of neurological disorders
central peripheral and autonomic components of the which are accompanied by demonstrable
nervous system either selectively or in combination neurological deficits can be classified as follows:
may be involved in various pathological processes. Developmental defects: Serious developmental
In addition, many primary systemic diseases also defects of the nervous system invariably result
Part–I: Internal Medicine
affect the nervous system secondarily during their in death of the fetus in utero or shortly after birth.
course or as sequelae. The spectrum of neurological Minor defects may not be clinically evident.
disorders in India is almost the same as in the West, Moderately severe defects lead to neurological
though their incidence varies. Some of the common disabilities in later life. These include neural
neurological problems encountered by the general tube defects evident at birth or soon afterwards,
physicians in India are briefly highlighted below. congenital hydrocephalus in children and a
Arbitrarily, these disorders can be broadly cate- variety of craniovertebral anomalies such as
gorized into two groups: basilar invagination, Arnold-Chiari malformation,
i. Those with no or few neurological signs. congenital atlantoaxial dislocation, other
ii. Those with multiple neurological signs. abnormalities of cervical spine and syringomyelia.
Those in the first group include headache, Infections: Meningitis, encephalitis, poliomyelitis,
epilepsy, dizziness, pain in the neck, back and limbs herpes zoster, cerebral malaria and suppurative
and syncopal attacks which together, form the infections form the main bulk of neuro infections.
greater bulk of the patient material in general Bacterial meningitis due to pneumococcus,
practice. An accurate diagnosis of the cause of Meningococcus, and H. influenzae is still common
these problems can be established only by a carefully in all age groups. Gram-negative meningitis due to
elicited history, repeated physical examinations and E. coli and others occur in neonates. Tuberculous
appropriate investigations. Among all types of meningitis has to be considered in every case of
headaches, tension headache and migraine are the subacute or chronic meningitis. Syphilitic meningitis
most frequent ones in all age groups. Though mild may be seen at times. Fungal meningitis due to
hypertension and diseases of eye, ear and paranasal Cryptococcus neoformans, Aspergillus and Mucor
air sinuses coexist in many patients with headache, should be considered in immunocompromised
they are seldom the primary cause for the individuals. Encephalitis and meningoencephalitis,
symptom, though they certainly aggravate the caused mainly by viruses are also common. In many
distress. Among the various types of epilepsy, cases the nature of these viruses is not known.
generalized tonic-clonic seizures is the most Japanese B encephalitis, herpes simplex ence-
common type in children and adults. In neonates, phalitis, encephalitis due to rabies and measles are
hypoxicanoxic brain damage, intracranial identifiable viral infections. Encephalitis may also
hemorrhage and CNS infections are the major occur as a complication during systemic viral
causes for convulsions, followed by hypoglycemia, infections. Poliomyelitis incidence has come down
hypocalcemia and inborn errors of metabolism. remarkably in several communities as a result of
Chapter 31: General Considerations in Neurology 383
vaccination. AIDS related neurological problems, muscular atrophies and muscular dystrophies are
should always be kept in mind. Cerebral malaria the common degenerative diseases.
and neurocysticercosis are frequently seen in many Miscellaneous disorders: Mental retardation due
parts of the country. to birth injury and neonatal CNS infections, cerebral
Vascular lesions: Stroke or cerebrovascular palsy, peripheral neuropathy due to diabetes,
accident is the most common cause for any sudden Hansen’s disease and of undetermined etiology,
focal neurological deficit. Among the two common coma due to metabolic and toxic causes are also
types of stroke, occlusive vascular disease leading commonly seen in general practice.
to cerebral infarction is more common than
hemorrhagic strokes. Neurological Disorders having Higher
Incidence in India
Age above 60 years, diabetes, hypertension and
atheroscleros are the predisposing factors for Neurotuberculosis It is seen throughout the country.
occlusive cerebrovascular disease. Cerebral embo- It is the greatest imitator of all diseases as it manifests
lism and primary subarachnoid hemorrhage are in so many different ways.
seen mainly in younger individuals. Cerebral i. Tuberculous meningitis, seen more commonly
embolism in the young is most commonly asso- in children and younger age groups.
ciated with rheumatic or congenital heart disease ii. Intracranial tuberculoma, which may be
and infective endocarditis. Atrial fibrillation due to solitary or multiple, large ones, manifesting
South Indian paraplegia (Syn tropical myelo- Atypical forms of Motor Neuron Disease
pathy): It is a condition of unknown etiology, i. Amyotrophic lateral sclerosis (ALS)-like
affecting subacutely the spinal cord, with involve- condition in juvenile and young subjects.
ment of the pyramidal tracts and dorsal columns, ii. Pattern similar to ALS but with nerve deafness—
peripheral sensory nerves and sphincters. Contrary Madras pattern of motor neuron disease.
to what the name suggests, it occurs all over the iii. Purely LMN type of involvement of one extre-
country. mity monomelic or segmental amyotrophy.
An epidemiological study in a rural district in
Neurolathyrism West Bengal Saha SP et al (JIMA 2002.101, 299-
This is a condition seen in central and northern 304) reveal that in a population of 100,000 the
parts of the India in which there is subacute onset frequency of neurological diseases were:
and slow progression of pure upper motor neuron • Headache 870
type of paraplegia. It is caused by consumption of • Vertebral diseases with
food grains contaminated with the seeds of neurological involvement 540
Lathyrus sativus (Kesari dal) which is a drought • Seizure disorders 360
resistant crop. • Vertigo 230
• Stroke 147
Fluorosis • Movement disorders 140
Part–I: Internal Medicine
32
1 Clinical Examination of
the Nervous System
V Loss of sensation in the skin of the face and in the mucous membrane of nasopharynx, Difficulty in
clenching the jaws and opening the mouth
VII Facial paralysis, distortion of face, watering from eyes, inability to close the eye
VIII Deafness, tinninuts, vertigo
IX to XI Dysphagia, dysphonia, dysarthria, nasal regurgitation of fluids
XII Weakness of tongue, wasting
Motor system Weakness of limbs, wasting of muscles, fasciculations, spasticity
Sensory system Pain, paresthesia, anesthesia, hyperesthesia, ataxia of gait
Sphincter disturbances Urinary retention/incontinence, fecal retention/ incontinence, priapism, reflex ejaculation
Autonomic nervous system Trophic changes, impotence, constipation diarrhea, urinary retention or incontinence, postural vertigo,
syncopal attacks
Meninges Headache, nuchal pain
are much more common to occur as the presenting hemorrhagic strokes. Structural heart diseases such
symptoms in primary neurological diseases. as valvular heart disease and congenital heart disease,
arrhythmias such as atrial fibrillation, ischemic heart
GENERAL EXAMINATION disease and infective endocarditis account for a high
Before proceeding to neurological examination proportion of cerebrovascular complications.
specially look for:
Diabetes Mellitus
State of consciousness and mental state: Metabolic
Several neurological complications can occur
disturbances such as diabetic ketoacidosis, hypo-
due to diabetes mellitus. These complications usually
glycemia, uremia, hepatic failure and poisoning may
occur in patients known to have diabetes mellitus,
give rise to abnormalities of consciousness and
but occasionally they may be the presenting
mental functions. These should be looked for.
manifestations. The neurological complications can
Cardiovascular Findings be acute or chronic.
Examination of the pulse, blood pressure and the The acute complications are coma and convuls-
heart gives clues regarding the etiopathogenesis of ions due to severe hyperglycemia with or without
several neurological disorders. Hypertension is ketoacidosis and hypoglycemia. The chronic
associated with a high-risk of thrombotic and complications are generally due to:
Chapter 32: Clinical Examination of the Nervous System 387
iv. Inability to sustain long conversation, with by simultaneous recording of EEG, EMG and
frequent drifting from one topic to another. electro-oculogram; this combination is called
v. Disorientation in time and place. polysomnogram. When a person falls asleep he
Note: At times a patient with Wernicke’s dysphasia passes through stages I to IV of NREM sleep which
may mimic confusion state. This has to be borne takes about 70 to 100 minutes, followed by REM
in mind. sleep for the next 25 to 30 minutes. After this again
stage I of NREM begins. This cycle of NREM-
Somnolence REM sleep is called a sleep cycle and usually 4 to 6
A somnolent person appears to be asleep, but he such sleep cycles are repeated in a night’s sleep in
can be aroused transiently by verbal or painful a healthy adult. However, the duration and the
stimuli and made to perform simple motor tasks number of sleep cycles vary with age and sex.
and appropriate verbal responses, but immediately Stage I of NREM is called drowsiness and stage
he drifts back into a sleeplike state when the II, light sleep. Stages III and IV of NREM sleep
stimulus is stopped. and REM sleep are called deep sleep. During
drowsiness and light sleep, the muscle tone in the
Stupor
limbs is maintained, there may be gross body
The patient who appears to be asleep can be aroused movements but no eye movements. In the deep
transiently only by vigorous and repeated painful sleep stage of NREM also, there will not be any
stimuli. When aroused, the eyes are opened but eye movements, the limb tone is maintained, and
and recording the patient’s responses. The results more skillful motor acts. If a person prefers his
are scored numerically and the total score is right hand to perform these acts, he is labeled as
determined (Table 32.2). right handed person and if he prefers his left hand,
Once the test is completed, find out the total left-handed person. More than 90 to 95% of the
score. The maximum score of 30 is normal. Scores general population are right-handed. Hereditary and
below 15 indicate severe dementia and scores evolutionary factors, learning during childhood, and
between 15 and 22 indicate moderate-to-mild cerebral dominance are responsible for the hand
dementia. preference.
The patient’s handedness is determined by
Detailed Mental Status Examination asking him which hand he normally uses to comb
Record the following points: his hair, lift an object, throw a ball and thread needle.
Handedness Educational Status
This refers to preference to use the hand of a This should be known because the patient’s
particular side, to perform intricate, complex and behavior is heavily influenced by his educational
392 Section 11: Neurology
attainment. Ask him his formal or informal level of Close your right eye and touch your nose with the
education. left thumb.
Level of Consciousness Visual Comprehension
Alert/somnolence/stupor/semicoma/coma. Only Show him familiar pictures and ask him to identify.
if the patient is alert further tests are relevant.
Insight
Appearance and Behavior This refers to the patient’s understanding of the
Note whether he is tidy/unkempt/cooperative/ situation and attitude towards the general nature,
indifferent/hostile/agitated/dull. cause and implication of his illness, and his ability
to appreciate the need for treatment.
Affect and Mood
Memory
Affect
This is the capacity to retain and recall stored
It is the patient’s emotional status, as manifested information at will. It consists of:
externally to the examiner. Note whether he is a. registration, retention and immediate recall
elated/fearful/anxious/apathetic or sad. b. recent memory
c. remote memory.
Mood
Part–I: Internal Medicine
It is the patient’s subjective mental state. It must Registration, Retention and Immediate Recall
be explored by the examiner. i. Digit span test: Give a series of digits at the
rate of the one per second without rhythmic
Orientation spacing and ask the patient to repeat. Normal
Orientation to Time person above the age of 14 years should be
Ask him the current day, date, time, month, year able to repeat 7 to 8 digits forwards, and 6
and season. digits backwards.
ii. Tell him 3 numbers and names of 3 places
Orientation to Place and ask him to repeat after 3 minutes, after
Ask him to name the city and hospital he is in. informing him in advance that he has to
remember and recall the items later.
Orientation to Persons iii. Test the ability to repeat a three-part sentence
Ask him to identify the persons, previously known of several words without error.
to him. iv. Give 4 unrelated words and ask him to recall
after 5, 10 and 30 minutes. This tests new
Attention learning ability.
It is the ability to attend to a given task. Note the v. For non-verbal response, ask him to carry
speed and accuracy. Recite a series of digits and out a three stage motor act on command.
ask him to tap on the table when a specific digit is vi. Ask the patient to look at a group of objects
repeated. Note your observations as: attentive/ placed on a table and then name as many of
inattentive/distracted/wandering attention. them as possible from memory without
looking at the objects. This is the test for visual
Comprehension
memory.
It is the ability to perceive correctly, interpret, and
understand the meaning of sensory stimuli. Recent Memory
Auditory comprehension: First simple and then Ask the patient details about the following:
complex commands are given and the responses i. Duration of his hospital stay.
noted. ii. Food items in his last meal.
For example: Close your eyes. iii. When, how, and with whom he came to
Stick out your tongue hospital.
Raise your left arm iv. Details of the doctors he consulted recently.
Chapter 32: Clinical Examination of the Nervous System 393
v. Significant events of the previous day and experience of different situations. Ask him some
week. of the following:
• Names of past and present presidents and prime
Remote Memory ministers of India.
Enquire some of the following as are applicable to • Dates of some of the important national and
the patient. international events.
Date and place of birth and age of the patient. • Reports from current newspaper.
Name and place of the school he studied. Places • Names of the national holidays and their
of his residence in the past. significance.
Past employment history, date of his marriage, • Names of some of States in India and their
and age at the time of marriage. capitals.
Names, ages, and addresses of his siblings. Ask • Names of some important rivers and lakes in
him to recite the alphabets or any song or prayer the country.
he learnt in his childhood.
Calculation
Note: Verify the correctness of the answers with The serial subtractions test: Ask the patient to do
the attendant. subtraction of 7 or 3 serially starting from 100. If
Judgment, Reasoning he fails the test, he should be given simpler additions
• “Lick the upper lip” gnosis. It is the inability to identify shapes and
• “Blowing a smoke ring” sizes of objects placed on the hand.
• “Coughing out” SPEECH AND LANGUAGE
Ideomotor Apraxia
In neurological parlance, speech has many more
This refers to the dissociation of idea of a movement facets to it than what is understood by the lay public.
from its execution, though both the idea and ability Speech and language are the main modes of
to execute are intact when tested separately. expression and communication available to humans.
First Stage In addition to spoken speech, gestures, signs, signals
and graphic symbols of written language all can
Patient performs poorly to command. He may not
serve the same purpose. All these modes of
be able to carry out any movement or he may be
expression of thoughts and ideas to others and
clumsy, often using body parts as the object.
comprehension of their thoughts and ideas constitute
For example, Pounding the fist or running the
language. Thus, language can be described as the
fingers through the hair when asked to pantomime
medium of communication. Communication through
the use of a hammer or comb.
signs, signals, gestures and vocalizations, mainly to
Second Stage convey one’s emotions is called emotional language.
Performance improves when he imitates the action Communication through the medium of symbols or
of the examiner, though often it still remains words is called symbolic language (spoken and
imperfect. written speech). Infants and to some degree animals,
communicate through emotional language. The
Third Stage diencephalon (upper brainstem) and hypothalamus
Most patients perform normally given the actual mediate emotional language and it is independent of
object. the cerebral hemispheres. As opposed to this, the
symbolic language which is unique to man is
Constructional Apraxia dependent on fully mature, intact cerebral functions.
First the patient is asked to draw simple figures Synthesis of spoken and written language is a
like a square, circle or triangle. function of the brain. This function is lateralized in
Then he is given more complex task and as the left cerebral hemisphere in 99% of right handed
drawing a 3-D cube, face of clock with time of and 75% of left handed individuals and it is the
day, a flower, or a tree. dominant hemisphere for speech and language.
Chapter 32: Clinical Examination of the Nervous System 395
Four distinct areas concerned with speech and is called aphasia, and a minor disturbance is called
language are identified in the brain which constitute dysphasia. Loss of ability to read, writing being
the cortical areas for speech. Two of these are unaffected is called alexia without agraphia. Loss
anterior to the central sulcus and the other two are of ability to write is called agraphia. Dysfunction
posterior to it. All the four are located in the of the peripheral mechanism of speech leads to
perisylvian region which is called the central zone defective articulation which is called dysarthria.
of language. Just as the cortex anterior to the Depending on the site of the lesion in the speech
central sulcus is motor and that posterior to it is areas in the brain, the following types of aphasia
sensory in function, the two anterior speech areas may occur (Table 32.3, Fig. 32.1 and Flow chart
are responsible for motor aspects of speech, one 32.1).
for spoken speech and the other for visual speech,
i.e. writing. The two posterior areas are concerned Examination of Speech and Language
with the sensory aspects of speech, one for Before proceeding to examine speech, ascertain
comprehension of spoken speech and the other the following:
for comprehension of visual speech, i.e. reading. i. Handedness of the patient
The motor area for spoken speech, is situated in ii. Language familiar to him for speaking, reading
the posterior part of the left inferior frontal gyrus and writing
and it is called Broca’s area. The motor center for iii. His general level of education and intelligence
writing is thought to be just anterior and superior
The level of consciousness, hearing and vision grammatically correct (e.g. it, the, on, of, but,
should be sufficiently preserved to administer the etc.) are called fillers. In one type of aphasia
tests. Detailed evaluation of speech and language the patient may not be able to produce
functions is a time-consuming process and it is grammatically correct sentences, but by means
not usually required for the purpose of localization of substantive words he can convey his ideas
in clinical neurology. Hence a short and practically or thoughts reasonably well. This is called
useful method of examination is described below. Broca’s aphasia or “telegraphic” speech. On
The patient is assessed for the following: the other hand in Wernicke’s aphasia, he cannot
1. Can he repeat verbatim words or sentences told convey his ideas and thoughts meaningfully
to him? because he uses filler words more than the
2. Can he comprehend the spoken language? substantive words. This is called “jargon” speech.
3. How is his spontaneous speech? Due to difficulty in retrieving the intended
4. Can he read, and understand what he reads? or desired word, the patient puts out a wrong
5. Can he write spontaneously, or to dictation, or word, e.g. ‘She is my husband’. ‘You are my
copy? medicine’, etc. Sometimes he produces a
Repetition: Tell him names, letters, words or word-like sound which is not existent in the
sentences and ask him to repeat verbatim. dictionary of any language. Use of wrong
Note: Whether he is able to repeat or not. words is called “paraphasia” and use of non-
Comprehension of spoken language: Give a series
Part–I: Internal Medicine
Table 32.5: Common terms used to describe special forms of dysphasia and the site of lesion responsible for each
Pure word deafness:
• Inability to comprehend and repeat spoken language Heschl’s gyrus and/or its afferent
• Relatively preserved written language connections
Semantic aphasia:
• Inability to comprehend spoken and written language Parietotemporal border zone
• Normal repetition of spoken language Angular gyrus and its connections to posterior inferior temporal cortex
Aphasic anomia:
• (Syn: word finding difficulty, nominal aphasia)
• Word production anomia: Broca’s area and its connections
• Inability to produce correct words, but does so on prompting
Word selection anomia:
• Inability to produce correct word even on prompting, Left second temporal gyrus-posterior part
but can select the word if choice is given of temporo-occipital junction.
Semantic anomia:
• Inability to select the correct word even if the same is offered Left angular gyrus
Alexia with agraphia:
• Reading difficulty and writing difficulty Left angular gyrus
Alexia without agraphia:
• Reading difficulty with normal writing (pure word blindness) Medial part of occipital lobe and splenium of corpus callosum
Alexia for syntax:
• Inability to comprehend the meaning of a series of Broca’s area
Part–I: Internal Medicine
Table 32.6: Clinical features and causes of common dysarthrias and other speech defects
Type Features Disease
A . Due to lesions in the central nervous system:
a. Slurred speech Individual letters are slurred, precision of consonant Diffuse cerebral disease
pronunciation is lost as in a state of intoxication
b. Scanning speech Speech is slow, and the syllables in a word are pronounced Cerebellar disease
clearly with unduly prolonged pauses in between
c . Staccato speech Intermittent, jerky and explosive pronounciation of some syllables Cerebellar disease
d. Monotonous speech Low pitched voice lacking in melodic intonations Parkinsonism
e. Hiccup speech Abrupt interruption in the pronounciation of words or abrupt jerky Chorea, myoclonus
pronounciation of words
f. Cortical dysarthria Slow, thick and indistinct speech Lesion in left frontal cortex and
(spastic speech) recovering phase of Broca’s aphasia
B . Due to lesions in the peripheral nervous system
a. Slurred Difficulty in pronounciation of vibratives (R) Bulbar palsy myopathy
lingual and labial consonants (P,L,M) making the speech indistinct myasthenia gravis
b. Dysphonia Low pitched voice Bulbar palsy
c . Hoarse voice Low pitched, rough, harsh voice Laryngeal palsy
C . Of undetermined cause
a. Stammering Repetition of syllables in a word
b. Stuttering Repetition of syllables in a word
usually only at the commencement of the word
prosody and nasality of voice depend on adequate sensory and motor components. The nuclei of the
respiratory airflow. In conditions with low vital motor cranial nerves (lower motor neurons—LMN)
capacity, all the modalities tend to be abnormal. receive impulses from the motor cortex through
corticonuclear or corticobulbar fibers (upper motor
CRANIAL NERVES neuron fibers—UMN). Bilateral UMN connections
are present for all the motor cranial nuclei except
General Considerations that part of the facial nucleus which supplies the
There are 12 pairs of cranial nerves which leave or muscles of the lower part of the face and that part
enter the brain through foramina at the base of the of the hypoglossal nucleus which supplies the
skull. All these nerves supply different structures genioglossus muscle.
in the head and neck. The tenth nerve also supplies The sensory afferents of the cranial nerves are
the viscera in the thorax and abdomen. The formed by the axons of the nerve cells situated in the
olfactory, optic and vestibulo-cochlear nerves are ganglia on the nerve trunks or from sensory organs
purely sensory nerves. The oculomotor, trochlear, such as nasal mucosa, retina or internal ear. These
abducent, spinal accessory and hypoglossal nerves form the first order neurons. Their central processes
are purely motor nerves. The trigeminal, facial, terminate on the cells in the brainstem which form
glossopharyngeal and vagus nerves contain both the second order neurons. The axons of the second
400 Section 11: Neurology
order neurons cross the midline and ascend to other Abnormalities of the sense of smell include
sensory nuclei such as the thalamus where they inability to perceive smell (anosmia), and perversion
synapse with the third order neurons. The axons of smell (parosmia).
of the third order neurons terminate in the sensory Anosmia occurs due to lesions in the olfactory
cortex of the cerebrum. bulb or tract. Fracture of the floor of the anterior
Systematic examination of the cranial nerves cranial fossa, tumors of the olfactory bulb such
is an important component of neurological exam- as olfactory groove meningioma, frontal lobe
ination. tumors pressing on the olfactory pathways or basal
meningitis may lead to anosmia. Parosmia occurs
OLFACTORY NERVE—I CRANIAL NERVE following head injury.
The olfactory mucous membrane in the upper part Since the olfactory tracts on both sides are
of the nasal cavity contains olfactory receptors. interconnected through the anterior commissure,
The central processes of these receptors form the unilateral lesions of olfactory cortex do not result
olfactory nerve fibers which pass through the in anosmia.
openings of the cribriform plate of the ethmoid
bone and synapse with specialized cells in the OPTIC NERVE—II CRANIAL NERVE
olfactory bulb. The central processes of the cells (Also Refer to Section 17—Ophthalmology)
in the olfactory bulb form the olfactory tract which The optic nerve is the sensory nerve concerned
Part–I: Internal Medicine
travels posteriorly to reach the anterior perforated with vision. Rods and cones in the retina are the
substance. Here it divides into medial and lateral visual receptors. Rods mediate vision in the dark
olfactory striae. The medial olfactory stria connects whereas cones are for vision in brightness. Macula
the olfactory bulb of one side with that of the situated at about the center of the retina contains
opposite side. The lateral olfactory stria carries more cones than rods and it is responsible for the
the fibers to the primary olfactory cortex situated clearest central vision. Fovea which contains only
in the periamygdaloid and prepyriform areas of cones is responsible for color vision and central
the temporal lobe. The primary olfactory cortex vision. The remaining portions of the retina contain
has connections with the secondary olfactory more rods than cones. They take part in peripheral
cortex in the parahippocampal gyrus of the vision, perception of movement of objects in the
temporal lobe and also with many other areas in visual field and vision in darkness, but not for color
the brain. These subserve emotional and autonomic vision. The fibers of the optic nerve are the axons
responses resulting from olfactory sensations. of the ganglionic cells in the retina which are
connected to the rods and cones through inter-
Test mediate neurons. The nerve fibers converge on the
Local causes which impair the sense of smell like optic disk and exit posteriorly to form the optic
rhinitis, sinusitis and gross deviation of nasal nerve. Optic nerve head (optic disk) produces the
septum should be looked for and excluded before physiological blind spot in the visual field, being
testing the smell. Each nostril is tested separately devoid of rods and cones. The blind spot lies on
after occluding the other one, by using substances the temporal side of the point of visual fixation,
with mild aroma like coffee powder, soap, talcum slightly below the horizontal meridian of the visual
powder, clove or peppermint oil. The patient is asked field. Fibers of the optic nerve have central type
to close his eyes and mouth and inhale the odor of of myelin sheath. The myelin sheath stops short at
test substance and indentify it. Ability to perceive the lamina cribrosa. The dura, arachnoid and pia
the smell and differentiate one smell from the other mater extend forward around the optic nerve up
is taken as normal, even though proper identification to the lamina cribrosa. The subdural and subara-
may not be possible. Substances which give pungent chnoid spaces around the optic nerve are in direct
smell such as ammonia, should not be used because communication with those around the brain. Optic
they may stimulate the trigeminal nerve endings nerve leaves the orbital cavity through the optic
and irritate the nose, even when the sense of smell foramen and unites with the optic nerve of the
is absent. opposite side to form the optic chiasma. In the
Chapter 32: Clinical Examination of the Nervous System 401
chiasma the fibers from the nasal half of each retina or parastriate cortex and area 19 or peristriate
including that of the macula cross the midline, pass cortex), which is responsible for visual localization
anteriorly for a short distance into the opposite and discrimination, spinal orientation and complex
optic nerve and then pass posteriorly to enter the visual perceptions.
optic tract. The fibers from the temporal half of There is a definite topographical arrangement
each retina including that of the macula do not of the retinal fibers in the visual pathways. Fibers
cross. They pass in the optic tract of the same from the upper part of the retina occupy the upper
side. part of the optic nerve and those from the lower
Position of the optic chiasma may vary within part of the retina occupy the lower part of the
small limits even in healthy individuals. The optic nerve. The macular fibers occupy a central
chiasma lies directly above the sella turcica, if the position. In the optic chiasma, optic tract and optic
optic nerves are short, but more commonly it lies radiation, the fibers from the upper part of the
slightly behind and above the sella turcica. Due to retina occupy the upper or dorsal position, and the
this anatomical variation the visual field defects fibers from the lower half of the retina occupy a
caused by pituitary tumors may vary in different lower or ventral position.
patients.
Tests of function: The following features must
The optic tracts pass posterolaterally around always be examined:
the lateral surface of the cerebral peduncles of the i. Visual acuity, ii. Visual fields,
wear their reading glasses when their visual acuity Other local ocular conditions such as cataract,
is tested. Alternatively, the patient can be asked to glaucoma, and opacities in the media are also
read an ordinary newsprint or identify small pictures common causes of visual impairment.
on a card held at 30 to 35 cm from his eye. Patterns of onset of visual impairment in
Distant Vision neurological disorders:
i. Sudden, transient, monocular blindness,
The standard clinical test for distant vision is coming on like a curtain falling swiftly over
Snellen’s test. The Snellen’s chart contains letters the upper half of visual field and lasting for 5
of various sizes, arranged in horizontal lines. The to 15 minutes should suggest embolism of
number beside each line indicates the distance in central retinal artery. This is called “amaurosis
feet, at which the letters can be read by a person fugax”. It may persist for a longer time if it
with normal vision. Snellen’s chart is kept at a leads to retinal infarction. Visual loss occurring
standard distance of 6 meters (20 feet) from the at the onset of calssical migraine may also
patient's eyes. At this distance, ocular accommodation follow a similar pattern. It is due to vasospasm.
does not occur and the light rays will be parallel. ii. Severe visual loss in one eye usually
Normally, the smallest letters in the line designated developing over a few hours or even a day or
“6” can be read at 6 m and then the visual acuity two to reach its peak, occurs in optic neuritis
for distant vision is recorded as 6/6. If distant vision or ischemic optic neuropathy. Patient with
is affected, the patient can read only larger letter hypertension, diabetes, atherosclerosis,
Part–I: Internal Medicine
types, in which case, the visual acuity is recorded collagen vascular disease or temporal arteritis
as ‘6/x’, ‘x’ being the number designated to the are more prone to develop vascular occlusion.
smallest line the patient could read. iii. Brief, transient, hazy obscurations of
Modified Snellen’s charts with vernacular vision lasting for less than 10 seconds in one
letters, numbers, symbols or pictures are available or both eyes occur characteristically in patients
for those who are not able to read English letters. with severe papilledema caused by raised
If a patient cannot read any letter on the intracranial pressure. In the later stages
Snellen’s chart, even when standing near it, visual progressive diminution of vision develops.
acuity is tested by noting the ability to count fingers iv. Insidious and progressive visual loss in one
(CF), ability to appreciate the movements of the eye may result from a tumor such as optic
examiner’s hand (EH), or ability to perceive light nerve glioma compressing the optic nerve
(PL). With increasing degrees of visual loss, these either in the orbit or optic foramen.
faculties disappear progressively. When the patient v. Insidious and progressive visual loss affec-
cannot even perceive light, the vision is recorded ting both eyes is the hallmark of compression
as “no PL”. Projection of light is the ability to of the optic chiasma by tumors. Toxic,
know the direction from which the light is entering nutritional, and metabolic causes and here-
the eye. ditary optic atrophies also lead to such a
For patients who are disabled and bedridden, a progressive visual loss.
quick method is to find out the ability to count
Visual Fields
fingers correctly at various distances. Finger-
counting at 3 m is approximately equal to visual Visual field is the visual space in front of the eye in
acuity of 6/60 on Snellen’s test. which objects are visible when the eye is fixed in
one direction. In each eye the normal visual field
Pin-Hole Test extends up to 100° on the temporal side, 60° on
The patient is asked to look at an object through a the nasal and upper side, and 70° on the lower
1 mm size pin hole, punched in a card. The pin- side. The visual field extending up to 30° from the
hole allows the light to fall only in the central part point of ocular fixation is called central field and
of the retina. If the visual acuity which is originally the rest is called peripheral field. During binocular
impaired improves on pin hole test, the visual vision, the visual fields of both eyes overlap except
impairment is due to refractive error and not due over a crescent shaped area at the periphery of the
to any neurological cause. temporal field of each eye which is perceived only
Chapter 32: Clinical Examination of the Nervous System 403
by the ipsilateral eye. Damage to the visual pathway 60 to 75 cm distance in such a way that his eyes
at any point from the retina to the visual cortex and the eyes of the patient are almost at the same
can result in an abnormality in the visual fields. level. Each eye is tested separately, while the other
The pattern of such a visual field defect helps to eye is covered. For testing the right eye of the patient
localize the lesion. he fixes his eye on to the left eye of the examiner
Tests: Visual field can be assessed at the bedside and vice versa. Throughout the examination, the patient
by confrontation method. It can also be precisely and the examiner should not change the position
charted using a perimeter or Bjerrum’s screen. of their eyes. The examiner should bring a moving
object such as his finger, pen or preferably a white
Assessment of Peripheral Fields of Vision pinhead from the periphery towards the point of
(Figs 32.2A to D) fixation, keeping the moving object midway
between the patient’s eye and the examiner’s eye,
Confrontation Method the upper nasal, lower nasal, upper temporal and
In this method the visual fields of the patient are lower temporal quadrants are tested individually.
compared with the visual fields of the examiner The patient is asked to indicate by saying ‘yes’ or
which have to be normal. The examiner positions raising his hand, as soon as he sees the object. By
himself face to face in front of the patient at comparing with his own visual field, the examiner
C D
Figs 32.2A to D: Confrontation method for testing field of vision: (A) Lateral (temporal) field
(See text for description), (B) Upper field, (C) Lower field, (D) Medial (nasal) field
404 Section 11: Neurology
can detect gross defects in the patient’s visual field. can be detected by the red-pin test. Its size should
This method detects the outline of the visual field. coincide with the examiner’s blind spot. More
A less accurate method is to test the ability to reliable method is to do perimetry.
count the fingers of the examiner in each quadrant
Note: I. Confrontation method is partly sub-
of the visual field. While examining patients who
jective and it detects only gross defects
are less cooperative or demented, and in children,
in the peripheral field of vision.
a small shiny or colorful object can be brought into
II. The visual field is larger when the test is
the visual field from the periphery in each quadrant
done with (1) larger objects, (2) moving
and the response of the patient noted. Turning the
eyes and head in the direction of the object may give objects, and (3) white color objects
clue to normal visual function. instead of other colors.
When standard procedures are not applicable Types of Visual Field Defects
as in totally bedridden patients, uncooperative
i. Hemianopia (Syn: hemianopsia): Loss of one
children, or demented subjects the defensive
half of visual field.
blinking response brought about by moving the
examiner’s hand rapidly from the periphery • Homonymous hemianopia: Loss of vision
towards the patient’s eye can be tested. Absence in the nasal half of one eye and temporal
of expected response should suggest loss of vision half of the other eye, i.e. loss of the right
in the part of the visual field. or left field of vision.
Part–I: Internal Medicine
upper nasal, bilateral upper temporal, Site of Lesion in Visual Pathway and
bilateral lower nasal and bilateral lower the Resultant Visual Field Defects
temporal. (Figs 32.3A and B)
iii. Altitudinal hemianopia: Loss of vision in the
Optic Nerve
upper or lower half of visual field in one or
both eyes. A complete lesion such as optic nerve injury
iv. Concentric constriction: Loss of vision at the produces total blindness in the eye. Conditions such
periphery of the visual field, often progressing as optic neuritis and compression of the optic nerve
in a concentric fashion. result in incomplete lesion which gives rise to
central scotomas in the affected eye. Bilateral
Scotoma central scotomas occur in optic neuropathies. If
This is an area of defective vision in the visual field. the lesion is in the posterior most part of the optic
Total blindness in the area is termed ‘absolute nerve close to the optic chiasma, loss of vision in
scotoma’ and partial visual loss is called ‘relative’ the ipsilateral eye and contralateral upper temporal
scotoma. If the patient is aware of the defect such quadrantanopia may develop. Optic neuritis, optic
a scotoma is called ‘positive’ scotoma. ‘Negative’ atrophy, trauma, tumor and ischemia are the
scotoma is one which is not appreciated by the common lesions which affect the optic nerve.
patient, but detected by the examiner. ‘Subjective’ Swinging flash test: Normally when the pupils on
scotoma is one which is felt by the patient, but not both sides are rapidly and alternately stimulated by
A B
Figs 32.3A and B: (A) Visual field defects, (B) Visual pathways
Part–I: Internal Medicine
4. Normal visual acuity with preservation result in color blindness. In hysterical conversion
of light reflex and no signs of optic reaction, color blindness is a common symptom.
atrophy in the presence of homonymous Color vision is impaired earlier in optic nerve
hemianopia suggests a lesion beyond the lesions that retinal lesions. Retinal diseases affect
lateral geniculate body. In lesions anterior blue color first and green last; whereas lesions in
to the lateral geniculate body, the visual the optic pathway affect red and green colors first.
acuity will be reduced, light reflex will be The exceptions are ischemic optic neuropathy and
absent and there may be associated optic autosomal dominant inherited optic atrophies.
atrophy. Normal color vision with grossly reduced visual
acuity suggests that the visual loss is not of
Visual Disturbances Caused by Lesions
neurologic cause. If a colored object appears less
in the Cerebral Cortex
bright when viewed with one eye as compared to
A variety of subjective visual sensation or the other, a lesion of the optic nerve should be
disturbances occur with or without defects in visual considered, if an ophthalmological cause is
acuity and visual fields as a result of cortical excluded.
or subcortical lesions. Some of these are given
in Table 32.8. Pathways for the Pupillary Reflexes
When a beam of light is thrown into one eye,
Color Vision
normally both the pupils constrict. The constriction
rays entering the eyes. All the three components reach the constrictor pupillae and ciliary muscles
occurring simultaneously constitute the accomm- (see pathway for light reflex). Accommodation
odation reflex. brought on by a visual stimulus is mediated through
The afferent pathway travels in the visual this pathway.
pathway reaching the occipital cortex (visual Normal persons can also accommodate for
cortex). The visual cortex on either side is near vision voluntarily even without visual stimuli.
connected to the frontal eye fields from where the This response is mediated through the frontomesen-
efferent corticomesencephalic fibers descend cephalic pathway.
through the internal capsule to reach the oculomotor
nuclei. Some fibers from the oculomotor nuclei Fundus Examination—Funduscopy
reach the medial recti muscles. Some of the (See Chapter 48) Funduscopy is the examination
descending fibers synapse with the Edinger- of the interior of the eyes using the ophthalmoscope.
Westphal nuclei on both sides from where fibers For best results the optic fundus is examined in a
Chapter 32: Clinical Examination of the Nervous System 409
dark room. Hold the ophthalmoscope in your right i. Drusen bodies which are glistening structures
hand, and use your right eye to examine the patient’s over the optic disk.
right eye and vice versa for examining the left eye. ii. Myelinated nerve fibers which are opaque
Ask the patient to fix his vision at any distant object nerve fibers appearing as bright feather-like
at eye level and then keep the eyes still. Focus the patches radiating for a short distance from
ophthalmoscope light through the pupillary aperture the margins of the optic disk.
onto the retina. Generally start with ‘0’ lens of the iii. Smaller or hypoplastic optic disk.
ophthalmoscope and adjust the appropriate lens iv. Large sized disk or megalopapilla.
so as to get a clear vision of the disk margins. v. Tilted and obliquely elongated optic disk.
Identify the following structures—arteries, vi. Coloboma which is a small pit-like depression
veins, optic disk, macula, fovea and remaining parts in the temporal region of the optic disk.
of the retina. To get a proper view of the various
Assessment of Optic Disk
media of the eye such as cornea, lens, and vitreous,
Elevation in Papilledema
start examination with +10 lens. Then the cornea
will be in focus. Reduce the strength of the lens in Start the ophthalmoscopic examination with a +10
order to bring the other structures into focus. lens. Gradually reduce the strength of the lens until
Normally, retinal arteries are vessels of smaller the retinal vessels are seen distinctly. Note the
caliber which look orange-red with a pale strip in strength of the lens used. Repeat the procedure to
focus the vessels on the optic disk and again note
in the macula
Onset Generally insidious Acute
Symmetry Usually bilateral Usually unilateral
Pain Generalized headache Pain in and around the affected eye
Common causes (a) Bilateral papilledema: Raised intracranial pressure Toxic agents such as tobacco, methyl alcohol,
due to any cause, malignant hypertension, toxemia lead, quinine, and others infections
of pregnancy. demyelination and multiple sclerosis. In some
Less common causes are severe emphysema, severe cases, it is idiopathic.
anemia, hypoparathyroidism and Guillain-Barrè syndrome.
(b) Unilateral papilledema: Orbital tumors,
central retinal vein occlusion, papillophlebitis.
Note: Under certain conditions papilledema may not
develop even when the intracranial pressure rises.
These include pre-existing optic atrophy, severe myopia
and presence of adhesions in the subarachnoid space
around the optic nerve.
OCULOMOTOR NERVE—III CRANIAL NERVE supplies the superior rectus muscle in the opposite
eye through the opposite III nerve. The caudal
Applied Anatomy subnucleus supplies the levator palpebrae superioris
muscles of both eyes. The parasympathetic
This nerve has two major nuclei:
subnucleus which lies dorsal and rostral to the main
i. Main motor nucleus nucleus supplies the ciliary and constrictor pupillae
ii. Accessory or parasympathetic nucleus (Edinger- muscle of the iris on both sides. The fibers
Westphal nucleus). innervating the medial rectus, inferior rectus and
The main motor nucleus is situated close to the inferior oblique muscles are uncrossed. Those to
midline in the gray matter that surrounds the the superior rectus are crossed and those to the
cerebral aqueduct, at the level of the superior colliculi levator palpebrae superioris, ciliary muscle and
in the midbrain. It has several subnuclei that innervate constrictor pupillae of the iris are completely mixed,
different extraocular muscles. The ventral, dorsal i.e. both crossed and uncrossed. Hence, a nuclear
and intermediate subnuclei supply the ipsilateral lesion of the III cranial nerve on one side results in
medial rectus, inferior rectus and inferior oblique paralysis of the medial rectus, inferior rectus and
muscles respectively, whereas the medial subnucleus inferior oblique muscles with bilateral ptosis and
Chapter 32: Clinical Examination of the Nervous System 411
superior rectus involvement on the opposite side. the inferior branch supplies the medial rectus,
Bilateral nuclear lesion may at times spare the central inferior rectus and inferior oblique muscles,
subnucleus innervating levator palpabrae superioris constrictor pupillae and the ciliary muscle. The fibers
and hence ptosis may be absent. Thus a nuclear of the III nerve form the efferent pathway for the
III cranial nerve affection is often incomplete. For pupillary light reflex and accommodation reflex.
the same reason, a unilateral total III nerve palsy The nerve fibers to the constrictor pupillae of the
with normal contralateral superior rectus is unlikely iris are thin and situated at the periphery of the main
to be due to lesion at nuclear level. trunk of the III nerve on its superomedial aspect.
The oculomotor nerve after its formation from These fibers receive their blood supply mainly from
the nuclei emerges on the anterior surface of the the perineural vascular plexus in contrast to the
midbrain in the interpeduncular fossa. It passes other fibers in the nerve which are supplied by the
anteriorly between the superior cerebellar and penetrating vasa nervosum. Because of these
posterior cerebral arteries and travels forward in anatomical features, compressive lesions of III
close relation to the posterior communicating artery nerve lead to ipsilateral pupillary dilatation and loss
before entering the lateral wall of the cavernous of light relfex as the earliest sign, whereas ischemic
sinus, where it divides into superior and inferior lesions of the nerve usually spare the pupil. The
branches. These branches pass forward to enter other signs of III nerve paralysis like ptosis and
the orbit through the superior orbital fissure. extraocular muscle palsies appear much later, in
Because of this course of the nerve, it is more the course of temporal lobe herniation.
vulnerable for compression in temporal lobe
herniation associated with supratentorial space TROCHLEAR NERVE—IV CRANIAL NERVE
occupying lesions and in aneurysms of the The nucleus of this nerve is situated in the gray matter
neighboring arteries. that surrounds the aqueduct in the midbrain at the
In temporal lobe herniation, this nerve often level of the inferior colliculi. After leaving the nucleus
gets compressed at the tentorium cerebelli. The the nerve fibers pass posteriorly around the central
superior branch of the nerve supplies the superior gray matter in the substance of the midbrain and on
rectus and levator palpebrae superioris, whereas reaching its dorsal surface, decussate in the superior
412 Section 11: Neurology
medullary velum with the fibers from the nucleus with each other, and to the vestibular nuclei
of the opposite side. The nerve then passes anteriorly, and also to other structures in the brainstern.
enters the lateral wall of the cavernous sinus and
then passes forward to enter the orbit through the Tests of Function of Oculomotor Nerves
superior orbital fissure. It supplies the superior 1. Test for levator palpebrae superioris.
oblique muscle. The two unique features of this 2. Tests for ocular movements (Figs 32.4 to
nerve are: (i) it is the only cranial nerve which 32.7).
decussates between its nucleus and its point of exit 3. Tests for pupils.
from the brainstem and (ii) it is also the only cranial 4. Tests for squint.
nerve that emerges on the dorsal aspect of the 5. Tests for diplopia.
brainstem. Because of this anatomical arrangement, 6. Tests for nystagmus.
a nuclear lesion of IV nerve results in paralysis of
superior oblique muscle on the opposite side Test for Levator Palpebrae Superioris
whereas infranuclear lesion leads to paralysis of The levator palpebrae superioris is a voluntary
this muscle on the same side. However, isolated muscle that helps to elevate upper eyelid. Normally,
involvement of IV nerve or its nucleus is rare. the upper eyelid covers about 0.5 to 1.0 mm of the
upper portion of the cornea, when the eye is in neutral
ABDUCENT NERVE (SYN: ABDUCENS
position. In this position, the lower eyelid margin
NERVE)—VI CRANIAL NERVE just touches the lower border of the cornea. Paralysis
Part–I: Internal Medicine
The nucleus of this nerve is situated beneath the of levator palpebrae results in ptosis, i.e. drooping
floor of the fourth ventricle near to the midline in of the upper lid with consequent narrowing of the
the pons. Fibers from this nucleus pass anteriorly palpebral fissure. Ptosis may be total or partial. Partial
and the nerve emerges at the junction between the ptosis has to be differentiated from a narrow palpebral
pons and the medulla oblongata. It then passes fissure that results from enophthalmos or
through the cavernous sinus and enters the orbit blepharospasm in which the palpebral fissure is
through the superior orbital fissure. It supplies the narrowed from above and below.
lateral rectus muscle. This nerve may have several Muller’s muscles in the upper and lower eyelids
anatomical variations in its origin and course. It are involuntary muscles supplied by the sympathetic
may arise as two distinct trunks or it may split into nerves and these muscles are in a state of tonic
two branches. If only one of such branches is contraction. Sympathetic paralysis leads to loss of
affected in a disease process, the result may be tone of Muller’s muscles resulting in partial ptosis
only partial weakness of the lateral rectus muscle of the upper lid and elevation of the lower lid. Ptosis
instead of its total paralysis. Lateral rectus paresis due to sympathetic palsy is always partial and the
or paralysis often develps as false localizing sign in upper lid can be raised voluntarily to some extent.
raised intracranial pressure. Irrespective of the side Ptosis due to III nerve may be total or partial and
and site of the causative lesion leading to intracranial voluntary elevation of the eyelid is not possible in
pressure, the VI cranial nerve is subjected to greater complete paralysis. The frontalis muscles may
pressure as it passes over the sharp upper surface compensate to overcome the drooping and this may
of the petrous temporal bone and this leads to its lead to prominent wrinkling of the forehead.
paralysis.
The fiber connections of III, IV and VI cranial Test: Ask the patient to look at a distant object,
nerve nuclei include the following: keeping the eyes in primary position. Observe the
i. Corticonuclear fibers from both cerebral width of the palpebral fissure on both sides and
hemispheres. compare. Note the extent of cornea covered by
ii. Tectobulbar fibers which connect these the upper and lower eyelids. Ask him to voluntarily
nuclei to the visual cortex through the superior elevate the upper lids. Also observe the degree of
colliculus. frontalis muscle contraction on both sides.
iii. Fibers from the medial longitudinal fasciculus Neurological causes of ptosis include III nerve
(MLF) by which these nuclei are interconnected palsy, sympathetic palsy, myasthenia gravis and
Chapter 32: Clinical Examination of the Nervous System 413
ocular myopathies (Fig. 32.8). Ptosis due to these Other extraocular, pharyngeal and limb muscles
lesions can be distinguished clinically. may also be affected. There is no significant response
to neostigmine.
III Nerve Palsy
Partial ptosis can also occur in local ocular
Ptosis is usually total but can be partial and voluntary conditions such as trachoma and tumors of the
elevation of the eyelid is defective. Frontalis muscle eyelid. Rarely, it can be congenital in which case it
may be in a state of contraction in an attempt to is usually bilateral. The Gunn phenomenon is the
elevate the eyelid (Figs 32.4 and 32.5). exaggerated elevation of the eyelids on opening
Pupil is dilated, other extraocular muscles supp- the mouth or during jaw movements. This is seen
lied by III nerve may also be affected (Fig. 32.5) in some cases of congenital ptosis due to pathologic
Sympathetic Palsy synkinesis. Involuntary eye closure on jaw opening
is called inverse Gunn phenomenon.
Ptosis is partial and voluntary elevation of the upper
lid is possible. Pupil is constricted (miosis). Tests for Ocular Movements
Other components of sympathetic palsy such The eyes can be moved voluntarily in horizontal,
as enophthalmos (retraction of eyeball) and anhy- vertical and diagonal directions. Horizontal
drosis (absence of sweating) on the same side of movements outwards and inwards are called
face may be present. These features constitute
abduction and adduction. Vertical movements
Horner’s syndrome.
Fig. 32.4: Third nerve palsy left showing complete ptosis Fig. 32.5: Third nerve palsy–Note the absence of medial
due to paralysis of levator palpebrae muscle. Note also movement of the left eye due to paralysis of medial rectus
wrinkling of the forehead in an attempt to elevate the eyelid
414 Section 11: Neurology
Table 32.12: Diagnostic features and causes in nuclear and infranuclear ophthalmoplegias
Site of lesion Neurological signs Common causes
1. Lesion at the level of the nuclei
a. III Cranial nerve i. Paralysis of ipsilateral medial and Brainstem lesions: Vascular disease, multiple
inferior recti, contralateral superior sclerosis, poliomyelitis, Wernicke’s encephalopathy,
rectus and bilateral levator palpebrae tumors, congenital agenesis of nuclei
ii. Bilateral total III nerve palsy with or
without ptosis
iii. Bilateral total III nerve palsy with or do
without pupillary involvement
b. IV Cranial nerve Contralateral paralysis of superior do
oblique muscle
c . VI Cranial nerve Ipsilateral paralysis of lateral do
rectus muscle
Note: Nuclear lesions are almost always associated with neighborhood signs such as other cranial nerve palsies and deficits due to
involvement of ascending sensory and descending motor tracts, e.g. Weber's syndrome. Exception congenital agenesis of the
nuclei.
2. Lesions distal to the nuclei
a. At the base of the brain III, IV and VI cranial nerve palsies in Meningitis, nasopharyngeal carcinoma, cranial
different combinations with or without neuritis, basilar artery aneurysm. Aneurysm of
other cranial nerve palsies and signs of posterior communicating artery, temporal lobe
meningitis. Isolated III nerve palsy herniation due to raised intracranial pressure,
Part–I: Internal Medicine
A B
Figs 32.10A and B: Testing for accommodation reflex. (A) Patient looking at distant object,
(B) Patient looking at near object. (See text for description)
Accommodation reflex (Syn. reaction to accomm- parallelism in the visual axis of both eyes. The
odation): This reflex occurs when the person abnormal deviation of the eye may be divergent,
focuses his vision on a near object. convergent, upwards or downwards. It may affect
Part–I: Internal Medicine
Method of testing: The patient is asked to fix his one eye or both eyes alternately. If it is noticeable
eyes on the examiner’s index finger which is when both eyes are kept open it is called manifest
held a meter away and then rapidly brought near squint. If it can be detected only by covering one
to the patient’s nose. Convergence of the eyes and eye it is called latent squint. Basically, there are
pupillary constriction can be observed (Figs 32.10 two types of squint—paralytic and non paralytic
A and B). or concomitant. Paralytic squint results from
Ciliospinal reflex: When the skin over the neck is paralysis of a muscle or a group of muscles acting
pinched, pupil on the same side dilates reflexly. on the eyeball. Squint manifesting without paralysis
This results from stimulation of the sympathetic of extraocular muscles is called nonparalytic squint
fibers which supply dilator pupillae muscle. (concomitant squint). The vision in the squinting
Ciliospinal reflex is abolished in lesions of eye, in the case of nonparalytic squint, is defective
cervical sympathetic nerves, affection of the upper from early childhood. In paralytic squint, the
thoracic and cervical segments of the spinal cord, abnormality may be obvious when the eyes are in
the medulla oblongata, and D1 root. the resting position and it becomes accentuated
when the eyes are turned in the direction of action
Note: The following points should be kept in mind of the paralysed muscle. The images of an object
before assessing the significance of pupillary fail to fall on corresponding points in the retina of
abnormalities. both eyes and this leads to diplopia. On the other
1. Ensure that no drugs are applied to the patient’s hand, in nonparalytic squint, the squint may be
eye, e.g. miotics such as pilocarpine and obvious at rest, but it remains the same in all positions
mydriatics such as homatropine. of the eyes. The movements of the affected eye are
2. If the pupils are unequal in size decide which normal on testing and there will be no diplopia.
side is the abnormal one. In the presence of In paralysis of medial rectus and superior
ptosis or weakness of the extraocular muscles, oblique muscles, the squint is divergent due to
the pupil in that eye is most likely to be the unopposed action of the lateral rectus, and in
abnormal one. paralysis of the lateral rectus, it is convergent due
to unopposed action of the medial rectus. Upward
Squint
or downward paralytic squint is rare. Sometimes,
Squint or strabismus is defined as abnormal position divergent squint may occur in high degree of myopia
or deviation of the eyes, resulting in loss of and in deep coma.
Chapter 32: Clinical Examination of the Nervous System 419
blurring or double vision which may occur and is designated by its fast phase because it is more
also in which position, the separation of the two easily recognizable than the slow phase.
images is greatest. Applying the following rules, “nystagmus to left” means the fast phase is to
the paretic extraocular muscle can be identified. the left and “nystagmus to right” means the
i. The distance between the true and false images fast phase is to the right of the patient.
will increase when the patient looks in the
Direction of Nystagmus
direction of action of the paretic muscle.
ii. The outer image is always the false image, The direction of the oscillatory movements of the
seen by the abnormal eye. This eye can be eyes may be horizontal, vertical or rotary.
identified by the color of the outer image. Both Rate
diplopia and squint tend to come down in
severity and may even disappear as time The rate of the oscillations is variable. It may be
passes. slow (10-40 oscillations/mt), medium (40-100/ mt),
or rapid (more than 100/mt).
NYSTAGMUS Amplitude
Nystagmus is defined as involuntary, usually If the amplitude of the oscillations of the fast phase
rhythmic oscillations of the eyes without an is less than 1 mm, it is described as fine nystagmus,
appreciable interval between consecutive oscil- if it is 1 to 3 mm, as medium nystagmus and if it
lations. Most often, it is a manifestation of disturbed is more than 3 mm, as coarse nystagmus.
ocular movement due to a neurological disease.
Sometimes, it may also result from disorders of Intensity
the eyes and vestibular apparatus. The basic defect This applies only to jerk nystagmus. This can be
in nystagmus is failure to maintain the eyes in a graded into 3 degrees:
certain position. First degree or grade 1: Nystagmus will be present
Whenever there is nystagmus, the following only when the patient looks towards the direction
aspects should be observed: of the fast phase of the nystagmus.
i. Type. Second degree or grade 2: Nystagmus will be
ii. Direction. present not only while looking in the direction of its
iii. Rate. fast phase, but also in the primary position of the
iv. Amplitude. eyes.
Chapter 32: Clinical Examination of the Nervous System 421
Third degree or grade 3: Nystagmus will be present muscle contraction of the agonist and antagonist
even when the patient looks in the direction opposite extraocular muscles, thereby keeping the eyes
to that of its fast phase. steady in different postures. If this balancing
mechanism is disturbed, the eyes tend to drift in
Duration
one or other direction which gives rise to the slow
Nystagmus may be unsustained, being noticeable phase. As a corrective phenomenon the eyes are
only for a very brief period or it may be sustained brought back to the neutral position as the quick
for longer periods. phase, only to drift back again. These cycles of
drift and corrective movements in opposite
Test
directions give rise to nystagmus.
Always look for nystagmus under good illumination. In many cases, the nystagmus is conjugate with
First observe the eyes in their primary position. In co-ordinated movement of both eyes. Occasionally
this position, congenital pendular nystagmus and it is dysconjugate with the eyes converging and
second degree jerk nystagmus can be detected. diverging or moving up and down in opposite
Then ask the patient to look for a few seconds at directions. Rarely, unilateral nystagmus occurs in
least, at your finger held at about 60 cm in front of conditions like amblyopic squint, astigmatism, high
his eyes, to the right and to the left of the midline, refractive error or internuclear ophthalmoplegia.
so that the eyes deviate not more than 30° from The cause of nystagmus may be a defect in
the primary position. Horizontal nystagmus is
Different Types of Ocular Fixation b. When there is supranuclear ocular palsy, i.e. gaze
Nystagmus paretic or true gaze nystagmus.
a. Hereditary nystagmus: This is a pendular nystagmus c. When the gaze is directed up or down or laterally
in forward gaze and horizontal jerk nystagmus in the absence of ocular palsies, i.e. gaze-evoked
on lateral gaze, manifesting within a few weeks nystagmus.
of birth and persisting throughout life. It shows • Gaze-type nystagmus. This occurs:
X-linked transmission. 1. When there is extraocular muscle
b. Latent nystagmus: This is a jerk nystagmus of paresis either due to a lesion in III, IV
both eyes which becomes evident only when or VI cranial nerve or due to myasthenia
one eye is occluded. The fast phase is towards gravis.
the nonoccluded eye. It is also probably a variety 2. When there is internuclear ophthalmo-
of hereditary nystagmus. Usually, it is associated plegia due to a lesion in the medial longi-
with strabismus and markedly reduced visual tudinal fasciculus (MLF).
acuity on occluding one eye. Nystagmus due to extraocular muscle paresis is
c. Occupational or miner’s nystagmus: This is a a jerk nystagmus that appears only when the eyes
rapid, rotary nystagmus that increases on upward are moved in the direction of action of the weak
gaze and decreases on downward gaze, seen extraocular muscle. The fast phase of the nystagmus
in persons who have worked for many years is always towards the side of gaze that evokes the
Part–I: Internal Medicine
under poor illumination such as in mines. nystagmus. Although the nystagmus is seen in both
eyes, it is greater in the eye with paretic muscle.
‘Neurological’ Fixation Nystagmus
Nystagmus due to a lesion in medial longitudinal
This nystagmus is mainly due to lesions in the fasciculus (MLF) is a jerk nystagmus confined
brainstem, the vision being normal. to the abducting eye brought on by attempting to
a. A pendular nystagmus on forward gaze which look to one side, the other eye does not adduct
changes into horizontal jerk nystagmus on lateral correspondingly, or does so only minimally.
gaze and vertical nystagmus on upward gaze, In these conditions, there is no true gaze paresis.
occurs rarely in brainstem demyelinating disease
and vertebrobasilar insufficiency. Internuclear Ophthalmoplegia
b. See-saw nystagmus is another rare type of This occurs when there is a lesion of the MLF
nystagmus characterized by pendular-rotatory usually in the pons or in the midbrain. On looking
nystagmus in which one eye moves up and to the side opposite to the lesion, the ipsilateral eye
rotates outwards and the other eye moves down stops short in adduction, whereas the opposite eye
and rotates inwards rhythmically. It is usually abducts, but shows nystagmus. The ipsilateral eye
seen in lesions of middle cranial fossa such as can adduct during convergence.
pituitary tumors compressing the optic chiasma In lesions higher up in the brainstem, the medial
and distorting the brainstem. The exact rectus nucleus will also be involved along with
mechanism of this nystagmus is not known. MLF and this results in total loss of adduction of
c. Periodic, alternating nystagmus is also rare and the ipsilateral eye both during lateral gaze to the
it is characterized by horizontal jerk nystagmus opposite side and during convergence.
which changes its direction spontaneously at The term ‘one-and-a half syndrome’ refers to
set intervals of about 90 seconds. It is seen in the condition where the lesion involves the MLF
lesions of lower brainstem. and the abducent nucleus on the same side. This
Nystagmus due to Defective Gaze Mechanism leads to internuclear ophthalmoplegia with loss of
abduction on the same side of lesion.
Pathological gaze related nystagmus occurs under
the following conditions: Gaze Paretic or True Gaze Nystagmus
a. When there is internuclear or infranuclear ocular This occurs when there is paresis of gaze due to a
palsy, i.e. ‘gaze type nystagmus’. lesion either in the frontomesencephalic pathway
Chapter 32: Clinical Examination of the Nervous System 423
or in the paramedian pontine reticular formation istically seen in lesions at the level of cranio-vertebral
(PPRF). Lesions in frontomesencephalic pathways junction such as Arnold Chiari malformation, basilar
produce either horizontal or vertical nystagmus invagination, foramen magnum meningioma and
depending on the type of gaze paresis whereas others. It results from an impairment of spinovesti-
lesions in PPRF produce horizontal nystagmus. The bular input. Lesions limited to lateral lobes of the
resultant nystagmus is a jerk nystagmus that cerebellum do not produce nystagmus.
develops only on deviation of the eyes, with fast
Nystagmus Due to Defective
phase towards the side of the gaze. If the
Vestibular Mechanism
nystagmus appears on gaze to the right and to the
left, at an equal distance from the primary position, This is called vestibular nystagmus. It may be
it is called symmetrical gaze-paretic nystagmus. peripheral when the lesion is in the labyrinth or
This is characteristic of multiple sclerosis and vestibular division of VIII cranial nerve or ‘central’
Friedreich’s ataxia. It also occurs in drug toxicity, when the lesion is in the vestibular nuclei or their
degenerative disease of brain and vascular and connections. Vestibular nystagmus is always a jerk
neoplastic diseases of the brainstem. On the other nystagmus, usually with a definite rotary component.
hand, if the horizontal nystagmus on gaze to the It can be first, second or third degree in intensity.
right and to the left are of different intensity and Peripheral vestibular nystagmus is always
occur at different distances from the primary horizontal and never vertical. It is always associated
position, it is called asymmetrical gaze-paretic with vertigo. It usually results from destructive
nystagmus, either there is no change in the capsule to terminate in the pretectal and superior
nystagmus or its direction reverses (inversion). collicular nuclei of the midbrain and paramedian
In infants and children in whom testing visual reticular formation in the pons (PPRF) on the
acuity by conventional methods may be difficult, opposite side, mostly crossing at the levels of III
normal OKN suggests that the vision is grossly and IV nerve nuclei.
normal. Normal OKN in a ‘blind’ person should Tests: Ask the patient to look steadily first at an
suggest hysterical blindness. object held at a distance of about 6 m and then
The slow phase of optokinetic nystagmus also a near one, such as his own finger held in front of
tests the slow pursuit movements of the eyes his eyes. Observe the movements of his eyes.
whereas its fast phase tests the rapid saccadic eye Inability to fixate and interruption of fixation are
movements. both abnormal.
Inability to fixate may be due to:
SUPRANUCLEAR MECHANISM 1. Disturbance of the fixation mechanism as a
OF EYE MOVEMENTS result of lesion in its pathway (impersistence
For normal vision, in addition to the visual pathways of gaze).
being normal, the objects in the environment should 2. Lack of effort.
be brought into the field of vision, both when they 3. Altered consciousness.
are stationary as well as moving in space. In order Interruption of fixation may be due to various
and rhythm of the eye movements in all directions. part in vertical saccadic movements. Fibers from
If the visual acuity is low, use a torch instead of your these areas in the frontal cortex pass through the
finger. anterior limb of the internal capsule as fronto-
mesencephalic tract, decussate in the midbrain and
Abnormalities of Pursuit Movements pass down to terminate in the pretectal region of
a. Unilateral parieto- Absence of pursuit the midbrain and pons and paramedian reticular
occipital lesion movement to the opposite formation of the pons (PPRF) of the opposite side.
side. The connections with the pretectal nuclei control
b. Unilateral lesion in the vertical saccadic movements and the
the occipitomesen- connections with the PPRF control the horizontal
cephalic pathway saccadic movements.
i. Before its Absence of pursuit move-
decussation ment to the opposite side Test
ii. After its Absence of pursuit move- Hold both your index fingers vertically about 60
decussation ment to the same side. cm in front in the same horizontal plane as the
c. Bilateral lesions in The pursuit movements eyes, one on either side of the midline, in the mid-
the occipitomesen- cannot be tested because lateral position of the visual field. Instruct him to
cephalic pathway of visual loss, that is fix the gaze first on one index finger and then shift
usually associated it rapidly to the other index finger, when he is asked
Part–I: Internal Medicine
A B
Figs 32.13A and B: Testing saccadic movements of the eye. (See text for description)
d. Horizontal gaze palsy: respective centers or nuclei in the pons and medulla,
i. To the hemiplegic side Frontal lobe, where the medial longitudinal fasciculus (MLF)
thalamus or midbrain lesion, contralateral connects these areas to PPRF and nuclei of III,
to the hemiplegic side IV and VI cranial nerves.
ii. To the normal side
Tests
Pontine lesion (PPRF), contralateral to
Part–I: Internal Medicine
A B
Figs 32.14A and B: Eliciting doll’s eye movements—description in text
and vertical movements of the eye, by bending the middle cranial fossa. The peripheral processes
and extending the neck. of the neurons in the ganglion group together to
Test: Hold the patient’s head with both hands, form 3 divisions, ophthalmic or first division:
keeping his eyelids open with your thumbs. If he maxillary or second division and mandibular or third
division.
nucleus and the motor nucleus. The main sensory ascend along with the medial lemniscus to terminate
nucleus is situated in the posterior part of the pons in the ventral posteromedial (VPM) nucleus of the
and is continuous below with the spinal nucleus. thalamus. The axons of the second order neurons
The spinal nucleus extends from the pons down in the main sensory nucleus are both crossed and
through the whole length of the medulla oblongata uncrossed and they also terminate in the VPM
and into the spinal cord as far as the second cervical nucleus of the thalamus. The central connections
segment. The mesencephalic nucleus is situated of the mesencephalic nucleus are not well established
in the lateral part of the grey matter around the but probably they project to the cerebellum. From
cerebral aqueduct in the midbrain and extends the VPM nucleus of the thalamus, the thalamo-
inferiorly into the pons as far as the main sensory cortical fibers travel through the internal capsule
nucleus. The motor nucleus is situated in the pons, to the lower part of the postcentral gyrus of the
medial to the main sensory nucleus. cerebral cortex.
Sensory Component of the Trigeminal Nerve Motor Component of the Trigeminal Nerve
The sensations of touch, pressure, pain, temperature The motor nucleus of the trigeminal nerve supplies
and proprioception from the face are carried by the muscles of mastication (temporalis, masseter,
axons in the three peripheral divisions of the the medial and lateral pterygoid muscles), the
trigeminal nerve whose cell bodies are situated in tensor tympani, tensor veli palatini, mylohyoid and
anterior belly of the digastric. The motor nucleus
Part–I: Internal Medicine
A B C
Figs 32.16A to C: Palpating contractions (A) Temporalis, (B) Masseter, (C) movement of the jaw by pterygoids
432 Section 11: Neurology
Normally, the chin should move on the opposite side is stimulated. In unilateral facial
downwards in the midline. Deviation to either nerve palsy, the paralyzed side does not blink but
side indicates weakness of the lateral pterygoid the eye on normal side does so on stimulating the
of the side to which the chin deviates. While cornea of either side.
opening the mouth the lateral pteygoid muscle Note:
pushes the jaw to the opposite side and i. Touch both upper and lower parts of the
balanced action of both these muscles keep cornea while testing the corneal reflex
the jaw in the midline. because at times the lower part of cornea may
Minor deviation of the jaw can be detected be supplied by the maxillary division.
by comparing the relative positions of the ii. Bring the wisp of cotton from the lateral side
middle of the chin and the upper central incisor and not from the front to avoid defensive eye
teeth which should all be in the same line. blinking even before the cornea is touched.
The strength of the lateral pterygoid iii. Do not wipe or rub the corneal surface with the
muscles can also be assessed by asking the cotton wool, so as to avoid injury to the cornea.
patient to open his mouth while applying
The Conjunctival Reflex
resistance to the chin from below.
iii. Side to side movement of the jaw (lateral and This is elicited by touching the bulbar conjunctiva.
medial pterygoid muscles): Ask the patient to Both corneal and conjunctival reflexes have the
same pathway and clinical significance, but the
Part–I: Internal Medicine
iii. Unilateral lesion Marked weakness, situated deep in the pons. That part of the nucleus
in motor nucleus wasting and fascicu- which supplies the muscles of the lower part of
(LMN paralysis lations of the muscles the face receives corticonuclear fibers only from
of mastication on the contralateral cerebral hemisphere, whereas that
the side of the lesion. part of the nucleus which supplies the muscles of
Absence of jaw jerk and the upper part of the face receives corticonuclear
normal corneal reflex. fibers from both cerebral hemispheres. This accounts
iv. Unilateral infra Same as in nuclear for the fact that in unilateral upper motor neuron
nuclear lesion lesion, but fascicul- (UMN) type of facial palsy only the lower part of
in the motor root ations are rare. the face is affected on the opposite side. The
or mandibular superior salivatory and lacrimal nuclei, which are
division (LMN parasympathetic, lie posterolateral to the motor
paralysis) nucleus. The sensory nucleus is the upper part of
the nucleus of the tractus solitarius and lies close
Sensory Loss to the motor nucleus. Sensation of taste from the
i. Unilateral lesion in Loss of tactile sensation anterior 2/3 of the tongue travels through the chorda
the main sensory only over the face on the tympani to the sensory nucleus. The fibers from
nucleus side of the lesion. the facial nucleus wind round the abducent nucleus
ii. Unilateral lesion in Loss of pain and temp- in the pons and emerge from the brainstem at the
pressure from the face. However, it does not carry palsy, the angle of the mouth on the affected
any superficial sensation from the face. side will not move as much as the normal side.
The superior salivary nucleus supplies the 5. Ask him to purse his lips tightly against resistance.
submandibular and sublingual salivary glands and This tests power of orbicularis oris muscle.
the lacrymal nucleus supplies the lacrymal gland. 6. Ask him to blowout his cheeks keeping his
mouth closed. Tap or press with your finger on
Tests for the Facial Nerve the inflated cheek, first on one side and then on
the other. Normally air should not escape through
Motor Part
pursed lips. Escape of air on one side points to
Muscles of facial expression, orbicularis oculi, weakness of the buccinator muscle. Weakness
frontal belly of occipitofrontalis, buccinator, of buccinator also leads to collection of food
orbicularis oris, mentalis and platysma can be tested material between the cheek and teeth on the
separately. affected side during eating (Figs 32.17 and
1. Observe the patient’s face for any abnormality 32.18).
or asymmetry between the two sides when he 7. Ask him to clench his teeth and simultaneously
is at rest and when he is talking, smiling and attempt to depress the corners of the mouth
blinking. In facial palsy the face on the affected downwards as if he is grimacing. This tests
side will be flatter, nasolabial fold is obliterated contraction of the platysma muscle. Longitudinal
and angle of the mouth is at a lower level due to folds of skin become visible in the neck when
Part–I: Internal Medicine
A B
Figs 32.17A and B: Testing the superficial muscles of the face
(A) Frontalis, (B) Orbicularis oculi (arrow) and orbicularis oris (star)
trigeminal nerves, center is in the pons and facial palsy so that the whole cornea goes under
efferent is through the facial nerves. It is absent the upper eyelid. This exaggerated response is
in LMN facial paralysis and is exaggerated in called Bell’s phenomenon. In UMN type of facial
UMN facial paralysis. It is also exaggerated and palsy, Bell’s phenomenon does not occur.
persistent in parkinsonism (Fig. 32.19). 6. Orbicularis oris reflex(Snout reflex): Normally,
5. Palpebral-oculogyric reflex (Bell’s phenomenon) percussion with a finger over the lateral part of
Normally, while attempting to close the eyes, the upper lip or by the side of the nostril results in
the eyeballs roll up reflexly equally on both sides. elevation of the upper lip and angle of the mouth.
The afferent is through the proprioceptic fibers V nerve is the afferent and VII, the efferent. This
of the facial nerve and the center is the portion reflex is exaggerated in UMN type of facial palsy
of the third cranial nerve nucleus supplying the and also in extrapyramidal disorders. If both the
superior rectus, levator palpebrae superioris and upper and lower lips protrude, it is called “snout”
inferior oblique muscles which are the effectors. reflex, which occurs in bilateral UMN type of facial
This response is exaggerated on the side of LMN paralysis and some cases of dementia (Fig. 32.20).
436 Section 11: Neurology
Fig. 32.19: Orbicularis oculi reflex (glabellar reflex) (see Fig. 32.20: Snout reflex (See text for description also
text for description page 463) refer to the page primitive reflexes page 463)
Table 32.14:
LMN and UMN type of facial palsy
The lesion in the facial nerve pathway may be either
Clinical features LMN lesion UMN lesion
in
Degree of weakness Usually dense Usually partial paresis
i. its nucleus, paralysis
ii. in the peripheral portion of the nerve, or Extent of paralysis Both upper and lower Only lower part of face,
iii. in its corticonuclear connections. Nuclear and part of face on the contralateral to the
nerve lesions cause LMN paralysis. Supranuclear side of lesion side of lesion
(corticonuclear) lesions cause UMN paralysis. Watering from the Present May not be present
eye
Features that distinguish these two types are
Voluntary Lost Lost
given in Table 32.14. movements of
facial muscles
LMN Type of Facial Paralysis
Emotional movements Lost Preserved and even
A. Nuclear lesion: Lesions in the pons may affect of facial muscles exaggerated
the nucleus of facial nerve. They are almost Taste sensation in Lost in lesions Present
always accompanied by other cranial nerve the anterior 2/3 of proximal
the ipsilateral half to geniculate
palsies especially the sixth. Long tract signs-
of the tongue ganglion
both motor and sensory are present on the
Corneal reflex Lost Usually preserved
opposite side, leading to crossed hemiplegia. Glabellar reflex Absent Exaggerated
The common causes are infarction, hemorrhage, Orbicularis oris reflex Absent Exaggerated
demyelinating diseases and tumors occurring Bell’s phenomenon Present Absent
in the pons. Common association LMN palsy of other Often this is part of
cranial nerves hemiplegia
B. Infranuclear lesions
i. Involvement of the facial nerve after its
emergence from the pons and before it present. The common lesions are acoustic
enters the facial canal in the petrous neurinoma, cysts, metastatic deposits and
temporal bone is usually due to lesions in abscess in the cerebellopontine angle region.
the cerebello- pontine angle. In such cases ii. Involvement of the nerve within the petrous
the facial palsy is associated with affection temporal bone. The facial nerve is affected
of VIII, ophthalmic division of V and other in its intrapetrous course by lesions such
lower cranial nerves on that side (Table as fractures, osteomyelitis, otitis media and
32.15). Cerebellar signs may also be metastatic deposits.
Chapter 32: Clinical Examination of the Nervous System 437
Clinical features of different sites of tumors of the parotid gland, fracture of facial
Table 32.15:
lesions in the facial canal bones, surgical trauma and chronic granulomas
LMN facial Loss of taste Hyperacusis such as leprosy.
palsy in anterior
2/3rd of
In India, leprosy is a common cause of isolated
tongue affection of one or more branches of the facial
* Lesion between + + – nerve. This may affect the upper branches
internal auditory selectively.
meatus and
geniculate ganglion Upper motor neurone (UMN) type of facial palsy:
Lesion at or just + + + This may take three forms:
proximal to geniculate i. Volitional type: Loss of voluntary contraction
ganglion
of facial muscles with preservation of mimetic
$ Lesion between + + +
nerve to stapedius movements.
and ganglion of ii. Mimetic type: Loss of involuntary contraction
facial nerve of facial muscles during smiling, crying, etc.
Lesion between + + – (mimetic movements) with preservation of
chorda tympani
and nerve to stapedius voluntary movements.
Lesion at stylom + – – iii. Mixed type: Both volitional and mimetic
astoid foramen movements are lost.
Fig. 32.21: Right facial palsy (LMN) showing weakness of Fig. 32.22: Bilateral facial palsy occurring in Guillain-Barre
upper part (absence of wrinkling and defect in eye closure) Syndrome. Note the defect in eye closure and horizontal
and weakness of lower part (deviation of angle of mouth position of angles of mouth (Patient was given command
to left) typical Bell’s palsy to close the eyes and smile)
438 Section 11: Neurology
This is due to faulty reinnervation during recovery of numbers or letters and ask him to repeat the
phase. Its presence suggests chronic LMN type same as you whisper. Give ten such numbers or
of facial paresis. letters. Repeat the test on the opposite side by
turning the patient so that the other ear to be tested
VESTIBULOCOCHLEAR NERVE—VIII faces towards you. If hearing is normal, the person
CRANIAL NERVE should be able to repeat at least 9 out of 10 letters
or numbers. Whispering test cannot differentiate
Applied Anatomy conduction deafness from nerve deafness. Similarly,
It is a purely sensory nerve concerned with hearing a conversational voice should normally be heard
and equilibration. Vestibulocochlear or the eighth at 3.5 m.
cranial nerve consists of two distinct divisions—
the vestibular division which is concerned with Tuning Fork Test
sense of movement, position and balance and the The tuning fork helps not only to detect deafness
cochlear division, concerned with hearing. but also to differentiate conduction deafness
The vestibular nerve fibers arise from the utricle, from nerve deafness. Tuning fork with a frequency
saccule and the semicircular canals in the internal of 256Hz and above is used.
ear, pass proximally in the vestibulo cochlear nerve a. Rinne’s test: Place the base of the vibrating
through the cerebellopontine angle and enter the tuning fork on the mastoid process of the
patient. The sound will be heard by the patient
Part–I: Internal Medicine
Ataxic Gait
This is of two types, namely gait of sensory ataxia,
due to a lesion in proprioceptive pathways and gait
of cerebellar ataxia, due to a lesion in cerebellum
and its connections.
Fig. 32.28: Tandem walking (See text for description)
Gait of sensory ataxia: If the proprioceptive deficit
is mild, the gait may not be abnormal when the
Spastic Gait
patient walks with eyes open but it becomes
abnormal when he is asked to walk with his eyes This is seen in upper motor neuron lesions
Part–I: Internal Medicine
closed. He may complain that towards evening affecting the limbs. Depending on whether the lesion
when it becomes dark his walking becomes is unilateral or bilateral, the gait also differs.
difficult. When the deficit is severe, even with his Hemiplegic Gait
eyes open, the gait is irregular and jerky with a
broad base. The heel touches the ground before This type of gait is seen in hemiplegia. The affected
the toes with a slapping or stamping sound. This is lower extremity is extended at the hip and knee,
called stamping gait. The patient closely looks at the ankle and toes are plantar flexed. The affected
his feet and the floor while walking, to maintain foot is dragged, scraping the floor by the toes.
posture. The pelvis is tilted upwards on the involved side in
order to clear the foot off the ground while walking.
Gait of cerebellar ataxia: Abnormalities occur The entire stiff lower extremity is swung around
when the patient walks, irrespective of his visual in a semicircle from the hip towards the midline.
input. In lesions of the midline cerebellar structures The upper extremity is adducted at the shoulder
or vermis, the gait is staggering, unsteady, irregular and flexed at the elbow, wrist and interphalangeal
and wide-based, with a tendency to sway to either joints. The patient can turn towards the affected
side or anteroposteriorly. With unilateral cerebellar side and walk sideways towards the affected side
hemisphere lesions and vestibular lesions the patient more easily than towards the normal side. When
tends to sway and deviate towards the affected the lesion is mild, the only recognizable abnormal-
side. When the patient is made to walk in a straight ity may be dragging of the foot, shorter steps, and
line drawn on the floor and on tandem walking, absence of associated movements of the upper
i.e. walking by placing the heel of one foot just in extremity on the affected side.
front of the other. The abnormalities are exaggerated
and tandem walking may be impossible (Fig. 32.28). Spastic Paraplegic Gait
If the patient is asked to walk around a chair in The lower limb shows the same abnormalities as
both directions, always he tends to fall towards is seen in hemiplegic gait, but on both sides. In
the side of the lesion. When he is asked to walk addition, in severe cases, due to spasm of adductor
6 to 8 steps forwards and then backwards muscles of the thighs, the knees may cross in front
repeatedly with his eyes closed, he gradually turns of each other during walking. This is called
towards the affected side (compass gait). scissors gait. The upper limbs are not involved.
Chapter 32: Clinical Examination of the Nervous System 445
A B
Figs 32.32A and B: Testing the muscle tone (A) Passively flexing the elbow. Note the tone of the extensors;
(B) Passively extending the elbow. Note the tone of the flexors (See text for description)
Abnormal Movements
Ask the patient to grasp your hand or finger firmly
for about 5 seconds and then release the grip A variety of characteristic abnormal movements
suddenly. Persistence of the grip or its slow (or hyperkinesias) resulting from involuntary
relaxation in spite of the patient’s efforts to release, contractions of voluntary muscles occur in several
suggests myotonia. Normal persons will be able to neurological disorders.
grip and relax quickly on command. Hyperkinesias may affect any part of the body.
They may result either from organic neurological
Percussion Myotonia lesions or they may be psychogenic. Metabolic
Tap sharply over the thenar eminence, brachioradialis, abnormalities such as hepatic failure, respiratory
deltoid, quadriceps or calf muscles with a failure, and uraemia and side effects caused by
percussion hammer. If myotonia is present the certain drugs (phenothiazines, reserpine, salbutamol
depression produced by muscle contraction persists and others) also lead to abnormal movements in
for several seconds. In the case of thenar eminence the absence of primary neurological disease.
opposition of the thumb develops and it persists The following points should be noted when
for several seconds before relaxing. Myotonia can abnormal movements are present:
be demonstrated in the tongue by percussing over 1. The part involved.
the tongue, protruded over a wooden spatula kept 2. Rate, range, rhythm, speed and amplitude of
under the tongue, to prevent injury from the teeth. the movements.
Myotonic reaction may be localized to certain 3. Whether they are present at rest, on adopting
group of muscles or it may be generalized. It is particular postures, or during voluntary activity.
better elicited after a period of relaxation and 4. The influence of fatigue, emotional tension,
it tends to reduce with repeated contractions of attention by others and sleep on these
the affected muscles. Exposure to cold evokes or movements.
enhances myotonia. 5. Whether the movements are stereotyped or
Hereditary conditions showing myotonia are constantly changing in pattern.
myotonia congenita, dystrophia myotonica, Those abnormal movements which fit into a
hyperkalemic periodic paralysis, paramyotonia and specific clinical description include tremors, chorea,
chondrodystrophic myotonia. Myotonia occurs in athetosis, myoclonus, hemiballism, dystonia,
acquired disorders such as myxoedema and vitamin spasms, convulsions, tics, cramps and fasciculations.
Chapter 32: Clinical Examination of the Nervous System 449
If the pattern does not fit into the classic types it is activity. These tremors may be of medium amplitude
better to describe the movement clearly, for clinical and regular or they may be coarse, irregular and
purposes. jerky. They can be demonstrated by making the
patient touch the tip of his nose with his finger
Tremors
(finger-nose test). Tremors which occur only at
Tremors consist of a series of involuntary, rhythmic, the end of voluntary action are called ‘terminal
regular and rapid oscillatory movements that result tremors’. This type of tremors are characteristically
from the alternate contraction and relaxation of seen in cerebellar lesions.
opposing groups of muscles. It is called ‘simple Postural tremors are fine and more rapid than
tremor’ when only one muscle group and its resting tremors, occurring at the rate of 8 to11/
antagonist produce the involuntary movement. sec. They can be brought out better by maintaining
‘Compound tremors’ result from contraction of the limb in a particular posture, e.g. keeping the
several groups of muscles and their antagonists, upper limbs and hands outstretched. They usually
producing a series of complex movements. Tremors disappear during voluntary movements and at rest.
may affect whole body or only a part. The rate of Familial tremor occurs in family members. This
the oscillatory movement may be 3 to 5/ second worsens during voluntary activity but disappears
(slow tremors), 5 to 10/ second (medium tremors) at rest. Benign tremors (essential tremors) are
or 10 to 20/ second (rapid tremors). Their range similar to familial tremors, but occur sporadically
may be fine, medium or coarse. The tremors may
Athetosis Dystonias
These are involuntary, irregular, semirhythmic, Dystonia is an abnormal involuntary movement
writhing movements which are slower in rate, characterized by sustained muscle contractions,
larger in range and more sustained than choreic frequently causing twisting and repetitive
movements, usually involving the distal parts of movements or abnormal postures. Dystonic
the extremities. Characteristically these movements movements are usually slow, but quick components
result in a combination of flexion, extension, may also coexist causing confusion with myclonic
abduction, adduction, pronation and supination in jerks. They are arrhythmic and tend to aggravate
varying degrees. These movements become with stress, fatigue and emotional upset but are
exaggerated during voluntary activity and are relieved by sleep and rest. An interesting feature of
associated with increased tone of the limbs. These dystonia is the patient’s ability to suppress the
movements may be congenital in origin or caused movement by a sensory trick that is usually tactile
by acquired disorders of the caudate nucleus and or proprioceptive. According to the site of
putamen. involvement dystonia may be classified as
Involuntary movements which share the i. Focal,
characteristics of chorea and athetosis are called ii. Segmental,
choreoathetoid movements. Athetosis and similar iii. Multifocal,
abnormal movements are included under the term iv. Hemidystonia or generalized.
Part–I: Internal Medicine
dystonias. Spasms
Myoclonus These are involuntary contractions of a single
muscle or group of muscles. Spasms can be of
It is an involuntary, abrupt, brief and rapid, jerky two types-clonic and tonic. Clonic spasms are
movement of a part of a muscle, entire muscle or rapid, brief, repetitive contractions often resulting
a group of muscles. These movements are in movements of the affected part. Tonic spasms
nonrhythmic, may be single, and random or are prolonged or sustained contractions often
repetitive. They may affect a part of the body or resulting in either alteration of posture or limitation
the whole body. They may occur at rest or during of movement. A painful, tonic spasm of a muscle
motor activity but are generally decreased during is called ‘cramp’. Spasms usually result from irritation
voluntary movement. They are seen in acute, of nerve fibers. Local painful conditions may lead
subacute and chronic encephalitides, toxic, to tonic or clonic muscle spasm with reflex rigidity.
metabolic and hypoxic encephalopathies, and Mechanical stimulation of muscle may also
degenerative diseases of the brain. They may also produce a focal spasm. Tetanus and tetany produce
occur rarely in diseases of spinal cord, spinal roots, characteristic muscle spasms due to hyperir-
and peripheral nerves. These movements may also ritability of the nerves and muscles. Facial spasms
be a part of seizure disorders. Myoclonic jerks are brief, repeated, clonic contractions of any of
unassociated with other neurological abnormalities the muscles supplied by the facial nerve. Spasm
occurring during sleep, particularly in children may affecting the orbicularis oculi muscle selectively
be seen in the absence of organic disease. is called ‘blepharospasm’.
Hemiballism Tics (Syn: Habit Spasm)
These are unilateral, purposeless, involuntary Unlike spasms, tics are of psychogenic origin. A
movements of larger amplitude, greater force and tic is a well co-ordinated, semipurposive, repetitive
higher rate than choreic movements. Predominantly act, involving a group of muscles. Although tics
they affect the proximal portions of the limbs. The start initially due to physical or emotional stress,
face and trunk muscles are generally spared. later on they become stereotyped, brief, repetitive,
Hemiballism is caused by vascular lesions of the involuntary movements occurring at irregular intervals.
contralateral subthalamic nucleus or its connections. These movements can be suppressed to a certain
Chapter 32: Clinical Examination of the Nervous System 451
extent by voluntary effort, but they are usually muscles varies, according to their physiological
compulsive in nature and aggravated by emotional requirements. In general, the larger the muscle,
stress. the greater the muscle power. However, there are
exceptions to this statement. For instance, the
Convulsions
power generated by the muscles of mastication in
These are violent, shaking, rhythmic movements closing the jaws is considerably greater than the
caused by spasmodic alternating contraction of power generated by some of the larger muscles
agonist and antagonist groups of muscles, often like pectoral muscles. In disease states such as
caused by irritative lesions in the brain. They are muscular dystrophies, pseudohypertrophied
characteristically seen in generalized tonic-clonic muscles are weak in spite of their larger size. In
epilepsy with the sequence of tonic, clonic and disuse atrophy following prolonged immobilization
postictal stages. Convulsions may affect either a of a limb, though the muscle size is reduced, power
part of the body (partial) or the whole of it is relatively preserved to a greater degree.
(generalized). Convulsions can also be seen in There are two alternate methods to test the power
metabolic conditions such as hypoglycemia, of muscles.
hypocalcemia, uraemia and others. i. Patient initiates the contraction and continues
Fasciculations to do so against resistance offered by the
examiner.
These are fine, flickering, irregular, inconsistent, ii. Muscle to be tested is made to contract fully
uncooperative children, classical method of testing cerebellar lesions do not impair muscle power per
is not possible. In them the following points should se, they interfere with voluntary movement
be observed to assess muscle power. considerably. Since full testing of individual
• Does he move the limbs voluntarily or muscles is time consuming, taxing to both patient
spontaneously? and the examiner, and often unnecessary, a rapid
• Does he withdraw a limb purposefully to painful assessment of muscle power can be made by a
stimulus. If he does so, is the movement “mini muscle power testing”.
vigorous or weak?
• Are the spontaneous or withdrawal movements Mini Muscle Power Testing
symmetrical or asymmetrical on both sides? We suggest this as a short, quick, systematic
• In a comatose patient, when the limb is lifted method to assess muscle power, suitable for routine
from the bed and dropped, does it just drop down survey.
or is there any resistance?
Before attributing weakness of muscles to Movements to be Tested
neurological causes, several non-neurological
Upper Extremities
conditions which reduce strength of contraction
have to be excluded. These include painful Hand grip, flexion and extension at wrists, flexion
conditions, deformities of joints, involuntary and extension at elbow, pronation and supination
movements and extreme degrees of spasticity and of the forearm, abduction, adduction, flexion and
rigidity. (Figs 1 to 28). extension at the shoulders.
contraction of abdominal muscles which can be without involvement of the face. This is due
seen to contract and can be palpated. If the upper to UMN lesion.
or lower abdominal muscles are paralysed the 2. Monoplegia: Paralysis of all muscles in one
umbilicus is pulled by the actively contracting limb, either upper (brachial monoplegia) or
muscles towards their side. This is called ‘Beever’s lower limb (crural monoplegia).
sign’. A rapid assessment of the power of the 3. Bilateral hemiplegia (Syn: tetraplegia):
proximal muscles of the lower limb can be made by Paralysis of upper and lower limbs on both
asking the patient to get up from the sitting position sides with poor head and trunk control.
and walk. 4. Quadriplegia: Paralysis of all four limbs and
the trunk due to upper or lower motor neuron
Detailed Muscle Power Testing lesions.
Power of individual muscles should be tested under 5. Paraplegia: Paralysis of both lower limbs due
the following situations: to upper or lower motor neuron lesions.
a. If there is restricted weakness in one group of Diplegia is a special form of congenital
muscles in a limb on mini muscle power testing. paraplegia in which the lower limbs are very
b. If there is differential weakness of muscles, i.e. spastic and considerably more affected than
some muscles are more affected than the others the upper limbs. This is caused by bilateral
and some others are completely spared, and cortical lesion.
c. If the history and physical examination suggests 6. Paraplegia in flexion: The paralysed lower
Contd...
Chapter 32: Clinical Examination of the Nervous System 455
Contd...
Reflex Afferent pathway Center Efferent pathway
Testing Muscle Stretch Reflexes to clench his jaws tightly or to press the sale of
(Table 32.17) the foot strongly against the foot board of his bed.
Sometimes, reflexes may become elicitable only
Note: In the following description (Table 32.17), after applying reinforcement techniques and such
all the reflexes are elicited with the patient in supine reflexes can be taken as normal. Even after
position in bed. Depending on the convenience of reinforcement if a reflex cannot be elicited, it has
the patient and the examiner, other postures can pathological significance.
be adopted.
Clonus
Reinforcement of Muscle Stretch Reflexes This term denotes a series of rhythmic, involuntary
muscle contractions, induced by sudden passive
When a reflex is difficult to elicit in spite of good stretch of a tendon. At times, it may occur
relaxation of the muscles concerned, and spontaneously too. A true clonus persists as long as
employing correct technique of elicitation, effort the stretch on the muscle is maintained. This occurs
should be made to reinforce the reflex, before in extensive UMN lesions, and is always associated
concluding that it is absent. By reinforcement the with exaggerated muscle stretch reflexes and
threshold for muscle contraction is diminished and spasticity. Instead of sustained clonus a few ill
the contraction is elicited better. sustained clonic movements may be present at the
For reinforcing the reflexes in the lower limbs start of the muscle stretch which soon fade out
the patient is instructed either to hook the fingers even when the stretch is maintained. Such clonic
of one hand to those of the other and then strongly movements are irregular in rate and rhythm. This
pull them apart (Fig. 32.36) or to make a fist is called pseudoclonus. Several non-neurological
forcefully, while eliciting the reflexes. To reinforce conditions that are associated with brisk muscle
the reflexes in the upper limbs, the patient is asked stretch reflexes, do not produce true clonus.
456 Section 11: Neurology
Table 32.17: Method to elicit muscle stretch reflexes (Figs 32.33 to 32.38)
Reflex Method Normal responses Abnormality and remarks
1. Jaw reflex Ask the patient to open his mouth No contraction or mild contraction Absence of jaw reflex may not be
partially. Keep your left index finger not strong enough to produce any significant since it may occur in normal
horizontally on the patient’s chin gently appreciable movement of the jaw persons. Exaggerated response occurs
pressing it downwards. Strike on your in bilateral UMN lesion of fifth cranial
finger with the knee hammer bringing nerve. Unilateral UMN lesion does not
it from above downwards. Watch the affect this reflex grossly
movement of the lower jaw
2. Biceps reflex Keep the elbow flexed to 30-40º and Contraction of biceps-flexion of Absent response—no contraction of
resting on the bed while forearm and forearm at the elbow—to some biceps, no flexion or supination of the
hand rest relaxed on the abdomen. degree, supination of forearm forearm. LMN lesions at C5,6 spinal
Place your left index and middle fingers segments or roots. Exaggerated
on the biceps tendon with sufficient response—exaggerated flexion and
pressure to stretch the biceps tendon. supination of the forearm along with
Strike on your fingers with the hammer flexion at the wrist and fingers and
(Fig. 32.33A) adduction of the thumb. UMN lesion
above C5 spinal segment
3. Supinator reflex Keep the upper limbs in the same Contraction of brachioradialis- Absent response—no contraction of
(Syn: brachioradialis position as for biceps reflex except that flexion of the forearm at the elbow brachioradialis, no flexion or supination
reflex, radial the forearms should be kept in and supination of the forearm of the forearm—LMN lesion at C5,6
periosteal reflex) midpronation. Strike directly on the may occur spinal segments or roots. Exaggerated
distal portion of radius just proximal to response—exaggerated flexion or
the styloid process. Observe the supination of the forearm, along with
Part–I: Internal Medicine
movement and palpate the flexion at the wrist and fingers and
brachioradialis muscle (Fig. 32.33B) adduction of the thumb. UMN lesions
above C5 spinal segment. Inverted
response—no flexion or supination of the
forearm. Only marked flexion at the wrist
and fingers due to a lesion at C5 spinal
segment involving the pyramidal tracts
as well
4. Triceps reflex Keep the upper limbs in the same Contraction of the triceps muscle— Absent response—no contraction of
position as for biceps reflex. With your extension of the forearm at the triceps, no extension of the forearm.
left hand hold the patient’s wrist and elbow LMN lesion at C6,7 spinal segments or
pull the forearm slightly towards midline roots
so that the elbow is lifted slightly above Exaggerated response—exaggerated
the bed. Strike the triceps tendon with extension of the forearm, UMN lesion
the hammer and watch for contraction above C6 spinal segment. Paradoxical
of triceps and extension at the elbow flexion response—instead of of extension,
(Fig. 32.33C) flexion of the forearm takes place due
to unopposed action of normal biceps
muscle. Lesion at C6,7 spinal
segments
5. Finger flexion reflex Hold the patient’s hand with your left Gentle flexion of fingers or no The reflex may be exaggerated or
C8-T1 spinal segments hand so that his palm faces up and your response on both sides asymmetrical between the sides. This
and roots. palm faces down producing slight reflex does not give any additional help
Median and ulnar extension at the patient’s wrist and in neurological localization, but
nerves. Flexor flexion at the metacarpophalangeal and exaggeration or asymmetry should
digitorum interphalangeal joints. Ask him to rest suggest UMN lesion on the abnormal
profundus muscle the weight of his forearm and hand on side above C5
your hand. Tap lightly the dorsum of
your fingers with the hammer. Observe
and feel the movements of his fingers
6. Hoffman’s reflex Hold the sides of middle phalanx of the No visible movements of the other Exaggerated flexion of fingers and
C8- T1 spinal middle finger of the patient between fingers or thumb thumb or asymmetrical response on
segments and roots, your left thumb and index finger. Hold both sides occurs in UMN lesion, above
median. Flexor terminal phalanx of the same finger with C8. This has no additional localizing
digitorum your right thumb and index finger and value
profundus muscle suddenly and forcefully flex it at the
terminal interphalangeal joint.
lmmediately release the terminal
phalanx so that it pops up into extension.
Watch the movements of other fingers
and thumb (Fig. 32.34)
Contd...
Chapter 32: Clinical Examination of the Nervous System 457
Contd...
Reflex Method Normal responses Abnormality and remarks
7. Knee reflex Keep the hip and knee slightly flexed to Contraction of the quadriceps Absent response—no contraction of the
(Syn: Quadriceps 30-45º and support the limb at knee muscle extension of the leg at the quadriceps, no extension of the leg.
femoris reflex) with your left forearm or hand and ask knee LMN lesion at L2,3,4 spinal segments
the patient to relax the limb muscles by Note: This was the first MSR to be or roots
allowing his limb to rest completely on introduced into clinical neurology. Brisk response—extension of the leg is
your hand. Strike the patellar tendon Hence, the percussion hammer abrupt and amplitude of movement is
with hammer, watch for quadriceps came to be known as ‘knee’ larger. Exaggerated response—in
contraction and movement of the leg hammer addition to the extension of the leg. There
(Fig. 32.35A) will be adduction of the thigh on the
same side and occasionally on the
opposite side also. Sometimes,
extension of the leg on the opposite side
may also occur
The best position to elicit knee reflex
is with the leg hanging down freely from
the edge of the bed. Pendular
knee jerk occurs in cerebellar
diseases. This phenomenon can be
demonstrated only with the leg hanging
down (see page 464)
8. Ankle reflex Keep the lower limb slightly flexed and Contraction of calf muscles, i.e. Absent response—no contraction of
A B C
Figs 32.33A to C: Testing the reflex in the upper limb. (See text for details). The arrows show the
direction of jerk of the forearm (A) Biceps reflex, (B) Supinator reflex, (C) Triceps reflex
458 Section 11: Neurology
A B
Figs 32.35A and B: (A) Eliciting knee reflex; (B) Eliciting ankle reflex (See text for details)
Table 32.18:
Characteristics of muscle stretch Bilateral, symmetrical brisk or exaggerated MSR
reflexes of various grades are pathological if they are associated with muscle
Parameter Diminished Brisk Exagge- Hyperactive weakness, spasticity, extensor plantar responses and/
rated or true clonus.
Speed Variable Increased Increased Decreased
(latent period) Note: Although clinically, hyperreflexia in UMN
Range of Decreased Normal Increased Increased lesions is accepted as due to damage to the
movement pyramidal tracts, pathophysiologically, it is the
Duration of Decreased Normal Increased Increased result of damage to the reticulospinal and vesti-
contraction bulospinal tracts which descend along with the
pyramidal tracts.
Based on these observations a reflex is
subjectively graded and expressed according to any Qualitative Changes in Muscle
of the three grading systems given below: Stretch Reflexes
1. Inversion of MSR: This is an abnormal
1 2 3 Remark phenomenon in which, when a MSR is elicited,
Absent 0 0 No contraction is elicited instead of the expected muscle group
even on reinforcement contracting, another group of muscles
Diminished 1 + Slow and mild contracts, e.g. inversion of supinator reflex.
This phenomenon occurs due to a combination
into clonus, as long as the stretch on the tendon is reflex arc. Sometimes in obese individuals and those
maintained (Fig. 32.38). with lax abdominal walls the movement of the
Wrist clonus: This can be elicited by suddenly umbilicus may not be visible. Still the contraction
hyperextending the wrist and maintaining the stretch of abdominal muscles can be palpated.
on the long flexors of the hand.
Cremasteric Reflex
SUPERFICIAL REFLEXES (L1-2 Spinal Segments and Roots)
Abdominal Reflexes (T6–L1 Spinal With the patient in supine position and the lower
Segments and Roots) limbs slightly abducted, the skin on the upper and
inner aspect of the thigh is stroked with the same
The abdominal reflexes are elicited by stroking the
object used for eliciting the abdominal reflexes (Fig.
skin of the abdominal wall (Fig. 32.39). Upper
32.40). The normal response is a reflex contraction
abdominal (T6– T9 spinal segments), midabdominal
of the cremasteric muscle resulting in visible
(T9–T11 spinal segments) and lower abdominal
elevation of the testicle on the stimulated side. Like
(T11–L1 spinal segments) should be tested
the abdominal reflex, this reflex is lost in upper
individually on both sides. To elicit these reflexes
motor neuron lesions above the level of L2 spinal
the patient should lie supine with the abdominal
muscles kept relaxed. Using a blunt object like the segment or lower motor neuron lesion involving
the reflex arc.
Part–I: Internal Medicine
Fig. 32.39: Eliciting abdominal reflex. Fig. 32.40: Eliciting cremasteric reflex. Method stroke the
(See text for details) area shown. Look directly for contraction of the ipsilateral
scrotum. (See text for details)
Chapter 32: Clinical Examination of the Nervous System 461
1. Anxious and psychoneurotic persons. Plantar Reflex and (L5, S1,2 Spinal
2. Parkinsonism and other extrapyramidal Segments and Roots)
diseases in which a center in the midbrain which There are several methods of eliciting plantar reflex.
normally inhibits superficial reflexes may be However, the method of Babinski is probably the
involved. most sensitive, and reliable method and hence, this
Easy fatigability of these reflexes may be an early is more widely adopted.
sign of UMN lesion. Asymmetrical loss of
abdominal and cremasteric reflexes is always Babinski’s Method
pathological, whereas symmetrical loss may The patient lies supine with his lower limb in full
sometimes occur physiologically or due to non- extension. Employing the handle of a reflex hammer
neurological causes. or a key or a small nail file, the lateral aspect of the
plantar surface of the foot is stimulated beginning
Anal Reflex
at the heel and moving up to the ball of the foot,
(S3,4 Spinal Segments and Roots) but not up to the great toes. The movements of
This reflex tests the contraction of the external the great toe and other toes of the foot and leg in
anal sphincter in response to stimulation of the response to this stimulation are observed. In normal
perianal skin. adults this stimulus results in a “flexor plantar
response” characterized by initial flexion movement
One finger of the gloved hand of the examiner
A B
Figs 32.41A and B: Testing the plantar reflex. Babinski’s method (A) Commencing to stroke the sole of the foot
laterally, (B) Towards the end of the stroke. Note movements of the big toes and other toes (See text for description)
462 Section 11: Neurology
plantar stimulation, the response is called “classical In anxious individuals or in patients with
extensor plantar response” or Babinski’s sign. This peripheral sensory neuropathy or when an unduly
is seen in upper motor neuron lesions above L5 sharp stimulus is given, the patient quickly pulls
spinal segment. Occasionally the extension of great the foot back away from the stimulus. This is called
toe may be followed by flexion movement of the a “withdrawal response”.
other toes, instead of fanning out, the lateral toes Other methods of eliciting plantar response: There
show no movement at all. This type of response is are several methods to elicit plantar response,
also called ‘extensor plantar response’, and it also especially an extensor response. In UMN lesions
indicates upper motor neuron lesion above L5 spinal the reflexogenic zone over the lower limb extends.
segment. The sequence of events taking place in Hence, these techniques employ stimulation of
extensor plantar response is extension of big toe, areas other than the sole of the foot. When the
fanning and extension of lateral four toes, sole of the foot cannot be stimulated due to any
dorsiflexion of foot and flexion at knee and hip. reason these alternative methods become useful.
1. Chaddock’s sign Stimulate the lateral aspect
Fallacies of the foot, under and around
In UMN lesion, stroking the posterior and lateral the external malleolus in a
border of foot produces extensor plantar response circular direction.
whereas stroking firmly the middle of the sole may 2. Schäffer’s sign Apply deep pressure on the
tendo-Achilles.
Part–I: Internal Medicine
A B C
Figs 32.42A to C: Alternate methods of eliciting plantar response
(A) Chaddock’s sign, (B) Schäffer’s sign, (C) Oppenheim’s sign
Chapter 32: Clinical Examination of the Nervous System 463
stretch reflexes, simultaneous application of any slowly and grasp the examiner’s fingers.
two of the above methods, is occasionally of value Sometimes the grasp may be so firm that the
of bring forth a latent extensor plantar response. patient can be lifted off his bed. This is seen in
An extensor plantar response (Babinski’s sign) contralateral frontal lobe lesions.
may be obtained in the following conditions: ii. Groping reflex: Mere sight of the examiner’s
i. Lesion of the corticospinal tract constantly fingers approaching the patient’s hand results
extensor on the affected side. in the movement of his hand to grasp the
ii. Immediately after generalized convulsion examiner’s fingers. This has the same significance
bilateral and transient as that of grasp reflex.
iii. During sleep—bilateral and transient. iii. Avoiding reflex: This is elicited by touching
iv. In deep coma due to any etiology—bilateral and the skin on the ulnar border of the hand. The
persistent patient’s hand reflexly moves away from the
v. In normal infants-up to the age of 1 year stimulus. It is present in patients with lesions
bilaterally extensor. in the contralateral parietal lobe or its connections.
Inversion of plantar reflex: In selective paralysis iv. Palmomental reflex: This is elicited by stroking
of short flexors of toes, plantar response may be the skin on the thenar eminence of the hand,
“extensor” due to unopposed action of extensor with a blunt object such as the handle of knee
group of muscles. hammer. Puckering of the skin over the chin,
caused by contraction of ipsilateral mentalis
the first 2 or 3 taps, but subsequent taps do ii. The procedure and the expected response
not evoke any response. But in patients with should be briefly and clearly explained to the
parkinsonism and other diffuse degenerative patient by demonstrating on the normal side
diseases of the brain, the blinking continues first under his direct vision. He should be
as long as the taps are given. See Figure 32.19. instructed to give precise and brief answers.
viii. Mass reflex: It is a reflex of spinal iii. Once he has understood the procedure,
automatism. In severe spinal cord damage, perform the test, keeping his eyes closed so
sometimes, trivial sensory stimuli to any part as to avoid distraction and any clue from direct
of the body below the level of lesion such as vision.
weight of the bed sheets, light touch, movement iv. Start testing the sensations from the face and
of the foot or even elicitation of reflexes in the proceed downwards, always comparing the
lower limbs, result in evacuation of the bladder responses from the corresponding areas on
and bowel, sweating, piloerection, penile either side.
erection and ejaculation, accompanied by slow, v. Leading questions should be avoided.
tonic flexion of the lower limbs at the hips, vi. While mapping out the areas of sensory
and knees. Sometimes, only the limb flexion abnormality, proceed from the abnormal to
component of the mass reflex may be present normal area. This gives better definition of
and this is called ‘spinal defence flexion reflex’. the border zone than proceeding from normal
This reflex should not be mistaken for return to abnormal area.
Part–I: Internal Medicine
of motor power or improvement. vii. In addition to his replies observe his emotional
response also.
Examination of Sensory System Once the sensory abnormality is detected, the
This part of the neurological examination is the most next step is to localize the site of lesion in the
difficult one because perception of sensations is sensory pathway.
purely a subjective phenomenon, varying from
Grading of Sensory Loss
person-to-person. Moreover the methods employed
to test them also tend to be crude and subjective. There is no commonly accepted grading system
The patient’s responses depend largely on his level to quantify sensory loss. Any such attempt tends
of consciousness, intelligence, attention, co- to be arbitrary. However, the impairment of any
operation, and fatigue. Even in normal subjects the sensation can be broadly quantified as mild, moderate,
perception threshold and the appreciation of severe on total loss. Still a semiquantitative grading
sensations differ in different areas of the body and system may be applied as a guide to assess
in the same area under different conditions. progress of the illness.
Aims of sensory examination are: Mild sensory 20–30% diminution as
i. To detect the presence of absence of sensory impairment compared to
abnormalities. normal side
ii. To detect the pattern of sensory alterations Moderate sensory 30–70% Do
which will help to localize the site of lesion in impairment
the sensory pathway, and Severe sensory more than Do
iii. To help in the follow-up of the illness. impairment 75%
While performing sensory examination the Sensory impairment of less than 15 % need not
following general points should be borne in mind. be always pathological. To grade a sensation, the
i. Sensory examination should be performed patient is asked to quantify and express in his own
when the patient is not fatigued and he is still words the appreciation of the sensation relative to
attentive and cooperative. In children and the normal side and his response is recorded.
apprehensive adults, it is better to perform
this part of the examination at the end of Method of Testing
neurological examination since a detailed Systematic detailed sensory examination all over
sensory examination often tires out the patient. the body is a tiring and time consuming procedure
Chapter 32: Clinical Examination of the Nervous System 465
Mini-sensory Examination
Examine touch and pin prick, over the face,
proximal and distal parts of the limbs, and over
chest and abdomen on both sides. Sense of position
and passive movement are to be tested in both
Fig. 32.44: Testing the sense of touch using a hair
thumbs and great toes.
brush. (See text for description)
In pathological conditions, the following felt proximally. Hold the sides of the distal phalanx
abnormalities may be observed: between the thumb and index finger of the right
i. Both hot and cold sensations may be affected hand and move it up or down randomly. Ask the
to the same degree or there may be dissociation patient to close his eyes and respond promptly each
in the degree of involvement, one more affected time the part is moved. Start with greater degrees
than the other. of movement and gradually reduce the amplitude
ii. Both hot and cold stimuli may be perceived in order to detect the smallest range of movement
only as ‘hot’ e.g. in high cervical cord lesions. that he can appreciate.
iii. When both hot and cold sensations are A normal person should be able to detect even
impaired, the area of impairment for ‘hot’ will 1° of movement at the terminal interphalangeal joint
be greater than that for ‘cold’. of the thumb and the great toe and 10º at other
iv. The border of demarcation between normal joints.
and affected areas will be more distinct and Inability to perceive the direction of the
consistent when tested for temperature than movements and the movements when they are of
for pain when both are affected. small amplitude, and errors in correct perception
v. Dissociated anesthesia, i.e. loss of pain and are all abnormal.
temperature sensation with preservation of Note: i. The examiner should hold the part to be
touch and other sensations suggests a lesion moved in a position away from the line
near the central canal of the spinal cord where
Note: Ability to perform the test with eyes open Upper limb: Dorsum of distal phalanx of thumb,
but not with eyes closed is suggestive of loss of ulnar and radial styloid process, olecranon and
proprioceptive sensation. Sense of passive movement acromion processes.
and sense of position have the same significance. Vibration over the spinous processes of the
However, the former is more commonly tested vertebrae can also be tested.
because it is easier to perform and can be graded.
It is also the first modality to be affected in lesions Ask him whether he feels the vibration of the
of posterior columns. fork or not. If he says yes, ask him to indicate
promptly when that feeling stops. Transfer the fork
Small toe in the foot and little finger in the
hand are affected earlier than the great toe or thumb immediately to the corresponding area on the
(Fig. 32.47). opposite side and enquire whether he feels the
buzzing sensation at that location. Duration of
Vibration vibration at a given site can also be compared with
Use a tuning fork of 128 Hz frequency. Greater that of the examiner.
frequencies are less easy to perceive. Inability to perceive the sense of vibration or
Demonstrate to the patient the difference in the reduction in the duration of perception compared
perception during vibration and after the cessation to the normal side, are abnormal. Absence of
of vibration of the tuning fork, by firmly applying vibration sense only in the distal parts of the limbs
the base of the fork to his sternum. A vibrating suggests lesion in peripheral nerves. If uniform
Part–I: Internal Medicine
fork gives a buzzy feeling, in addition to the loss occurs below a certain level, it suggests lesion
pressure of the fork on the sternum whereas a in the spinal cord. When the loss of vibration is
non-vibrating fork produces only a feeling of confined to one side of the forehead, sternum or
pressure. After he has understood the test, the symphysis pubis it suggests hysterical reaction.
vibrating fork is applied over the following bony In peripheral nerve lesions, loss of vibration occurs
prominences starting distally and proceeding earlier than other modalities of sensation. Dissociation
towards the proximal parts. Bony points are tested between vibration sense and joint sense may occur
mainly because the bone acts as a resonator of in some spinal cord lesions. Lesions above the
vibration.
thalamus usually do not affect the sense of vibration.
Lower limb: Dorsum of the distal phalanx of the Hence, in parietal lobe lesions vibration sense may
big toe, medial and lateral malleoli, tibial tuberosity, be intact whereas the joint sense is affected on the
anterior superior iliac spine (Fig. 32.48). opposite side.
Fig. 32.47: Testing sense of position. The patient is made Fig. 32.48: Testing sense of vibration over the medial
to hold the corresponding part of the opposite limb (arrow) malleolus. The intensity of stimulus can be varied and tested.
in the same position held by the examiner (See text for (See text for description)
description)
Chapter 32: Clinical Examination of the Nervous System 469
CO-ORDINATION
For proper smooth and harmonious performance
of a movement, motor, sensory and synergizing
functions should operate normally. For this,
sensations, especially proprioception should be
intact, the agonist muscles should contract
normally, their antagonists should relax to facilitate
the agonists, the synergistic muscles should assist
the prime movers, and the fixating muscles
should fix the proximal joints and the limbs.
The cerebellum should coordinate all these
Fig. 32.50: Testing for sensory inattention. Two stimuli are movements. Only when all these structures are
applied simultaneously at identical points on either sides. intact, the attempted movement will be properly
(See arrowheads) coordinated. Clinical tests for coordination are
directed to assess particularly the functions of
Explain to the patient that you will be applying cerebellum and proprioceptive pathways.
the stimulus either on one side, or both sides Co-ordination is of two types:
simultaneously. He should respond by saying ‘one’ i. The equilibratory co-ordination required for
Part–I: Internal Medicine
or ‘two’ as the case may be. If he feels only ‘one’ the maintenance of balance and posture.
he should indicate the side. Examination of stance and gait includes tests
Keeping his eyes closed, apply the stimuli for equilibratory co-ordination.
randomly to one or both sides with equal pressure ii. Nonequilibratory co-ordination required for
and note his response. the execution of voluntary limb movements.
Inability to perceive simultaneously applied
stimuli as two is abnormal even through he is able Tests for Nonequilibratory Co-ordination
to perceive each stimulus separately when applied
to the same areas. This is called sensory extinction Upper Limbs
or inattention. (Syn: sensory suppression, Finger-nose test: The patient should be in sitting
repression, eclipse, rivalry). It occurs in lesions or standing position. Instruct him to abduct and,
of the contralateral parietal lobe. It may be the only extend one upper limb completely to horizontal
sensory abnormality in some cases with parietal position and then touch the tip of his nose
lobe lesion. (Fig. 32.50). with the palmar aspect of the tip of his index finger
Guidelines to Localize the Site of Lesion Based on Sensory Abnormalities
Sensory loss Site of lesion
1. Loss of all sensations in a restricted area. Spinal root or peripheral nerve lesion
Sensory loss conforms to the distribution
of root or peripheral nerve
2. Loss of sensations in glove and stocking Peripheral polyneuropathy
distribution, i.e. distal parts of all four limbs
3. Saddle anesthesia (perianal region) lesion Conus medullaris or cauda equina
4. Loss of all sensations below a definite level Spinal cord—total transection
on the trunk on both sides
5. Loss of pain and temperature sensation Spinal cord anterior lesion,
with preservation of joint and vibration e.g. anterior spinal artery thrombosis, multiple
sense below a definite level on the trunk sclerosis
on both sides
6. Loss of joint and vibration sense with Spinal cord—posterior lesion, e.g. tabes dorsalis
preservation of pain and temperature below
a level on the trunk on both sides
Contd...
Chapter 32: Clinical Examination of the Nervous System 471
Contd...
Sensory loss Site of lesion
7. Loss of pain and temperature sense on one Spinal cord—hemisection on the side of loss of
side and vibration and joint sense on the joint and vibration sense
opposite side below a definite level on the
trunk
8. Dissociated, anesthesia, i.e. loss of pain and Spinal cord—central lesion, e.g. syringomyelia,
temperature sensation with other sensations hematomyelia, and intramedullary tumor
preserved over a band of skin on the trunk
on both sides with normal sensations above
and below that band
9. Loss of pain and temperature sensation on Lateral aspect of medulla oblongata on the side of
one side of face and contralateral side of affection of the face, e.g. lateral medullary
the body syndrome
10. Unilateral loss of all sensations on one side Thalamic lesion of the opposite side
of the body including face. Position sense
more frequently affected than others. Deep
sensations more affected than superficial
sensations
11. Relatively preserved superficial and deep Parietal lobe lesion of the opposite side
sensations with abnormalities in two-point
first slowly and then rapidly, initially with his eyes All these abnormalities will be noticed
open and then closed. Make him do this several irrespective of whether the test is performed with
times in different angles and at different planes. eyes open or closed, in the limb ipsilateral to the
The two sides are tested separately. While he is cerebellar lesion.
doing so, observe the speed, smoothness, rate, Minimal or latent ataxia can be brought out by
range, direction and force of movement of the applying slight resistance with two fingers of the
index finger. Normally the movement of the finger examiner on the ventral surface of the patient’s
will be smooth, regular, rhythmic and precise wrist or forearm while he is doing the test.
(Figs 32.51A and B). In sensory ataxia due to loss of proprioception,
In cerebellar lesion which also produce in the abnormalities will be apparent in the affected
coordination the following differences may be seen: limb only when the test is performed with eyes
i. There will be coarse and irregular tremor as closed.
the finger approaches the nose—‘intention Nose-finger-nose test: The patient is asked to
tremors’ touch with the palmar aspect of the tip of his index
ii. The finger may stop short of his nose— finger the tip of his nose and then the tip of the
hypometria index finger of the examiner held in front, alternately
iii. It may touch the nose with too much speed and rapidly, several times. The examiner shifts his
and force or it may overshoot the nose and finger to different positions within the reach of
touch the cheek—hypermetria the patient. To bring out the tremors fully the
iv. The tip of the finger may consistently deviate patient’s hand has to be abducted and extended
to the side of lesion. fully. Both sides are tested separately.
472 Section 11: Neurology
A
Part–I: Internal Medicine
B
Figs 32.51A and B: Finger nose test (A) With eyes opens, (B) With eyes closed
Observations and significance are the same as In cerebellar diseases, the rate of finger
for finger-nose test, but this test is more sensitive. wiggling will be slow and the rhythm and range
will be irregular. In rigidity due to extrapyramidal
Rapid Alternating Movements disorders the rate will be slow and the range of the
(Diadochokinesis) finger movements gradually diminish after a few
The patient is asked to alternately pronate and movements. In spasticity also the rate will be slow.
supinate the forearm rapidly, with his elbow flexed This is a sensitive test to detect minor cerebellar,
to 90° and tucked to the side of the chest. Both pyramidal and extrapyramidal dysfunction,
sides are tested separately. In cerebellar dysfunction especially when other tests for motor power, tone,
this will be defective and clumsy on the ipsilateral coordination and muscle stretch reflexes are all
side—dysdiadochokinesia (Figs 32.52 A and B) grossly normal.
Even in normal persons, minor differences may
Pointing test: With the patient in sitting or standing
occur in the nondominant hand.
position, he is asked to outstretch his upper limb in
Finger wiggle test: Keeping the upper limb relaxed front of him and then touch the tip of the examiner’s
and partially outstretched in front, the patient is index finger held in front of the patient, using his
instructed to wiggle his fingers (short quick index finger. Then he is asked to raise his upper
irregular movements) up and down, as demonstrated limb vertically up and bring it down to touch the
to him by the examiner. The rate, rhythm, range examiner’s index finger again and again. This should
and speed of the finger movements are observed. be done several times, first with eyes open and
The test is performed first on one side and then on then closed. The two sides are tested separately.
the other. Even in normal persons minor differences A normal individual can do this test with ease
may occur on the nondominant hand. and precision. In unilateral cerebellar lesion, the
Chapter 32: Clinical Examination of the Nervous System 473
A B
Figs 32.52A and B: Rapid alternating movements to test cerebellar function. Diadochokinesis. (See text for details)
A B
Figs 32.53A and B: Heel-knee test for co-ordination (arrows)
first looking at the legs and then with eyes closed. Foot Pat Test
The rate, range, smoothness, direction and force The patient is made to sit on a chair which his feet
of movement of the heel are noted. The test touching the floor flat. He is asked to pat the floor
(Figs 32.53A and B) is repeated on the other side. rhythmically and rapidly with his forefoot. Both
A normal individual performs this act smoothly, sides are tested separately. The rate, rhythm, and
rapidly and with precision. In unilateral cerebellar
Part–I: Internal Medicine
iii. Wide-based, ataxic gait there will be difficulty in holding the head steady
iv. Incoordination of voluntary movements, i.e. and the trunk erect with a tendency to fall forwards
finger-nose and heel-knee ataxia or backwards-trunk ataxia.
v. Dysdiadochokinesis, i.e. inability to perform Lesions of cerebellar hemispheres usually
rapid, alternate movements of the limbs produce features of cerebellar dysfunction only in
vi. Intention tremors the ipsilateral limbs, especially in the upper limb,
vii. Pendular knee jerk. With the subject sitting at with a tendency to sway and fall towards the side of
the edge of the bed and legs hanging down lesion. Dysarthria and nystagmus are also common
freely, elicit the knee jerk. There will be a series in cerebellar lesions.
of jerky oscillatory movements of the legs
(usually more than three) before it comes to a SIGNS OF MENINGEAL IRRITATION
halt. Normally, these to and fro movements
are prevented due to the aftershortening of These include neck rigidity (Fig. 32.55), Kernig’s
the quadriceps muscle. In cerebellar lesions, sign (Fig. 32.56) and Brudzinski’s signs. These
due to hypotonia of the flexor and extensor develop when the leptomeninges are inflamed as
muscles of the leg and due to lack to in meningitis, or irritated as in subarachnoid
restraining effect which they normally exert hemorrhage.
on each other, the reflex becomes pendular. a. Neck rigidity: It may be defined as the
viii. Nystagmus resistance to passive flexion of the neck
Fig. 32.55: Test for neck rigidity. Flex the neck passively Fig. 32.56: Kernig’s sign—Flex the knee to a right angle
and also turn it from side to side while the patient is fully and straighten the leg as shown (See text for description)
relaxed. Look for resistance to flexion and other movements
476 Section 11: Neurology
b. Kernig’s sign: This test is to assess the spasm innervate the detrusor muscle and internal sphincter.
of the hamstring muscles and response to Parasympathetic stimulation leads to contraction
stretch of the sciatic nerve. The patient lies of detrusor muscle and internal sphincter, resulting
supine. The examiner standing by the side, in emptying of the bladder. The external sphincter
passively flexes the hip and knee to right angles is supplied by somatic efferent fibers that arise from
and then straightens the leg. Normally this is S2,3,4 spinal segments (Onuf’s nucleus) and travel
a painless procedure, though in the elderly it in the pudendal nerves.
may be slightly uncomfortable. Painful spasm The bladder also receives sympathetic
restricting extension of the knee is positive innervation from L1,2 spinal segments via the
Kernig’s sign. hypogastric plexus, but its exact role in micturition
This is repeated on the other side as well. While is not fully known. Sensations arising from the
eliciting the Kernig’s sign, watch the patient’s face bladder are carried up by somatic and visceral
for expression of pain, and observe the other knee afferent nerves (pelvic and hypogastric nerves).
for automatic flexion. Sensory impulses from the pressure receptors
c. Brudzinski’s signs situated in the bladder wall ascend up to enter the
i. Leg sign: While eliciting the Kernig’s sign S2,3,4 spinal segments and these convey the
on one side the opposite lower limb flexes sensation of bladder distention whereas the visceral
automatically. afferent fibers from the peritoneal surface of the
Part–I: Internal Medicine
ii. Neck sign: While eliciting neck rigidity, bladder enter the lower portion of the thoracic spinal
both the lower limbs flex automatically. cord to convey a sense of bladder fullness.
Based on the clinical findings the investigations Sensations from the urethra and external sphincter
are determined. are carried by the pudendal nerves to S3,4 spinal
segment.
INNERVATION OF URINARY BLADDER AND
DISORDERS OF MICTURITION Note: Several local diseases affecting the lower
urinary tract lead to retention and/or incontinence
Disturbances of micturition are common and often and other urinary symptoms that are associated
they are early manifestations in some neurological with neurogenic bladder. All these should be
disorders. Lesions of the spinal cord and cauda excluded before attributing bladder dysfunction to
equina, and less commonly cerebral disorders give a neurological cause.
rise to abnormalities of micturition.
Innervation of the Urinary Bladder Act of Micturition
The urinary bladder is a hollow sac of smooth The complex act of micturition is both reflex and
muscle with two sphincters at its opening into the voluntary. Pressure receptors in the bladder wall
urethra—one internal and one external. The wall send afferent impulses to S2,3,4 spinal segments
of the bladder contains detrusor muscle which and this forms the afferent mechanism for the
contracts to empty the bladder. The internal micturition reflex.
sphincter is made up of smooth muscle fibers During micturition, the following actions take place
arranged in such a way that their contraction opens sequentially:
the sphincter. The detrusor and internal sphincter • Relaxation of the perineal musculature
are not under voluntary control. The external • Increase in the tension of the anterior abdominal
sphincter contains striated muscle fibers, and its wall
contraction and relaxation are under voluntary • Contraction of detrusor muscle and internal
control. The neural control of the bladder and its sphincter
sphincters is complex. It has a dual efferent nerve • Relaxation of the external sphincter
supply both from parasympathetic and sympathetic. • Voiding of urine.
The parasympathetic efferent innervation is from Voluntary contraction of the external sphincter and
the intermediolateral zone of gray matter of the perineal muscles causes cessation of the
S2,3,4 spinal segments. Their postganglionic fibers contraction of the detrusor muscle and stopping
Chapter 32: Clinical Examination of the Nervous System 477
Clinical Symptomatology in
Neurogenic Bladder
The following symptoms may occur to a variable
degree, in different types of neurogenic bladder
(Table 32.20).
Frequency
It is the number of times the bladder is emptied in
a day. A normal adult empties his bladder up to
3 to 6 times during day and upto 2 to 3 times during
night.
Fig. 32.57: Diagram showing the levels of lesion and types
of dysfunction in neurogenic bladder: (1) Uninhibited Urgency
bladder, (2) Atonic bladder (Acute stage), (3) Automatic
bladder (Chronic stage), (4) Autonomous bladder, (5) Once the sensation of distension of bladder is
Sensory bladder and (6) Motor paralytic bladder perceived, the patient finds it difficult to hold the
478 Section 11: Neurology
Distention
and retention ± + — + + +
sympathetic nerve fibers from L1,2 spinal segments. • Overactivity of parasympathetic pathways
Final ejaculation of semen from the penis occurs Priapism
as a result of the rhythmic contraction of the • Lesions of sympathetic pathways—Failure of
bulbospongiosus muscles which are innervated by ejaculation with normal erection
the pudendal nerve (S2,3,4). • Overactivity of sympathetic pathway—Weak
Though the acts of penile erection and ejaculation erection and premature ejaculation
are autonomic reflexes, they are heavily influenced Priapism occurs in lesions of spinal cord
by psychic factors, supraspinal descending neural above lumbar level or due to overstimulation of
pathways and hormonal factors. Organic lesions parasympathetic pathways. It may occur either
of the spinal cord and cauda equina may lead to spontaneously or as a reflex response to even mild
impotence. Autonomic neuropathy due to several stimulation of the penis resulting in erection and
causes may aslo result in impotence. When only ejaculation.
the sympathetic nerve supply from L1,2 spinal
segments is affected, normal erection may still
TESTS FOR AUTONOMIC FUNCTION
occur but ejaculatory failure is present.
(TABLE 32.21)
The term libido refers to sexual impulse, drive
or desire. This results from a variety of stimuli Tests for autonomic function are undertaken when
including purely imaginary ones, which arise in this system is affected either primarily like in Shy-
Part–I: Internal Medicine
neocortex and travel to sacral spinal centers via Drager syndrome or secondarily like in diabetes
limbic system and the hypothalamus. mellitus. Assessment of autonomic functions is of
Neurological lesions giving rise to abnormal - importance to diagnose neurological disorders and
ities in penile erection and ejaculation: also to assess the prognosis in systemic diseases.
• Lesions of parasympathetic pathways- For example, presence of autonomic neuropathy
Impotence due to failure of erection and in diabetes mellitus is associated with a high risk of
ejaculation fatal cardiac arrhythmias.
Contd...
Test Method Expected normal response Abnormal response Remarks
ii. Record the maximum by BP overshoot (phase 4)
heart rate in phase 2 and and a reflex bradycardia.
minimum heart rate in Ratio of more than 1 Ratio of less than 1
phase 4 and find out the
ratio of maximum to
minimum heart rates
4. Heart rate response Record the heart rate Sinus arrhythmia No sinus arrhythmia This is a test for efferent
to deep breathing during quiet breathing vagus pathway
and during deep breathing
5. Heart rate and Record the heart rate and Bradycardia and fall in BP No response This is a test for vagal
BP response to BP before and during efferent pathway to heart.
carotid sinus massage of carotid sinus Caution is necessary in
massage in the neck, first on one subjects with hypersensitive
side and then on the other carotid sinuses
side
6. BP response to Record the BP before and Fall of BP by at least No response or This is a test for central
hyperventilation after hyperventilation for 20 mm Hg systolic reduced response integrative function of
30 seconds autonomic nervous system
7. Hand grip test Record heart rate and BP Increase in heart rate and No response This is a test for
before and during systolic BP sympathetic efferent
hand grip for 90 seconds pathway
Contd...
Test Method Expected normal response Abnormal response Remarks
Fig. 32.58: Testing the strength of neck flexors and abdominal Fig. 32.60: Testing the rhomboids—With the hand placed
muscles. The patient is asked to flex the neck against on the hip, the patient is asked to retract the shoulder
resistance (arrow) while the examiner exerts forward pressure at the elbow.
The rhomboids stand up and can be palpitated (see finger)
Fig. 32.59: Testing extensors of the spine—In the prone Fig. 32.61: Testing the serratus anterior. The patient pushes
position the patient is asked to extend the neck and back against a wall with outstretched arms in front of him.
against resistance Normally, the medial border of the scapula should remain
close to the chest wall (arrows). ab: abnormal; N: Normal
Chapter 32: Clinical Examination of the Nervous System 483
Fig. 32.62: Weakness of serratus anterior—Note the Fig. 32.64: Testing the deltoid—The patient is asked to
elevation of the scapula from the chest wall (winging) abduct his arm against resistance. The contraction of the
when the patient pushes against the wall without stretched deltoid can be seen and palpated. Wasting of the deltoid
hands (arrow) leads to loss of the rounded appearance of the shoulder
(arrow)
Fig. 32.63: Examination of supraspinatus. Contraction of Fig. 32.65: Testing the pectoralis major. Contraction of the
the muscle fibers can be felt during early stages of muscle can be seen and felt during attempts to adduct the
abduction of shoulder (arrow) arm against resistance (arrow)
484 Section 11: Neurology
Fig. 32.66: Testing of the latissimus dorsi—On adduction Fig. 32.68: Testing the biceps and brachialis: flexion of the
of the horizontally and laterally abducted arm against elbow against resistance makes the biceps prominent and
resistance, the contracting muscle fibers can be seen and its size and consistency can be palpated (arrow)
palpated
Part–I: Internal Medicine
Fig. 32.67: Testing the infraspinatus—On external rotation Fig. 32.69: Testing the brachioradialis. On flexion of the
of the arm with elbow flexed and kept close to the body, semipronated forearm (thumb-up) against resistance, the
contraction of infraspinatus muscle can be seen and contracting brachioradialis can be seen and palpated
palpated (arrow) (arrow)
Chapter 32: Clinical Examination of the Nervous System 485
Fig. 32.70: Testing triceps—On attempting to extend the Fig. 32.73: Testing of flexor digitorum profundus. The patient
partially flexed forearm against resistance (arrow), is asked to flex the distal phalanx at interphalangeal joint
contraction of triceps can be seen and palpated against resistance after fixing the proximal IPJ (arrow)
Fig. 32.72: Testing extensors of the wrist—On attempting Fig. 32.75: Testing the extensor digitorum communis—With
to extend the wrist against resistance (arrow), the muscle hand outstretched and Interphalangeal joints held in
bellies of extensor carpi radialis, extensor carpi ulnaris and extension,the patient resists the attempt to flex the fingers
extensor digitorum communis can be seen and palpated at the metacarpophalangeal joints (arrow). The contracting
muscle can be palpated on the forearm dorsally
486 Section 11: Neurology
Fig. 32.77: Testing of palmar abductor—First dorsal Fig. 32.79: Adduction of thumb—The patient attempts to
interosseus—The patient is made to bring the index finger grasp a paper between the thumb and radial border of
towards thumb against resistance on patient’s finger (see index finger. The strength of adductors is assessed by
arrow) pulling on the paper
Fig. 32.78: Testing of palmar adductors—The patient is Fig. 32.80: Test for abductor pollicis. The patient attempts
asked to hold a paper in between fingers and resist attempts against resistance to bring the thumb vertically above its
to pull it out (see arrow on the examiner’s hand). Compare original position (arrow)
with the strength of the examiner
Chapter 32: Clinical Examination of the Nervous System 487
Fig. 32.81: Testing flexors of the thigh—The patient attempts Fig. 32.83: Mild weakness of dorsiflexors of foot is picked-
to flex the thigh against resistance (arrow). The knee is up by asking the patient to stand on heels. Note incomplete
flexed and the leg rests on the examiner’s arm dorsiflexion
Fig. 32.85: Examination of small muscles of foot—Ask the patient to adduct and flex the toes together (cupping). Inability
to adopt to this position indicates weakness of the intrinsic muscles. Note individual muscles cannot be tested separately
CHAPTER
• Drug intake: Type of drug, dose and duration. facilities. At least emergency measures should be
• Patient’s own ideas about his headache and its instituted without delay in every case so as to prevent
cause. deterioration and death.
• Reason for present consultation. The phenomenon called consciousness has two
• Any symptom, referable to the eyes, ears, nose facets, namely arousal and awareness. These two
and symptoms suggestive of systemic disorder, depend on two brain structures:
e.g. fever, anemia. i. The brainstem reticular activating system
• Past history of head trauma and infections of the (RAS) which extends from the medulla to the
central nervous system. thalamus and
• Family history of headache, epilepsy, brain tumor, ii. The cerebral cortex. Arousal is the phenome-
hypertension, diabetes and mental illnesses, non of being awake, and it is the primary
particularly important in chronic cases. function of RAS which is a nonspecific
• Social history: Patient’s way of life, diet, work transmission system for sensory inputs which
and attitude to work, hobbies, leisure, family activate the cortex. Awareness is a more
relationships, psychiatric problems. Depending sophisticated function requiring intact cortical
on the duration of illness, headache can be broadly activity in order to interpret the sensory input
grouped into the following categories. and respond accordingly. When both arousal
I. Recent headache in an ill patient, e.g. and awareness are lost due to dysfunction,
themselves lead to coma, but more often they • Within minutes Head trauma, intracranial
aggravate the condition and lead to irreversible hemorrhage, cerebral infarc-
brain damage. tion, brain herniation due to
b. If coma is due to anoxia, proper ventilation intracranial space occupying
should lead to recovery. lesions, epileptic or non-
c. In case of cardiac arrest, emergency cardio- epileptic convulsions, status
respiratory resuscitation should be instituted. epilepticus, Stokes-Adam’s
Delay beyond three minutes to establish the attacks, psychogenic cause
airways and restore cardiac function can result (hysteria).
in permanent brain damage and brain death in • Minutes to Hypertensive encephalopathy,
patients with cardiac arrest. If the patient is in hours hypotension, hypoglycemia,
shock, appropriate corrective measures should fluid and electrolyte distur-
be instituted to restore cerebral circulation. bances, fulminant in-fections
If there is any possibility of hypoglycemia of the CNS, over-dosage of
rapidly infuse 50 mL of 50% glucose IV. The sedative drugs.
hypoglycemic patient will rapidly regain • Hours to days Respiratory insufficiency,
consciousness. Even if the patient is in diabetic diabetic coma, uremic coma,
coma no harm will be done by this glucose hepatic failure.
administration. Administer 100 mg of thiamine • Fluctuating Subdural hematoma, fluid
Part–I: Internal Medicine
b. Neurological examination: Particularly look of the body. Carefully look for evidences of
for abnormalities of pupils, eye movements poisoning, either ingested or self-injected.
including reflex movements such as
oculocephalic and oculovestibular reflexes, Abnormal Breathing Patterns in
pattern of breathing, motor response and CNS Disorders
signs of meningeal irritation (Tables 33.2
to 33.4). Cheyne stokes Periodic breathing in which
respiration respiratory cycles gradually
c. Examination of the other systems—
Cardiovascular, respiratory, alimentary, wax and wane, i.e. hyperpnea
excretory, endocrine and others should be alternate with cycles of apnea.
examined. Particularly look for overt or Central neurogenic Continuous, regular, rapid, deep
occult trauma over the head or other parts hyperventilation respiration.
Table 33.2: Differentiating features of coma due to CNS lesions and toxic-metabolic coma
Coma due to CNS lesion Toxic-metabolic coma
Clinical features Common finding Exception Common finding Exception
Respiration Irregular Regular in central Regular Cheyne-Stokes respiration
neurogenic in pulmonary insufficiency,
hyperventilation apneic breathing in narcotic
overdosage
Pupils Asymmetrical Symmetrical and Symmetrical, Symmetrical dilatation in atropine
Size and symmetry constricted in midbrain normal size and glutethemide poisoning and
and pontine lesions. anoxia. Symmetrical constriction in
In the later stages morphine poisoning. Asymmetry
both pupils are due to pre-existing eye disease
dilated and fixed
Reaction to light Sluggish or absent Normal in diffuse CNS Normal except in the Absent in atropine and
infection terminal stages glutethemide poisoning
Oculocephalic and Absent or asymmetrical – Present Absent in barbiturate and
oculovestibular reflexes diphenylhydantoin intoxication
Unilateral decorticate Present May be bilateral in Absent May be present
or decerebrate posture rostrocaudal herniation bilaterally
Optic fundi Papilledema if – No papilledema Papilledema, if cerebral
intracranial pressure edema is severe.
is elevated
Part–I: Internal Medicine
Apneustic Regular breathing with longer 1. Lack of spontaneous movements of the limbs
respiration pauses for 2 to 3 seconds after on one side.
each inspiration. 2. Lack of withdrawal in response to painful
Ataxic respiration It is a chaotic breathing in which stimuli on one side.
the rate, rhythm and depth of 3. Tendency for the limb to remain in any position
respiration are all irregular. even if it is an uncomfortable one.
Hypoventilation Regular, rhythmic, shallow 4. Externally rotated position of one lower limb.
breathing. 5. The thigh on the paralyzed side appears to be
How to Recognize Paralysis in wider and flatter than the other.
a Comatose Patient? 6. When the limbs are lifted above the bed and
Presence of any or all of the features given below allowed to drop down, the paralyzed limb falls
should suggest paralysis: flaccidly.
Chapter 33: Special Problems in Neurology 493
Table 33.4:
Summary of clinical features which suggest 7. If there is facial palsy, the cheek on the
etiopathogenesis of coma paralyzed side puffs out with each expiration.
Clinical features Etiology Remember the following:
1. Coma with focal CNS diseases, e.g brain tumor,
neurological signs abscess, hemorrhage, infarction,
i. All that glitters is not gold: It is a well known
hypertensive encephalopathy, subdural saying. It also applies to a comatose patient.
hematoma, cerebral contusion, For example, alcoholic odor in the breath of a
encephalitis
comatose patient does not necessarily indicate
2. Coma without focal Meningitis or subarachnoid
neurological signs, hemorrhage
that alcoholic intoxication is the only cause of
but with signs of coma in him. It could as well be due to head
meningeal irriation trauma or poisoning sustained under the
3. Coma without focal Metabolic or toxic coma: alcohol influence of alcohol.
neurological signs or intoxication, barbiturate overdose,
signs of meningeal hepatic coma, diabetic coma,
ii. Which came first, hen or egg?: It is another
irritation hypoglycemia, uremia, fluid and universal unsolved dilemma. Such a dilemma
electrolyte disturbance, myxedema often arises when one is dealing with a
coma, other poisons
comatose patient. For instance whenever, a
494 Section 11: Neurology
person falls down especially from a height and manifestations of a seizure. “Fit” is a layman’s term
is found in an unconscious state, there could for seizure.
be at least two possibilities. One possibility is Originally, epilepsy was classified into grand
that the fall could have resulted from a stroke mal, petit mal, Jacksonian and psychomotor
and the injuries are secondary to fall or (temporal lobe ) types. Based on clinical, electro-
alternatively, he might have fallen down and encephalographic (EEG), neuradiological and/or
sustained head injury that led to uncon- pathological correlations, a new classification of
sciousness and hemiplegia. epileptic seizures has been put forward, which is
iii. Beware of the red herring: Presence of an widely accepted. This is known as the “International
obvious cause for coma in an individual should Classification of Epileptic Seizures”. However, only
not make the physician blind to other after a thorough clinical and investigative work
possibilities. For example, an elderly diabetic up it is possible to determine accurately the type
with painful polyneuropathy may become of epilepsy according to this International
comatose, not due to his diabetic state but it classification. As it is not always possible or
may be due to overdose of sleeping pills he had practicable to get access to all these investigative
consumed the previous night to get over his facilities in many parts of India, only the clinical
painful peripheral neuropathy. pattern of seizure disorders conforming to the
iv. Guard yourself: In these days of increasing International classification, will be described below.
suicidal and homicidal tendencies, consider the
Part–I: Internal Medicine
Partial seizures may progress into generalized may occur when air passes through the partially
tonic-clonic seizures. Sometimes, the secondary closed vocal cords—epileptic cry. All muscles go
generalization occurs so fast that the initial focal into tonic spasm. Respiration stops for a while and
onset may be missed clinically. EEG may be required the patient becomes cyanosed. The pupils become
to reveal its focal nature. dilated and nonreactive. This tonic phase lasts for
Unilateral seizures are seizures strictly confined about 10 to 15 seconds, and gradually the clonic
to one side of the body. Unclassified seizures are phase begins.
those to which accurate label cannot be given due It starts as a mild, generalized trembling, rapidly
to inadequate or incomplete information regarding going on to rhythmic, symmetric, intermittent
the seizure pattern. muscular contractions called clonic jerks. The
Usually primary generalized seizures have their eyeballs roll up. Excessive salivation and frothing
onset in the first or second decade of life, they are from the mouth develop. There will be excessive
not associated with mental retardation or focal sweating. Micturition, defecation or seminal
neurological signs and they have a strong familial ejaculation may occur. The entire clonic phase lasts
tendency. As opposed to this, partial and secondary for 1 to 2 minutes during which period the breathing
generalized seizures may start at any age, fequently is irregular.
they are associated with focal neurological signs or At the end of the clonic phase, the patient takes
papilledema and there is no familial tendency. a deep inspiration and lies still in deep coma for a
variable period lasting from a few minutes to several
with or without loss of consciousness and autonomic (Todd’s palsy) which may last for a few hours or
manifestations as in tonic seizures. even up to 3 to 4 weeks.
Myoclonic seizures: It is characterized by sudden,
Partial Sensory Seizures
bilaterally symmetrical, isolated jerking of the limbs.
Infantile spasms (syn: hypsarrhythmia: salaam Somatic sensory seizures are characterized by
spasms): These occur in infants between the age of recurrent transient attacks of “pins and needles”
3 to 12 months. Each attack is characterized by sensation, numbness and rarely pain or thermal
sudden forward bending of the trunk and head with sensation over one part of the body. Special sensory
extension of the arms and legs. They occur several seizures are characterized by recurrent, transient
times in a day. The child may be otherwise normal attacks of special sensory phenomena the nature of
or show developmental arrest and mental retardation. which depends on the site of lesion in the brain
Atonic seizures: These are characterized by sudden (Table 33.5).
loss of postural tone with sagging of the head and
Complex Partial Seizures
falling to the ground, without losing consciousness
(drop attacks), usually occurring in children. These are characterized by formed hallucinations,
Absence seizures: These are characterized by illusions, dyscognitive experiences such as deja vu
sudden cessation of all activities, loss of respon- (a feeling of intense familiarity), dreamy state,
siveness and a staring look, lasting for about 3 to 30 depersonalization and others. Affective states such
Part–I: Internal Medicine
seconds. Usual age of onset is 3 to 13 years. These as fear, depression or elation, and automatisms may
spells may or may not be associated with minor occur. These are caused by a focus usually in the
temporal lobe, but sometimes in the frontal lobe as
motor activities in the form of chewing, smacking
well.
movements of the lips, fluttering of eyelids, or rolling
up of the eyeballs. Usually the patient is not aware Status Epilepticus
of these episodes. They are recognized by others as
Status epilepticus is defined as “an epileptic seizure
brief pauses during conversation, eating, writing,
which is so prolonged or so frequently repeated as
reading or any other motor activity.
to create a fixed and lasting epileptic condition”. In
Typical absence attacks can be precipitated by other words, a seizure which is very prolonged or
hyprventilation for about 3 minutes. Unlike a grand which recurs at brief intervals can be called status
mal seizure, there is no postictal confusion, epilepticus. Any type of seizure may go into status
drowsiness or headache. The attacks may occur epilepticus although generalized tonic-clonic
several times in a day. Atypical absence attacks have
slower onset, longer duration and gradual cessation.
They may be associated with more complex motor Clinical manifestation of seizures for
Table 33.5:
activities and automatism. corresponding sites of lesions
Site of lesion Clinical manifestation of seizure
Partial Motor Seizures 1. Lateral surface of Visual phenomena in the form of
occipital lobe darkness or spots of light which may
These are characterized by turning of the head and
be static or moving
the eyes to one side with tonic contractions of an 2. Posterior part of Complex visual hallucinations
extremity and trunk, without loss of consciousness occipital lobe
(adversive seizures). At times there may be tonic or 3. Posterior part of Rarely auditory hallucinations
clonic movements in one part of the body, usually at temporal lobe
the angle of the mouth, thumb or the foot because 4. Posterior part of Vertigenous sensation
superior temporal gyrus
these areas have greater cortical representation. 5. Inferior and medial parts Olfactory hallucinations
These attacks usually last for 20 to 30 seconds. of temporal lobe (uncus
When the attack begins at one of these areas and and hippocampus)
progressively marches to involve contiguous 6. Temporal lobe Gustatory hallucinations
anatomical parts of the body, it is called Jacksonian 7. Insulo-orbital cortex Visceral sensations arising from the
or cingulate cortex thorax, epigastrium and the abdomen
seizure. There may be postictal focal paralysis
Chapter 33: Special Problems in Neurology 497
convulsive status is more frequent, more serious and mild or moderate. This may follow or precede the
easily recognisable. convulsion. Neurological examination will be
Status epilepticus may be of the following types: normal in between the attacks.
i. Generalized convulsive type Sometimes, there may be family history of febrile
ii. Partial convulsive type, i.e. epilepsia partialis convulsions or epilepsy. These type of seizures are
continua, or called simple febrile convulsions.
iii. Nonconvulsive type, i.e. absence status. A febrile convulsion is termed “complicated
In generalized convulsive status, generalized febrile convulsion” under the following circum-
convulsions follow each other so closely that stances:
consciousness is not regained in between the attacks, i. when a convulsion lasts for more than 15
or more than three convulsions occur within 30 minutes;
minutes or single convulsion lasts for more than 10 ii. when convulsions occur in quick succession;
minutes. iii. when a convulsion is focal or focal becoming
In epilepsia partialis continua, focal motor generalized or
convulsions persist nonstop for hours, day or even iv. when there are associated neurological or EEG
months. abnormalities.
Absence status is difficult to recognise as it In all such cases, examination of the cere-
presents like a “dreamy” state or “twilight” state or brospinal fluid is mandatory to exclude infection of
Clinical Approach to a Case of Epilepsy Although in most of these patients, the condition may
1. Consider epilepsy in every patient who pre- be benign, the symptom is most alarming to the
sents with sudden, transient and recurrent patient. Basically, all these patients have a feeling
attacks of symptoms suggestive of CNS dys- of disequilibrium in space. Normal spatial
function. equilibrium is a multimodal function dependent on
2. Obtain a detailed history from the patient and the integration of vestibular, visual, proprioceptive
at least from one eye witness to these episodes. and cerebellar inputs to the brain. It may be disturbed
3. Inquire into the following: either primarily or secondarily, due to a variety of
• Age of onset of symptoms. causes. Several terms may be used by patients to
• Accurate and full description of one attack describe their feeling of disequilibrium. These
if the attacks are stereotyped. Otherwise include dizziness, giddiness, whirling, rotation,
description of each type of attack separately. spinning, light headedness, shaking, swaying,
wobbling, instability, unsteadiness, vertigo and
• Particularly inquire about aura, focal onset
probably others too.
of a convulsion, loss of consciousness,
tongue bite, frothing from the mouth, The most useful clinical subdivision is to
bladder or bowel incontinence, sustained categorize these symptoms into:
injuries, postictal phenomena, interictal i. True vertigo and
symptoms and frequency of the attacks. ii. Pseudovertigo.
Part–I: Internal Medicine
• Epileptic attacks are precipitated by several True vertigo denotes a sense of rotation in one
stimuli. In many cases attacks are precipitated direction, which may be “subjective”, when the
by avoidance of the drug, failure, travel, subject feels he is rotating in his environment or
insomnia, photic stimulation by cinema or “objective” when he feels the objects in his environment
television, late dinner and others. are rotating around him. Pseudovertigo, which is
• Past history of trauma, CNS infections, much more common than true vertigo, encompasses
febrile convulsions or any other neuro- all sensations of disequilibrium, other than true
logical disorder should be elicited. vertigo. True vertigo is due to primary neurological
causes such as dysfunction of vestibular end organ
• Medication history, with details of anti-
(labyrinth), vestibular division of eighth cranial
epileptic drugs and their dosage. If drug has
nerve, vestibular nuclei in the brainstem and their
been discontinued, reason for doing so.
connections, flocculonodular lobe of the cerebellum
• After taking the history, perform full general
and very rarely cerebral hemisphere. Often pseudo-
examination and detailed neurological
vertigo may be due to non-neurological causes. In
examination.
true vertigo, in addition to feeling of rotation, other
Having done all this, decide whether the patient symptoms may coexist. These include impulsion, i.e.
is having seizures or not. Epilepsy has to be a feeling of being pulled to the ground or to one
differentiated from conditions such as syncope, side; tinnitus, deafness, diplopia or other focal
Stokes-Adam’s attacks, hypoglycemia, tetany and neurological deficits. True vertigo occurs as a single
hysterical fits. If it is seizure, determine its type episode or recurrent stereotyped attacks of definite
and possible cause. Plan for full investigation in all duration. Pseudovertigo occurs either as momentary
cases. The advent of CT scan and MRI has revealed attacks or as a very prolonged sensation lasting for
underlying causes such as slow growing tumors, hours or even days.
cysticercosis, tuberculoma and others in patients
When confronted with a patient having vertigo
thought to be having idiopathic epilepsy. After
or dizziness or some other similar complaint, enquire
confirming the diagnosis, start therapy with the
into the following:
appropriate anticonvulsant drug in adequate dosage.
1. Is it a true vertigo or pseudovertigo?
2. Is it paroxysmal or persistent?
VERTIGO-DIZZINESS-GIDDINESS COMPLEX
3. Is it associated with symptoms like nausea,
Dizziness or giddiness is yet another common vomiting, tinnitus, deafness, diplopia or any
symptom, for which many seek medical advice. other symptom?
Chapter 33: Special Problems in Neurology 499
4. Positional factors: Whether vertigo occurs fault and compels the patient to seek medical help.
during head movements or only in certain Total absence of pain sensation is as disastrous as
positions of the head or during change of uncontrolled severe pain. Both can do serious harm
posture, etc. to the body and the mind. However, uncontrolled
5. Precipitating factors: For example, exercise, pain is the single most common reason for people to
food intake, salt intake, stress and others. seek medical advice.
6. Exacerbating factors: For example, noise, Pain signals received from sense organs enter
straining, coughing, exercise and others. the spinal cord through the posterior nerve roots. In
7. Alleviating factors: Change of head position the spinal cord, pain conveying fibers occupy two
or body posture. distinct pathways, i.e. the lateral and medial systems.
8. Drug history: For example, aminoglycoside The lateral system conducts impulses rapidly and it
antibiotics, anticonvulsants especially dip- is concerned with the transmission of sudden phasic
henylhydantoin, antihypertensive drugs, pain to the cerebral cortex. The topographic
salicylates, etc. arrangement of its fibers helps to localize sudden
9. Past medial history: Head injury, ear infection sharp pain and also to appreciate different qualities
or trauma, antecedent upper respiratory of pain such as burning, pricking, throbbing and
infection, diabetes, psychiatric illness, and others. The medial system differs from the lateral
others. system in many ways. It is responsible for diffuse,
10. Family history: Particularly for familial unpleasant, persistent sensation of pain. The pain is
features. A proper understanding of the various Postherpetic neuralgia: Ophthalmic herpes: In the
clinical entities is necessary for an accurate diagnosis elderly patient, herpes zoster ophthalmicus may lead
and management. The diagnosis mainly rests on the to the development of neuralgic pain in the
history and therefore a detailed history is important. distribution of ophthalmic division of the trigeminal
Trigeminal neuralgia (Tic douloureux): It is a nerve. The discomfort of the acute stage will be
recurrent, paroxysmal, brief episode of intense pain followed by chronic, intractable, constant, burning
over one side of the face. The pain may be described sensation with superimposed episodes of stabbing
as lancinating, lightning-like, shooting or electrical pain. Even slight touch on the affected skin provokes
shock-like sensation. The pain is usually confined intense pain.
to one of the three divisions of the trigeminal nerve, Intermittent claudication of the masseters:
maxillary division being the most commonly affected Sometimes in temporal arteritis, the arteries to the
one and the ophthalmic division least affected. muscles of mastication and tongue may be involved.
Paroxysms may last only for a few seconds or up to Such patients have pain in the masseter and tongue
several minutes. Their frequency varies from once muscles on chewing movements due to intermittent
in a few minutes to only once or twice a day. Trigger claudication of these muscles.
zones may be present. Trigeminal neuralgia may be
idiopathic or secondary. Paroxysmal Hemicranial Cephalalgia
Glossopharyngeal neuralgia: Although it is less This is characterised by paroxysmal, throbbing,
common, it resembles trigeminal neuralgia in many unilateral, headache and facial pain, accompanied
respects. It is also a recurrent, paroxysmal, intense by mydriasis and perspiration on the affected side.
pain that originates in the tonsillar fossa and may In between the attacks of headache, there will be
radiate to the ipsilateral ear. Sometimes, the vagus ipsilateral Horner’s syndrome. There will be past
nerve may also be involved in which case the pain history of trauma to the anterior triangle of the neck,
may be accompanied by bradycardia and even probably affecting the carotid artery sheath. The
syncope. Swallowing, talking, chewing, yawning, condition is thought to be due to post-traumatic
laughing or similar acts trigger the pain. There will dysautonomic disturbance.
be no demonstrable evidence of sensory, motor or Carotidynia: It is characterized by spontaneous
reflex deficits of IX and X cranial nerves. Rarely, episodes of dull ache originating in the middle of
glossopharyngeal neuralgia may be secondary to the neck on one side and radiating to ipsilateral face,
peritonsillar abscess or carcinoma of the oropharynx. ear, jaw, teeth or down the neck, accompanied by
Chapter 33: Special Problems in Neurology 501
tenderness on palpation over the carotid artery, its the spinal column such as the periosteum, ligaments,
bifurcation, and induration of the overlying tissues. tendinous attachments of the muscles, synovial
Atypical facial pain: It is constant, unbearably membranes of the facet joints and annulus fibrosus
severe, deep seated pain over one or the other of the intervertebral discs are sensitive to pain.
maxillary regions, which may radiate either to the Direct or indirect involvement of the musculo-
mastoid region or down to the neck or across the skeletal structures account for the majority of painful
midline to the opposite maxillary region. Eventually, lesions. Another important cause is nerve root
the pain involves the whole face and the neck compression and irritation. It addition, referred pain
bilaterally. It usually occurs in young women. from thoracic, abdominal and pelvic viscera should
also be considered in the differential diagnosis.
Miscellaneous Conditions
a. Sudden onset of unilateral facial pain that Causes of Neck and Back Pain
disappears over a period of days or weeks, with
or without associated clinical features of Musculoskeletal Disorders
brainstem stroke, occurs in vertebral artery i. Congenital anomalies such as spina bifida,
dissection or its occlusion. Sometimes, similar sacralization of L5 vertebra, spondylolisthesis
pain which may be more or less persistent, and spinal canal stenosis.
occurs due to compression of the vertebral ii. Trauma, both acute and recurrent, leading to
artery in the neck by a cervical osteophyte, fractures and subluxation of the vertebrae,
ii. Involvement of nerve plexus in neuralgic 3. A nerve root, when it exits through the inter-
amyotrophy, compression by tumors, enlarged vertebral foramen, occupies a higher position
lymph nodes or congenital bony anomalies. in the foramen, than the disk. Hence in the lower
iii. Involvement of peripheral nerves by injuries lumbar region, a disk lesion does not affect the
including inadvertent intramuscular injections root that passes through that intervertebral
into or near a nerve, entrapment (carpal foramen, but it affects a lower one that passes
tunnel syndrome), nutritional and metabolic through the interspace below. Thus prolapse of
neuropathies. the disk between L4 and L5, vertebrae affects
L5 root and not L4 root and a disk lesion
Common Nerve Root Syndromes Caused
between L5 and S1 vertebrae affects the S1
by Prolapsed Intervertebral Disks
root.
Nerve root compression due to prolapsed inter- The musculoskeletal causes of pain occurring
vertebral disks is more common in the lower cervical in this region are given in the section on rheuma-
and lower lumbar levels. Disk prolapses at C5–C6 tology. Table 33.6 shows the clinical features of
and C6–C7 spaces in the cervical region and L4– common monoradicular syndromes.
L5 and L5–S1 spaces in the lumbar region account
for 90 to 95% of the total disk lesions. Neurological Causes of Pain
Certain important anatomical differences that in the Upper Limb
exist between the disposition of cervical and lumbar
Part–I: Internal Medicine
Brachial Neuritis
nerve roots in relationship to the inter-vertebral
disks, should be kept in mind while considering It produces diffuse, ache-like pain of acute onset in
intervertebral disk prolapse. the supraclavicular region, shoulder and the arm. It
1. As there are 8 cervical roots and only 7 cervical is usually unilateral. Pain is worse when the limb
vertebrae, C1 root emerges out between the hangs down and pain is relieved by recumbency. It
occiput and C1 vertebra. Consequently, other may be associated with weakness of shoulder girdle
cervical roots emerge above the respective muscles.
vertebrae. C8 emerges below C7 vertebra. Thoracic Outlet Syndrome Due
Thereafter the thoracic and lumbar nerve roots to Cervical Rib
emerge below their corresponding vertebrae. This is felt as a dull ache in the distal part of the
For example, L4 root emerges below L4 forearm and the hand, usually on the ulnar aspect,
vertebra at the interspace between L4 and L5, worse in erect posture and relieved by recumbency.
vertebrae. It may be associated with weakness and wasting of
2. Due to their shorter and more horizontal the hand muscles and trophic changes.
course, the cervical roots and their corres-
ponding intervertebral foramina bear a con- Ulnar Neuropathy
stant relationship, that is C4 root will be This presents as acute or subacute onset of pain and
affected by a prolapsed intervertebral disk paraesthesia on the unlar border of the forearm and
between C3 and C4 vertebrae only. However, hand with weakness of the little and ring fingers.
in the lumbar region, this relationship is Usually this follows trauma or pressure on the ulnar
altered because the spinal cord ends at the nerve behind the elbow.
lower border of L1 vertebra and the lumbar
roots have to travel through a long oblique Carpal Tunnel Syndrome
course before they exit from the intervertebral This is caused by compression of the median nerve
foramina. Hence, a disk lesion at any level in by the flexor retinaculum at the wrist. It leads to
the lumbar region can affect a root anywhere pain and paraesthesia in the hand on the lateral
between its origin from the spinal cord and its aspect, worse during sleep. At times pain may
exit through the intervertebral foramen. For radiate up the forearm and even the arm. Pain is
instance, S1 root which has more than 15 cm worsened by hyperextension of the wrist. This may
intraspinal course, may be affected by a disk be associated with weakness and wasting of the
lesion anywhere along its course. thenar muscles. At times it is bilateral.
Chapter 33: Special Problems in Neurology 503
34 Investigations in
Neurological Diseases
Several neurological abnormalities can be like protein C and protein S lead to venous and
diagnosed by biochemical investigations. The arterial thrombosis in the CNS. Management of
reader should refer to textbooks on neurology these cases is the realm of the hematologist. Several
for a complete list. hematological diseases such as sickle cell anemia
and leukemias lead to neurological syndromes.
Hematology
Serological tests
Hemoglobin level
Both syphilis and AIDS are common to produce
Anemia leads to headache, giddiness, throbbing in neurological complications and therefore, routine
the head, syncope and retinal changes such as testing is indicated in a suspected case-VDRL in
hemorrhage and papilloedema. These are more the serum or CSF for syphilis and Elisa and Western
pronounced when the hemoglobin level drops blot tests for AIDS.
below 6 g/dL. These clear up when the hemoglobin
level is restored to normal. Parasitology
Total and Differential Leukocyte Counts Falciparum malaria, trypanosomes, and cysticerci
are common to involve the CNS. Malaria and
Acute leukemias, particularly acute lymphatic trypanosomiasis can be diagnosed by blood smear
leukemia leads to neurological involvement which examination. Cysticercosis can be diagnosed by
may present clinically with the picture of meningitis, serological tests and the presence of these cysts in
as isotopic studies and CT scaning. meningitis and encephalitis where delay in specific
8. To introduce therapeutic agents into CSF, e.g. treatment may lead to mortality or severe morbidity,
antibiotics for meningitis, antileukemic drugs LP should not be delayed, since CSF examination
in acute lymphatic leukemia and others. is the gold standard of diagnosis. If there is any
9. To administer spinal anesthesia. contraindications or LP cisternal puncture should
10. As a therapeutic measure to reduce intracranial be done to collect CSF.
pressure in idiopathic intracranial hypertension,
neonatal intraventricular hemorrhage, and Procedure of LP
hydrocephalus complicating meningitis.
Explain the procedure to the patient and relatives
Contraindications for LP and get informed consent. The LP should be done
1. Sepsis at the site of lumbar puncture. The under strict aseptic precautions as for a minor
infection may spread into CSF and lead to surgical procedure.
maningitis. i. Position of the patient: Make the patient lie
2. Possibility of raised intracranial pressure, on the edge of a hard bed on his left side with
particularly due to intracranial space occu- his back perpendicular to the bed. Keep him
pying lesions. If CSF is released from below in in ‘fetal’ position, i.e. knees drawn up towards
the presence of raised intracranial tension, the chest and the head flexed, so as to widen
downward herniation of brain occurs leading the interspinous spaces maximally.
to pressure effects and reduction in blood supply ii. Preparation of skin at the puncture site:
of the brainstem, resulting in respiratory Expose his back from mid thoracic to mid
paralysis and death. This is known as ‘coning gluteal region. The skin is thoroughly cleaned
effect’. The common structures that herniate are in turn with spirit, iodine and spirit or
the uncus of the temporal lobe through the providone iodine. Drape the area with sterile
tentorium cerebelli and cerebellar tonsils into towels, exposing only the area to be punctured.
the foramen magnum. iii. Localization of the puncture site: LP is done
3. Possibility of spinal cord compression: Sudden usually through the interspinous space between
release of CSF pressure from below may L3-L4 or L4-L5 vertebrae. In infants, the L4-
worsen cord compression in cases of spinal L5 space is selected due to low placement of
tumors, edema or infection of the cord and the conus medullaris. The L3-L4 space can be
others. easily identified as it lies just below the line
Chapter 34: Investigations in Neurological Diseases 507
joining the highest points on the iliac crests. If no CSF emerges, refix the stylet, advance the
Select this interspace and mark it. needle a bit more and then remove the stylet to see
iv. Local anesthesia: It is produced by injecting CSF flow. If you feel that you have entered the
about 2 mL of 2%, lignocaine solution, first subarachnoid space by the ‘giving way’ feeling on
into the skin and then into deeper tissues. Start the needle, but still no CSF is coming out, perform
the LP only after ensuring that the spot is Queckenstedt’s test to raise spinal CSF pressure and
anesthetized. promote flow. If this is also unsuccessful withdraw
v. Insertion of LP needle: The LP needle is a the needle up to the subcutaneous tissue and
special hollow needle about 8 cm long with a reintroduce it in a different direction. If two or three
sharp, short bevel at its tip and provided with attempts fail, try the procedure through the adjacent
its style. LP needles are available in sizes of 9, interspinous space or defer the procedure to a
18, 20 and 21 gauge. The higher the number, subsequent occasion and perform LP preferably
smaller the bore and length of the needle. For after sedating the patient.
an average sized adult, 18 or 19 gauge needle An alternate position to do LP is with the patient
should be used. For children, 20 or 21 gauge is sitting up with his legs hanging by the side of the
to be preferred. couch, and leaning forward over a pillow held firmly
Stretch the skin over the site of puncture at the in front of his abdomen, so that his face touches his
same time feeling for the interspace with the tip of thighs. In this position, the interspinous spaces are
is tense and not fully relaxed or the head is flexed, lumbar subarachnoid space as a rise in pressure in
thereby the jugular veins are compressed. These the manometer or more rapid flow of CSF.
factors should be corrected before taking the final Subjectively, increase in flow can be observed by
reading. If the pressure is genuinely elevated, counting the number of drops in five seconds before
disconnect the manometer and withdraw the LP and after the procedure. On releasing the
needle after inserting the stylet. The CSF obtained compression in the neck, the CSF flow returns
from the manometer can be used for further tests. If to the original rate. If the spinal block is total,
the pressure is normal or low Queckenstedt’s test is there will be no rise of pressure in the lumbar
done before disconnecting the manometer. subarachnoid space on performing the test. In the
Even while doing LP note the rate of flow of early stages, when the block is partial, the rise in
CSF, its color and consistency and the responses to pressure may be prompt, but the fall on releasing
Queckenstedt’s test. If possible, collect the first few jugular compression is unduly delayed.
drops directly on glass slides for examining the If the lateral or sigmoid venous sinus of one side
cellular content and for Gram staining in the case is occluded by thrombus, there will not be rise of
of purulent CSF or opalescent CSF. intracranial pressure on compressing the jugular
vein on that side. Queckenstedt’s test is
Queckenstedt’s test: This test is employed to
contraindicated in the presence of raised intra-
determine whether there is spinal block, i.e.
cranial pressure.
any block between the intracranial and lumbar
Part–I: Internal Medicine
subarachnoid space. In conditions such as Collection of CSF: While performing LP, the CSF
intramedullary or extramedullar tumors in the spinal should be collected for the following tests, as per
canal and spinal arachnoiditis, spinal block may the clinical indications. In all about 5 mL of CSF
develop. may be collected in three sterilized containers.
With the patient lying in the lateral decubitus,
and CSF flowing freely through the LP needle or CSF EXAMINATION
during spinal manometry, compress the internal
jugular vein of one side at the root of the neck for Microscopic Examination (Table 34.1)
about 10 seconds. This hinders venous return from 1. Cell count: Normal CSF is clear like water,
the intracranial venous sinuses and thus elevates colorless and contains only up to 2 to 5
intracranial pressure. This rise is reflected in the lymphocytes per cmm. Pleocytosis is the
presence of excessive number of leukocytes. specimens are taken at the same time. Dispro-
When more than 200 cells/cmm are present, portionate fall in CSF glucose occurs in all types of
the fluid may become opalescent. Presence of bacterial meningitis. In tuberculous meningitis,
more than 1000 cells/cmm makes it frankly substantial reduction of CSF glucose is a very
turbid and purulent. Purulent CSF is suggestive valuable diagnostic clue which helps to arrive at the
of bacterial meningitis and the predominent provisional diagnosis early. In viral meningi-
cells are neutrophils. Morphology of the cells tis, encephalitis and neuroleukemia in which
can be made out by wet-staining with methylene lymphocytes may be seen in excess, the CSF glucose
blue. Absolute count can be done as is done for is not diagnostically altered.
WBC in a Fuchs-Rosenthal counting chamber.
Chlorides: The CSF chloride levels vary directly
CSF pleocytois may be due to lymphocytes,
with the blood chloride levels. Low CSF chloride
granulocytes or mixed. Presence of excess cells
levels occur in dehydration and electrolyte depletion.
is the most definite diagnostic evidence of
It is not of specific diagnostic importance.
meningitis. In infiltration of the central nervous
system by leukemia, lymphoma and carcinomas, Immunoglobulins: Identification and estimation of
the corresponding abnormal cells appear in IgG may help in the diagnosis of multiple sclerosis,
CSF. sarcoidosis and connective tissue diseases. Normally
2. Gram staining: This is the most easy and IgG in CSF is 6 to 12% of the total proteins. Values
readily available rapid method to diagnose the above 20% are abnormal. Electrophoresis of CSF
Several other tests are available which are to be by using the smallest bore needle for LP. The
employed by the neurologist under particular headache stops spontaneously over hours.
circumstances. Sometimes, it may be prolonged and distressing.
Blood Stained CSF Analgesics may help, so also rehydration of the
patient and reassurance.
This may be due to injury to one of the veins during 3. Infection and secondary meningitis is a rare, but
LP or it may be due to subarachnoid hemorrhage. grave complication. This should be avoided by
These can be easily distinguished by the points given strict aseptic precautions.
in Table 34.2. In subarachnoid hemorrhage, the 4. Chemical meningitis may result from irritation
erythrocytes break down releasing bile pigments by the drug introduced into the CSF.
which stain the CSF yellow. This is seen about 6
hours after the bleed. Alternative Methods to Obtain CSF
Complications of LP When examination of the CSF is mandatory and
1. Coning of the brainstem: This should be absolutely necessary to establish the diagnosis, but
suspected if: where the LP fails repeatedly, CSF can be obtained
a. The patient becomes less alert by cisternal puncture or cerebral ventricular
puncture. Sometimes cisternal puncture is done to
b. The pupils start dilating
introduce dye to delineate the upper level of spinal
c. The respiration becomes shallow and
block.
Part–I: Internal Medicine
slower.
To avoid this, the patient should be made to lie
SPECIAL NEUROLOGICAL INVESTIGATIONS
prone soon after LP and the foot end of the bed
raised by 45 cm by suitable blocks under the cot.
If coning is suspected, immediately give 20%. Tests for structural integrity Tests for functional
integrity
mannitol 200 mL intravenously rapidly and
Brain Computed tomography Electroencephal-
summon the help of a neurologist or neurosurgeon.
(CT) ography (EEG)
2. Postlumbar puncture headache: This is due to Magnetic resonance Evoked potential
disturbance of CSF hemodynamics and leak of imaging (MRI) study (EP)
CSF into extradural space. This is minimized Cerebral angiography Brain electrical
(conventional) activity mapping (BEAM)
Digital subtraction Single photon
Differentiation in CSF between traumatic angiography (DSA) emission computed
Table 34.2: tomography (SPECT)
bloody tap and subarachnoid hemorrhage
MRI angiography MRI spectroscopy
Findings Traumatic Subarachnoid Transcranial doppler study Positron emission
blood staining hemorrhage Radioisotope scan tomography (PET)
1. Observation of Tends to become Uniform blood staining Echoencephalography
CSF on flowing clearer Electrogencephalography by (PEG)
from the LP
Brain biopsy
needle or if it is
collected in 3 Spinal CT scan Evoked potentials
successive tubes cord MRI scan (EP)
Myelography
2. CSF is kept at The blood clots Does not clot, but the
room temperature erythrocytes settle to Nerve Nerve biopsy Nerve conduction
for 1 hour the bottom. In SA velocity (NCV)
hemorrhage study, Evoked
potentials
defibrination takes
place. Muscle Muscle biopsy Electromyography
(EMG)
3. Supernatant fluid Supernatant is Supernatant is
observed after colorless xanthochromic due to Muscle enzymes-
centrifuging for the presence of bile Neuro- CPK and LDH
2 minutes at 3000 pigment muscular Repetitive,
RPM, soon after junction electrical nerve
obtaining the CSF stimulation
Chapter 34: Investigations in Neurological Diseases 511
A B
detecting deep seated small pathological lesions in a peripheral nerve and a brief electric shock, slightly
the brain. However, it is very expensive and hence greater than that required to produce a maximal
is not easily, available for clinical studies. contraction of the innervated muscle (supramaximal
stimulus) is given to produce muscle contraction.
NERVE CONDUCTION STUDIES
The action potential generated by the contracting
Nerve conduction study is employed to test the muscle is picked up by recording electrodes placed
integrity of a peripheral nerve. The presence or on the skin over the muscle and this is displayed on
absence of denervation, the site of nerve block if a cathode-ray oscilloscope for analysis. The action
any, and nature of the lesion such as demyelination potential of the muscle occurs a few milliseconds
or axonal lesions can be detected easily even if the after the stimulus is delivered (stimulus artefact).
patient is not cooperative. Hence this test can be The time taken for the stimulus impulse to travel
employed in infants, children and in comatose along the nerve and the neuromuscular junction from
patients. the stimulation artefact to the beginning of the
Nerve conduction velocity studies (NCV) are evoked muscle action potential is called latency, and
of two types: it is measured in milliseconds. The duration and
i. Motor nerve conduction velocity (MNCV) amplitude of the evoked muscle action potential are
study also measured.
ii. Sensory nerve conduction velocity (SNCV) For determining nerve conduction velocity, the
study. same nerve is stimulated at two points along its
In motor nerve conduction studies, a stimula- course. The difference in the latency times of these
ting surface electrode is placed on the skin overlying two stimuli gives the conduction time between the
Chapter 34: Investigations in Neurological Diseases 513
two points of stimulation. The distance between 75% by 1 year and reach adult values by about 4 to
these two sites is measured and the NCV calculated 5 years of age. There is gradual slowing of conduction
as meters/ second. Normal is 50 to 60 m/sec. velocities as the age advances (3% decline per
NCV studies are valuable (i) to detect demy- decade after 30 years) with a steep decline after the
elination in the peripheral nerves where the NCV age of 60 years. Upper extremity nerve conduction
will be significantly slowed down (ii) to detect velocities are generally 10 to 15% faster than those
axonal lesion where the NCV may be within normal of the lower extremity nerves. Sensory nerve
limits but the evoked muscle action potential will conduction time is about 5% faster than motor
be of abnormally low amplitude and longer duration. conduction time.
NCV study also helps to localize the site of pathology For diagnozing neuromuscular disorders, such
in the peripheral nerves. as myasthenia gravis, a peripheral nerve such as
Using special techniques, it is also possible to median or ulnar nerve or the brachial plexus at the
study electrophysiologically the integrity of the Frb’s point in the neck is stimulated by delivering a
proximal portion of the nerve roots and the reflex series of supramaximal stimuli and the evoked
arc. response is recorded from the corresponding
Routinely, motor nerve conduction studies are muscles. A significant decrease in the amplitude of
performed on median and ulnar nerves in the upper the third or fourth evoked muscle response as
limbs and the lateral popliteal nerves in the lower compared to the first response suggests myasthenia
gravis. This phenomenon is known as decremental
a flash of light, or more commonly by a When the muscle contraction ceases, again the
checker board pattern on a TV screen. muscle becomes electrically silent.
2. Auditory evoked potentials (AEP) elicited by When a muscle becomes weak due to a primary
stimulating the ears by clicks through head muscle disease like myopathy, its EMG pattern
phones differs from that of a normal muscle. When the
3. Somatatosensory evoked potentials (SSEP) affected muscle is at rest, there will be spontaneous
produced by stimulating the peripheral nerves electrical activity in the form of fibrillation poten-
with electrical current. tials. During minimal voluntary contraction, the
The evoked electrical potentials, which are of generated action potentials will be of lower
very low amplitude are averaged by a computer and amplitude and shorter duration as compared to a
amplified by special equipment. These amplified normal muscle and during maximal contraction, the
potentials are picked up by surface electrodes on recruitment potentials will be full. As against this, a
the scalp or over the spine in the case of SSEP. By muscle which is weak due to a neurogenic lesion,
knowing the normal time taken for the impulse to i.e. its neural connection to the anterior hom cells of
travel from the site of stimulation to the cortex the spinal cord is affected, it shows spontaneous
(latency) it is possible to find out in a given patient, electrical activity at rest in the form of fibrillation
whether his EP latencies are normal or not. and fasciculation potentials and during minimal
If abnormal, it is also possible to localise the site of voluntary contraction, the action potentials will be
Part–I: Internal Medicine
abnormality in the sensory pathways. The advantage of larger amplitude and longer duration than normal
of these studies is that they do not depend on and during maximal contraction, the recruitment
subjective sensations by the patient and also they potentials will be less than normal.
can be performed in comatose individuals, in infants, Thus, EMG helps to differentiate muscle weak-
children and uncooperative adults under sedation. ness due to a primary muscle disease from that
due to a nerve or anterior horn cell disease. But
ELECTROMYOGRAPHY it does not indicate the causes or etiology of
Electromyography (EMG) is an investigation in the diseases for which other supplementary
which the electrical activity of muscle is recorded investigations are required. Many a time it is
through a needle electrode inserted into the muscle possible to distinguish primary myopathy from
and it is displayed on a cathode ray oscilloscope neuropathy clinically, but occasionally it is difficult.
and played over a loud speaker for simultaneous EMG is most valuable to distinguish such cases.
visual and auditory analysis. Usually this is Characteristic EMG pattern occurs in myotonic
performed by the neurologist and is associated with disorders (dive bomber sound) and EMG also helps
some amount of discomfort to the patient because to differentiate true myotonia from pseudomytonia
of multiple needle insertions into the muscle. and true weakness from hysterical weakness. Muscle
Basically it is carried out to know whether a enzyme levels like creatine phosphokinase (CPK)
muscle is normal or shows evidence of myopathy and lactic dehydrogenase (LDH) in the serum may
or neurogenic lesion, both of which can lead to transiently increase, following an EMG investigation
muscle weakness and wasting. A normal muscle is because of the needle trauma to muscles. Therefore,
electrically silent when it is at complete rest. the blood samples for estimation of these enzymes
When it contracts minimally voluntarily, the should be collected before performing the EMG.
action potentials of motor units that are activated
MUSCLE ENZYMES
appear on the oscilloscope which have a certain
configuration, amplitude and duration. With more There are several enzymes in the muscles which will
and more vigorous voluntary contraction, the be released into circulation whenever there is injury
number of these action potentials increases and to the muscles. Of these, creatinine kinase (CK)
during maximal contraction which recruits all the is the most important one. The CK is an enzyme
motor units for contraction, these potentials merge found primarily in skeletal muscles, heart and brain
with each other to give full recruitment pattern. with concentration in skeletal muscles being more
Chapter 34: Investigations in Neurological Diseases 515
than 3 times that in the heart and brain. There are 3 abnormal calcification or shift of the calcified falx
forms of CK isoenzymes - MM (skeletal muscles), cerebri and/or pineal gland across the midline in a
MB (cardiac muscle), and BB (brain). Normal adult few cases. Enlargement of the pituitary fossa caused
skeletal muscle contains about 95% MM and by a pituitary tumor, thickening of the skull vault in
5% MB. The normal serum CK concentration is acromegaly, and abnormal calcification in tuberous
< 130 u/L. sclerosis and Sturge-Weber syndrome can all be
Muscle damage due to any cause significantly detected by skull X-rays.
elevates CK levels in the serum. It should be X-rays of the vertebral column are indicated
remembered that normal exercise, an IM injection whenever lesions are suspected in the vertebrae,
or even EMG examination with needle electrodes spinal cord, spinal roots or the adjacent tissues.
may elevate CK levels as much as 3 to 8 fold which Routinely, both anteroposterior (AP) and lateral
may take 24 to 48 hours to return to normal level. views are obtained. In the cervical and lumbar
Marked CK elevation occurs only in polymyo- regions, additional right and left oblique views are
sitis or dermotomyositis, some types of muscular required because the intervertebral foramina are
dystrophies and hypokalemic myopathy. Serum CK seen well only in the oblique pictures. While
is also elevated in acute myocardial infarction, ordering for X-ray of the spine, the particular region
collagen vascular disease, burns, chest trauma, of interest should be specified so that this portion
status epilepticus, brain infarction, hyperthermia, can be focussed properly in the picture.
artery on either side. After positioning the catheter is injected into the lumbar subarachnoid space and
tip in the desired vessels, radio-opaque iodinated it is manipulated to enter the cerebral ventricles and
contrast agent is injected under pressure into the subarachnoid space.
catheter and a rapid series of X-rays is taken while The air acts as contrast agent in X-ray studies.
injecting the contrast agent. This procedure is invasive, and it is seldom done at
This is time-consuming and invasive procedure present.
with a definite risk of minor and major complications
Myelography
requires hospitalization of the patient.
This procedure which used to be carried out to
Digital Subtraction Angiography investigate spinal cord lesions such as compression
Digital subtraction angiography (DSA) is an by extramedullary tumors or prolapsed intervertebral
advancement over the conventional cerebral disks, intramedullary tumors and arachnoiditis is not
angiography. In this procedure, the contrast agent done regularly at present. Since the introduction of
A B
Figs 34.3 A and B: Carotid angiography. A and B show Berry aneurysm—arrows
Chapter 34: Investigations in Neurological Diseases 517
CT and MRI, myelography is required only for a rhinorrhea. This is also replaced now by CT and
much smaller number of patients, greater information MRI.
can be obtained by combining CT with myelography
(CT-myelography). COMPUTED TOMOGRAPHIC SCAN
At present computed tomographic scan (CT) scan
Complications has become a part of routine investigations in the
Angiography, pneumoencephalography, ventricul- evaluation of many neurological problems. In most
ography and myelography and associated with of the towns and cities in India CT scan centers
potential complications. Mild reactions include have come up. The cost is relatively high, ranging
anaphylaxis, headache, vomiting, and convulsions. from Rs. 1000 to Rs. 5000 depending upon the part
Serious reactions include, encephalopathy, imaged (Figs 34.4 to 34.6A).
worsening of neurological status, meningitis and Indications
death. Air embolism may complicate pneumoen-
The CT scan of the head is indicated and essential
cephalography.
for diagnosis and management of the following
conditions:
Radioiodinated Serum Albumin
Cisternography A patient with:
1. Focal neurological deficit of relatively recent
By injecting 99 technetium-tagged serum albumin
A B
Figs 34.4A and B: CT scan showing (A) extradural and (B) subdural hematomas. Note: The hematoma compressing the brain
tissue and leading to pressure effects, i.e. distortion of the ventricles and shift of midline structures
518 Section 11: Neurology
Fig. 34.5: CT scan showing hydrocephalus Fig. 34.6A: CT scan. Tuberculoma right parietal lobe (see
Note: The dilated ventricles and thinned cortex arrow). Male aged 26 with epilepsy. Completely cleared with
therapy
Part–I: Internal Medicine
5. Late onset seizures CT does not ensure that all possible structural
6. Subarachnoid hemorrhage pathologies have been excluded. In such situations
7. Head trauma MRI may reveal abnormalities.
8. Suspected intracranial mass lesion
9. Parasitic diseases of the brain, e.g. hydatid MAGNETIC RESONANCE IMAGING
cyst, cysticercosis. Magnetic resonance imaging (MRI) offers better
CT scan is also the procedure of choice in visualization of the anatomy of the brain and the
patients in whom MRI is contraindicated due to the spinal cord because of its high resolution. This is
presence of implanted cardiac pacemakers, also a safe, rapid and noninvasive procedure like
mechanical heart valves or magnetizable intra- CT, but it is more expensive (Rs. 5000 to Rs. 12000
cranial metal clips. per study). The advantages of MRI over CT scan
Although a normal CT is sometimes reassuring are (Figs 34.6B, 34.6C and 34.7):
to the patient as well as to the clinician, the practice 1. It has better spatial and contrast resolution than
of ordering CT scan indiscriminately should be CT
discouraged. Under no circumstances, CT should 2. It is free of exposure to radiation
be considered as a substitute to clinical examination. 3. It is free of bone artifacts
CT scanning delivers a high dose of irradiation 4. Several additions studies of function, e.g.
which should be avoided if possible cardiac output, cornonary blood flow and meta-
Limitations: While CT imaging of the supraten- bolic activities can be performed by suitable
torial structures in the brain is quite good, its use in modification.
the evaluation of the posterior fossa structures such For MRI scan, the patient has to be kept in a
as brainstem and the cerebellum is limited because highly confined space which makes some patients
of the beam-hardening artifacts of adjacent bones. claustrophobic, with modern machines the speed of
For the same reason, CT for the evaluation of spinal imaging is more, so also the tendency for claustro-
cord diseases is less than satisfactory. The other phobia and discomfort is less.
limitations of CT are its inability to reveal very small MRI is the investigations of choice for lesions
lesions, isodense lesions (lesion density same as that in the posterior fossa and spinal cord, such as
of normal brain) and cerebral infarcts in the first syringomyelia and other structural lesions. Because
24 to 48 hours of their occurrence. Hence, a normal of its higher resolution, it is also useful to detect
Chapter 34: Investigations in Neurological Diseases 519
Fig. 34.6B: MRI showing periventricular lesions in MS. Fig. 34.7: MRI cervical spine showing demyelinating lesions
Note: The demyelinated plaques in a patient with transverse myelitis. Note: (1) general swelling
of the cord and (2) hyperintense (whitish) lesions
4. Functional MRI (FMRI): Fast imaging transmitters and their receptors can also be
methods, such as echoplanar imaging can determined with PET. Combination of PET and CT
provide images of working brain, almost in real (PET-CT) is being employed more frequently to get
time with a good resolution. Using this proper diagnosis of lesions which are not clearly
technique, it is possible to delineate areas of diagnosed by CT or MRI.
brain that are responsible for specific functions
such as primary sensory and motor cortex, SINGLE PHOTO EMISSION COMPUTED
lateralization of language function and others. TOMOGRAPHY
This is being employed to delineate the speech Like PET, single photo emission computed
area during the neurosurgical procedures. tomography (SPECT) also provides information
5. Diffusion-weighted (DW) and perfusion- about the function of the brain. It also involves
weighted (PW) MRI: These are MR imaging administration of gamma ray emitting radio-
techniques that are sensitive to the early nucleides. However, these radionucleides are of
pathophysiologic changes induced by cerebral longer half life and hence do not need a costly
ischemia (e.g. acute ischemic stroke). Soon cyclotron near by. Therefore, SPECT can be
after the onset of ischemic stroke, if MRI is described as a poor man’s PET. It is now available
performed using these techniques, it is possible only in some centres for clinical use, especially to
to detect the extent of actual infarct on DW study cerebral blood flow, cerebral blood volume
Part–I: Internal Medicine
MRI and also the extent of the surrounding and cerebral neurotransmitter receptors.
ischemic area (ischemic penumbra) on PW
MRI . This information may guide the clinician ECHOENCEPHALOGRAPHY
for thrombolytic treatment in acute ischemic This noninvasive ultrasound investigation, which
stroke. was popular before the advent of CT scanner is still
useful to detect the shift of the midline structures
POSITRON EMISSION TOMOGRAPHY caused by supratentorial space occupying lesions,
Whereas CT and MRI techniques provide informa- and to detect the size of the ventricles. Currently,
tion regarding the structural details of the brain and an advanced real time ultrasound scanner capable
the spinal cord, positron emission tomography of high resolution is available to diagnose intra-
(PET) provides information about their function cranial hemorrhage in infants.
also.
IMAGING STUDIES OF MUSCLES
It is performed by administering intravenously
or by inhalation, a positron-emitting radio nucleide Although imaging studies of skeletal muscles are
of very short half-life. This necessitates the not routinely performed, ultrasound, CT, and MRI
availability of a cyclotron near the scanning site in can quantify muscle atrophy, identify the muscle
order to provide the radio-isotopes. Because of this groups that are affected, detect fibrofatty tissue
requirement, its cost is high (>Rs 15000). This replacement in the muscles, and locate muscle and
investigation is available in a limited number of tendon abscesses and other pathologies in the
centers in India. The PET which used to be used muscles and tendons. Technetium diphosphonate or
mainly as a research tool has found its place pyrophosphate imaging can demonstrate muscle
increasingly in clinical work. The combination of fiber damage in polymyositis.
PET and CT (PET-CT) is of great use in diagnozing
and qualtifying malignancy and other lesions when DUPLEX DOPPLER SCANNER
other modalities are inconclusive. Processes such Doppler ultrasound which is a noninvasive
as cerebral blood flow, glucose and oxygen investigation employed to study the arterial wall and
metabolism and cerebral blood volume can be the blood flow within the extracranial portion of
studied noninvasively both in health and disease. the carotid arteries, is useful to detect carotid
The concentrations and locations of various neuro- stenosis and occlusions.
Chapter 34: Investigations in Neurological Diseases 521
SECTION
12
Pediatrics
CHAPTER
35
1 Clinical Examination
of Children
KE Elizabeth
Case recording format, Physical examination, Hand to head to foot examination, Assessment of growth
(Anthropometry), Nutrition, Trivandrum development screening chart, Investigations, New born baby
Vaccines that have to be Given After that point of time. Immune attrition associated
Discussion with Parents with viral replication may particularly interfere
Age Vaccine Route
with memory responses. Consideration should be
> 15 months of age Varicella Vaccine# SC
given to readministering childhood immunizations
> 18 months of age Hepatitis A vaccine ^ IM to such children when their immune status has
> 6 weeks of age *rotavirus, improved following antiretroviral therapy.
pneumococcal conjugate IM
vaccine (PCV7) Vaccination Schedule for Adolescents
# < 13 years of age: 1 dose; > 13 years of age: 2 doses at 4 to 8 weeks interval No. Vaccine Age
^ 2 doses at 6 to 12 months interval 1. Td/TT Booster at 10 and 16 years
* Rotavirus vaccine—2 to 3 doses as per brand at 4 to 8 week interval 6 week to 6 2. MMR vaccine One dose if not given earlier
month old
PCV 7 to 3 primary doses at 6, 10 and 14 weeks followed by a booster at 15 to 18 3. Hepatitis B Three doses (20 mcg) 0, 1 and 6 months
months. if not given earlier
4. Typhoid vaccine Vi Polysaccharide vaccine every three
years
IMMUNIZATION IN SPECIAL CIRCUMSTANCES 5. Varicella vaccine* One dose up to 13 years and 2 doses
(at 4 to 8 weeks interval) after 13 years of
1. Immunization in preterm infants: In general, all age if not given earlier
vaccines may be administered as per schedule to 6. Hepatitis A Two doses 0 and 6 months if not
vaccine* given earlier.
stable babies, according to the chronological age,
7. Human papilloma Three doses 0, 1 or 2 months, 6
irrespective of birth weight or period of gestation. virus vaccine months starting at 10 years of
Very low birth weight/preterm babies can be given (for girls). age.
Part–II: Specialties
immuni zations after initial stabilization. HBV *Only after discussing with parents on a one to one basis
is usually given when baby attains 2 kg weight.
2. Children receiving corticosteroids: Children Family History
receiving oral corticosteroids in high doses (e.g. • Consanguinity, construct a three-generation
Prednisolone 1 to 2 mg/kg/day) for more than 14
pedigree in genetic disorders
days should not receive live virus vaccines until
• Age and health of parents
the steroid has been discontinued for at least one
• Family planning measures adopted
month. Killed vaccines are safe but may be
• Details of siblings, unexplained deaths in the
incompletely effective in such situations. Patients
family
on topical or inhaled steroid therapy should not
• Contact with TB, history of diabetes, allergic
be denied their age appropriate vaccines.
disorders, and similar illness in the family.
3. Children awaiting splenectomy: Children with
loss of splenic function are at high risk of Socio-economic History
serious infections with encapsulated organisms. Record socioeconomic status, occupation, education
If surgical splenectomy is being planned, and family income, any insurance or financial
immunization with pneuumococcal, HIB and reimbursement/ESI benefits.
meningococcal vaccines should be initiated a few
Also record housing conditions, sanitary
weeks prior to splenectomy.
facilities, source of drinking water, pets and recent
4. Vaccination in children with HIV infection:
travel.
Children infected by HIV are particularly
vulnerable to severe, recurrent, or unusual
PHYSICAL EXAMINATION
infections by vaccine preventable pathogens. It
must be emphasized that routine immunizations A. General Examination
seem to be generally safe in such children, but 1. General comment: Appearance, well-being,
the immune response following vaccination would attitude, hydration, color, sensorium
depend upon the degree of immunodeficiency at 2. Vital signs (Table 35.2)
528 Section 12: Pediatrics
a. Temperature: Keep the thermometer in- d. Blood Pressure: Use appropriate BP cuff
situ for 1 to 2 minutes before taking the size—in order to cover middle 3rd of the
reading. Oral, axillary, rectal, ear drum upper arm. Smaller cuff will give higher
or skin temperature can be measured. In BP. BP cuff sizes are given below:
newborns, rectal or axillary temperatures • 3.5 cm,
are measured. Low reading thermo- • 7 cm or
meters which can record as low as 30°C, • 12.5 cm (standard) Both palpatory and
may be needed to detect hypothermia. auscultatory methods are used.
In young children axillary temperature 50th centile of BP is roughly 90 + (2 X)
and in older children and adults, oral and 5th centile is 70 + (2X), where ‘X’
temperature is measured. Normal core is age in years.
temperature is 37°C or 98.6°F. Skin The average BP of newborn is 60/40,
temperature is 1°C lower than core
which is half of the adult BP and at 1
temperature. Hyperpyrexia is >41°C
year, it is 90/60 mm of Hg.
(105°F) and hypothermia <35°C(95°F).
Other methods of recording BP are
For axillary reading, 0.5°C or 1°F is
added to get the core temperature except oscillometric, doppler and intra-arterial
in newborn babies, who have relatively techniques. Noninvasive BP (NIBP)
more of metabolically active brown fat recording is done in ICUs.
in the axilla. e. Capillary filling Time (CFT): Raise the
Fever is accompanied by tachycardia, limb above the heart level and press the
Part–II:Specialties
Part–II: Specialties
Eye Opening • Shape of scalp, forehead bulging, prominent
• None veins
• To pain • Sutures: Metopic suture is noted in the
• To speech midline of forehead. Palpable sutures,
• Spontaneous. ridging of sutures like ‘Keel of the ship’ is
seen in craniostenosis and overriding sutures
Best Verbal Response for Adults with step formation is seen in microcephaly
• None due to reduced brain growth.
• Incomprehensible sounds • Fontanels—depressed/bulging, open/closed,
• Inappropriate words pulsatile, borders felt/not, measure the size
• Confused also.
• Oriented. Fontanel is the meeting point of 3 bones. At birth
For Infants and Toddlers there are 6 fontanels, anterior (AF) at the meeting
point of frontal and 2 parietal bones, posterior (PF)
• None
at the meeting point of occipital and 2 parietal bones,
• Restless, agitated
• Persistently irritable
• Consolable cry
• Appropriate words, smiles, fixes and follows.
Best Motor Response
• None
• Extensor response
• Abnormal flexion
• Withdrawal
• Localizes
• Obeys.
Score: 13 to 15 mild, 9 to 12 moderate and <8 is Fig. 35.1: Palmar creases in normal
severe coma and down syndrome (simian crease)
530 Section 12: Pediatrics
anterior lateral (ALF) at the meeting point of frontal, Mouth: Look for
parietal and temporal on either side and posterior • Oral hygiene, dental caries, throat /tonsil
lateral (PLF) at the meeting point of occipital, • Cleft lip/palate, vitamin deficiency
parietal and temporal bones on either side. • Color and no. of teeth,
AF closes by 9 months—1½ yrs, PF by 3 to 6 • Inverted V-shaped upper lip seen in myopathy.
months, Usually PF is not palpable at birth and if
posterior fontanel is open and palpable at birth, check Neck: Look for
for hypothyroidism, hydrocephalus or skeletal • Length of the neck (distance between external
dysplasia. occipital protuberance and C7 spine)
Bones may be brittle and ping pong sensation or
egg shell crack may be elicitable in preterms and in height
Normally the fraction length of the neck is >
rickets.
Hair 13.7. Values <13 indicate ‘short neck’ which is
suggestive of craniovertebral anomalies.
Look for color, pigmentation growth, texture, hair • Look for webbing of the neck and, low hair line,
lines, sparse hair, pluckability and seborrhic • Thyroid and lymph node enlargement, pulsations.
dermatitis (cradle cap).
Chest: Look for
Face
• Sternum—pectus excavatum (depression) seen in
Look for dysmorphism, mooning of face, coarse
upper airway obstruction, Marfan’s syndrome and
facies, midfacial hypoplasia, micrognathia/
Part–II:Specialties
Part–II: Specialties
Lower Limbs: Look for At birth 3 Kg
• Hyper mobility age in months + 9
• Joint swelling – knee, ankle 3–12 m
2
• Deformities, weakness
• Congenital talipes equino varus (CTEV) 1–6 yrs 2 age in years + 8
• Chappal sign (Sandal gap) between big toe and
2nd toe in trisomy 21 7 × age in years – 5
• Kennedy sulcus (a crease seen on the sole starting 7 – 12 yrs __________________________________
• The adult height is generally twice the height Upper Segment (US): Lower Segment
attained at two years (2 × height at 2 yr = adult (LS) Ratio
height)
Upper Segment is the distance between the upper
• Weech’s formula for height of children aged 2 to margin of the pubic symphysis to the vertex (It is
12 years is given below the total height – lower segment) - Height -LS.
• Height in cms = (6 age in years) + 77 LS distance between the upper margin of the
Waterlow classificaion for stunting (height for symphysis pubic to toes.
age) indicating chronic malnutrition is listed in Table 35.8 gives the US by LS ratios at different
Table 35.5. ages
Waterlow Classification for stunting Table 35.8: US/LS ratios
Table 35.5:
(Height for age)
Birth 6 months 1 yr 2 yr 3 yr 4 yr
Height for age Grade of stunting
Normal > 95% 1.7:1 1.6:1 1.5:1 1.4:1 1.3:1 1.2:1
I degree 90–95% The US is shorter (short trunk) in spondylo
II degree 85–89%
epiphyseal dysplasia, kyphoscoliosis, mucopolysa
III degree < 85%
ccharidoses and others.
Chapter 35: Clinical Examination of Children 533
Part–II: Specialties
• Should be measured at the level of substernal the first two, there is high variability in the
notch in mid inspiration appearance of the other carpal bones. The
• Infancy HC >CC, 1 yr HC = CC, > 1 year- CC ossification centers appear first on the left side
>HC of the body and then on the right side and in
• In Protein Energy Malnutrition (PEM) the ratio girls first and later in boys.
of HC : CC is more than 1 at 1 yr of age.
Mnemonic for 8 Carpal bones: ‘Please Take
Midarm Circumference (MAC) Lovely Susan To The Coffee House’— Pisiform
• Taken in children aged 1 to 5 yrs (last to appear, 9–10 years 9 in girls and 12 years
• The left arm (triceps) is measured midway in boys), Triquetral (3rd year), Lunate (4th year),
Scaphoid, Trapezium, Trapezoid (these 3 by 4th
between acromion and olecranon process with the
year in girls & 5th year in boys), Capitate (2nd
arm hanging freely by the side (Fig. 35.3).
month onwards) and Hamate (3rd month
– Normal 13.5 cms
onwards).
– Moderate PEM 12.5 to 13.5 cms Lower end of radius appears by 9 months and
– severe PEM 12.5 cms or less. lower end of ulna by 6th year. These ossification
• Skeletal maturation: In full term newborn centers are useful in assessing the bone age of
babies, five ossification centers are present the child. The bone age is delayed in hypo-
namely lower end of the femur and the upper end pituitarism, hypothyroidism, severe malnutrition
of the tibia in the knee and 3 tarsal bones namely and maturational/constitutional delay. It is
talus, calcaneus and cuboid in the ankle. The advanced in precocious puberty. Fusion of
Table 35.9: Head circumference at different ages
capitulum with the shaft at elbow predicts puberty
within a year. Bone age is assessed by comparing
Age HC Age HC
with references.
Birth 35 cm 3m 40 cm
6m 43 cm 9m 45 cm • Dentition and enamel formation (Tables 35.10 to
1 yr 47 cm 2 yrs 49 cm 35.13)
3 yrs 50 cm 4 yrs 50.4 cm – Young child: Number of milk teeth = Age in
5 yrs 50.5 cm 9 yrs 52 cm months – 6
Note: A difference of >3.75 cm above or below the normal indicate macro-or
– Primary / Milk teeth are 20 in number. All of
microcephaly one standard deviation (SD) is 1.25 cm. Variation of 3 SD is abnormal. them erupt by 2½ years.
534 Section 12: Pediatrics
Table 35.10: Eruption sequence of milk teeth Table 35.14: Growth velocity in the various age groups
• Central incisors 6 – 7 months • 0–6 months 15 cm
• Lateral incisors 8 – 9 months • 6 –12 months 7 cm
• Canine 16 – 18 months • 1st year 25 cm
• First molar 12 – 14 months • 1–2 years 10–12.5 cm/year
• Second molar 20 – 24 months • 2–5 years 5–6 cm/year
• 5–12 years 5–6 cm/year
Table 35.11: Completion of enamel formation
• Central incisors 1½ months
• Lateral incisors 2 ½ months Growth Velocity (Table 35.14)
• Canine 9 months
Weight gain or height gain over a unit period of
• First molar 6 months
time is velocity and it is a better indicator of growth.
• Second molar 11 months
It reflects the effectiveness of any intervention
Table 35.12: Permanent teeth eruption namely nutritional supplementation, stimulation,
• Central incisors 7 – 8 years growth hormone therapy and others. Weight
• Lateral incisors 8 – 9 years velocity is
• Canine 11 – 12 years 6 kg in the first year. In preschool child, it is 2 kg/
• First premolar 10 – 11 years year and in a school child, it is 3 kg/year till puberty.
• Second premolar 10 – 12 years Height velocity is 25 cm in the first year, it is
• First molar 6 – 7 years 12.5 cm in the second year and thereafter it is 6 cm/
• Second molar 12 – 13 years
Part–II:Specialties
Table 35.13: Permanent teeth enamel formation PHYSICAL EXAMINATION OF THE ADOLESCENT
Central incisors 4 – 5 years Adolescence is the period between 10 to 18 years in
Lateral incisors 4 – 5 years girls and 11 to 20 years in boys. WHO considers 10
Canine 6 – 7 years to 19 years as the period of adolescence for practical
First premolar 5 – 6 years
purposes. Sign of puberty before 8 years in girls
Second premolar 6 – 7 years
and 9 years in boys is considered precocious
First molar 2 ½ – 3 ½ years
puberty. Puberty/Adolescence is divided into
Second molar 7 – 8 years
prepuberty, puberty and postpuberty or early, mid
Growth Charts and Growth Assessment and late adolescence.
Growth charts were popularized by David Morley. Tanner’s Sexual Maturity Rating (SMR)
These are used for growth monitoring. Well baby scale is used to stage puberty. Increased height
clinics, primary health centers and ICDS (Integrated velocity is an important event during puberty in both
Child Development Services) Scheme program boys and girls.
utilize growth charts. The weight measurements of In SMR scale, the stages are categorized into 1
a child over a period of time are plotted on the growth to 5. The SMR picture scale that demonstrates the
chart and any deviation from the normal pattern can extent of breast development and hair growth is
be visualized and interpreted. An upward curve in available for comparison. Thelarche or breast
the ‘road to Health’ is ideal. In a child with normal development is followed by axillary and public hair
nutritional status, the curve is within the ‘road to growth (adrenarche/pubarche). This is followed by
health’. In a colored chart, this is the green zone. menarche, which marks the onset of menstruation
The curve of those with severe malnutrition will in girls. Menarche occurs in SMR stage 2 onwards
fall in the lower red zone and that for those with usually 2 years after breast development and 1 year
mild and moderate malnutrition will fall in the after pubarche. In 10% girls, menarche occurs during
blue and yellow zones. A flat curve and a downward SMR 2, in 80% during SMR 3 to 4 and in 10%
curve are not desirable. Such children should be during SMR 5. Early adolescence is SMR 1 to 2,
investigated and followed up. They must also be mid-adolescence is SMR 3 to 4 and late adolescence
given food supplementation. is SMR 5.
Chapter 35: Clinical Examination of Children 535
Part–II: Specialties
Fig. 35.4: Measurement of height
In boys, increase in testicular size is the first the same age among normal children. The
sign of puberty, followed by enlargement of genital milestones are categorized into 4 groups;
organs, adrenarche, spermarche and facial hair 1. gross motor,
growth. Voice change also occurs during puberty. 2. fine motor adaptive,
During puberty, growth spurt occurs and up to 3. language and
26 to 28 cm height gain can be expected. Prader’s 4. personal social development.
Orchidometer is used for assessing the size of the The four important key milestones are the
testes (Tables 35.15 and 35.16). following:
The onset of puberty is variable. Some kick off 1. Social smile Not later than 2 months
puberty early and their growth also stops early 2. Head control 4 months
leading to shortness of stature. Those who enter 3. Sitting without support 8 months
puberty later, get a longer period to grow and tend 4. Upright and making 12 months
to become taller. a few steps with or
without support
Assessment of Development Also ensure that the vision, hearing and speech
Gross motor, fine motor adaptive, language, personal are normal (Table 35.17).
social development, developmental age, development Developmental age is the average of the motor
quotient (DQ), School performance, intelligence, etc. and mental performances as per the milestones.
Development occurs in a cephalocaudal Developmental quotient (DQ) is calculated as
sequence and the milestones are attained at almost follows:
536 Section 12: Pediatrics
Contd...
Chapter 35: Clinical Examination of Children 537
Contd...
Part–II: Specialties
from prone to supine one cube in hand protrude tongue as
drops it if another is imitation, may show
offered stranger anxiety,
laughs when head is
hidden in towel in
peep -a- boo - game,
beginning to show
likes and dislikes of
food.
9 Months Stands holding on to Brings 2 cubes Puts arm in front of
furniture, in trying to crawl together as if to face to prevent mother
may progress backwards, compare the sizes from washing face.
sitting-can lean forward and bangs them
on the table
12 Months Walks with one hand held, Unassisted pincer Few words besides Plays simple ball
rises independently, grasp, releases object mama or dada, 2–3 game, may kiss on
bear walking to person on request, words with meaning request, mimicry
feeds with spoon with
spilling
18 Months Runs stiffly, sits on a small Makes tower of 4 Average 10 words, Feeds self, tells when
chair, walks upstairs with one cubes, imitates names one or more wet or soiled, clean and
hand held, walks normally, scribbling, imitates parts of the body, dry with occasional
pulls toy as he walks, throws vertical stroke, dumps points correctly to 1 accident, carries out
ball without falling pellet in the bottle, picture, names 1 2 simple orders, uses
feeds self-managing object stick to reach toy,
cup without spilling, dry by day
turns 2–3 pages at a
time
24 Months Runs well, walks up and down Tower of 7 cubes, Puts 3 words Handles spoon well,
stairs, one step at a time, 2 feet circular scribbling, together, talks listens to stories with
per step, opens doors, jumps, imitates horizontal incessantly, names 2 pictures, helps to
climbs on furnitures stroke, turns pages objects, tells a simple undress, obeys 4
one at a time, washes sentence simple orders, dry at
and dries hands night, wears socks or
shoes
Contd...
538 Section 12: Pediatrics
Contd...
30 Months Goes upstairs with alternating Tower of 9 cubes, Uses pronoun I, Helps put things
feet, jumps with both feet, makes vertical and knows full name, away, pretends to
walks on tiptoe when asked horizontal stroke but names 3 objects, play, beginning to
generally not a cross, repeats 2 digits, take interest in
imitates circular stroke, sex organs
forming closed figure,
holds pencil in hand
36 Months Rides tricycle, stand Tower of 10 cubes, Counts three objects, Knows age and sex,
momentarily on single foot, copies a circle and repeats 3 numbers or parallel play present,
goes upstairs with 1 foot per imitates a cross a sentence of 6 washes hands, helps
step and downstairs with 2 (copies a cross by syllables, constantly in dressing and does by
feet per step, jumps off 3½ years), beginning asking questions, self if helped with the
bottom step to draw spontaneously knows some nursery buttons, postpone
or on request rhymes, vocabulary toilet movement
= 250 words
48 Months Hops on one foot, throws ball Copies a square, draws Counts 4 numbers Plays with children,
overhand, climbs well, goes a man with 2–4 parts, correctly, tells a role playing present,
downstairs with one foot per names longer of the 2 story, obeys 4 goes to toilet alone,
step lines, uses scissors, commands, tells tall right – left
tripod grasp stories discrimination,
imaginative play with
a doll, can button
clothes fully
Part–II:Specialties
60 Months Skips Names the heavier Names 4 colors; Dresses and undresses;
object, copies a counts to 10, domestic role playing;
triangle distinguishes asks questions
morning from regarding meaning
afternoon, repeats of words
4 digits
66 Months Copies a diamond Repeats 5 digits Knows number of
fingers, names week
days, names 4 coins
Part–II: Specialties
Fig. 35.5: Trivandrum Developmental Screening Chart (TDSC)
Ref – MKC Nair, Babu George, Elsie Philip; Indian Pediatrics 1991;28:869-72
Contd...
540 Section 12: Pediatrics
Contd...
System Differences between adults and children
B. Systemic Examination (Refer respective done. In children with short stature, height age,
Chapters 3–11 for details) Table 35.18 bone age and developmental age may be compared.
Systemic examination is in the same lines as is In hypothyroidism, there is shortness of stature,
done for adults, but with modifications applicable delayed bone age and mental retardation, but in
for the child. hypo-pituitarism, there is no mental retardation.
Long bone X-rays are ordered in short stature,
Summary skeletal dysplasias and endocrine disorders.
History and examination-salient points.
General Principles in Treatment
Diagnosis and Differential Diagnosis • General/supportive care
Part–II:Specialties
Fig. 35.6: Down Syndrome Note: The coarse Fig. 35.7: Hypothyroidism
facies, macroglossia
Chapter 35: Clinical Examination of Children 541
Fig. 35.8: Hurler’s syndrome. Note: The coarse facies, Fig. 35.10: Kwashiorkor. Note: The edema of the face,
abnormal shape of head and clouding of cornea abdominen and limbs and skin changes over the face, legs
and feet
NEWBORN BABY
Definitions
Part–II: Specialties
1. Term Baby: Babies born with from 37 weeks
to less than 42 completed weeks of gestation
(259–293 days)
2. Preterm Baby: Birth before 37 completed weeks
of gestation (<259 days). The incidence is 8 to
10% of live births.
3. Post-term Baby: Birth after 42 or more
completed weeks of gestation (>293 days)
4. Low Birth weight (LBW) Baby: Babies with a
birth weight of <2500 g irrespective of gestational
age. The incidence is 20 to 30% of live births.
This forms 2 groups term LBW and preterm
Fig. 35.9: Marasmus. Note: The shriveled appearance, LBW.
wrinkling of the skin and absence of subcutaneous fat 5. Very Low Birth Weight (VLBW) Baby: Babies
with a birth weight of <1500 g. The incidence is
around 5% of live birth.
6. Extremely Low Birth Weight (ELBW) Baby:
health promotion, early screening, pollution control, Babies with a birth weight of <1000g. The
safe drinking water, public health engineering, incidence is about 1% of live births.
biosafety and prevention of accidents. 7. Appropriate for Gestational Age (AGA)
Baby: Babies with birth weight between 10th–
Secondary 90th percentile of the expected weight for the
period of gestation as per intrauterine growth
Specific protection, immunization, universal
curves.
precaution for nosocomial and opportunistic
8. Small for Gestation Age (SGA) or Light for
infection and personal protection.
Date (LFD) / Small for Date (SFD) Baby: Babies
with a birth weight <10th percentile for the
Tertiary
period of gestation (as per intrauterine growth
Disability limitation and rehabilitation. curves).
542 Section 12: Pediatrics
9.Large for Gestation Age (LGA) Baby: Babies c. Fetal causes like: Chromosomal anomalies,
with a birth weight >90th percentile for the period intrauterine infection, effect of teratogens.
for gestation. In a term baby it is >4 kg. Identification of preterm and term babies:
10. Neonatal Period: Duration up to the first 28 a. EDC calculation as per LMP
days of life; Early neonatal period - Birth to < 7 b. USS vise maturity assessment
days of life (168 hours) and late neonatal period c. Physical and neurological maturity.
– from 8 to 28 days of life. Preterm babies look smaller and have extended
• IUGR refers to intrauterine growth retardation posture, glistening skin and disproportionately large
• Low birth weight (LBW) Babies head. Physical and neurological maturity will help
• Those babies with weight < 2.5 Kg belong to in differentiation. Various scoring systems are
mainly 2 types—preterm and term SGA babies. available like Dubowitz scoring system and New
Bellard Score.
Classification of SGA Babies The Apgar score is assessed at 1 minute and 5
a. Hypoplastic SGA Babies: Babies with reduced minutes after birth to assess fetal neurological
growth potential due to abnormalities or insults status and prognosis for survival and health (Refer
during early part of gestation leading to internal chapter – 40).
or external congenital anomalies and reduction 1 YCN – Infant and young child
in weight, length and head circumference. These Nutrition – This includes breastfeeding, comple-
babies do not catchup with peer group, e.g. Down mentary feeding, family pot feeding and supple-
syndrome and intrauterine infections. These mentary feeding.
Part–II:Specialties
Part–II: Specialties
(Rh, ABO and minor groups), Exaggerated physiological Neo hepatitis,
Intrauterine infections, jaundice, prematurity, Neo cholestasis,
Maternal drugs such as Vitamin K, acidosis, hypoxia, Biliary atresia,
salicylates, sulfisoxazole, polycythemia,
Hemolytic anemias, cephal hematoma, Breastmilk jaundice due to inhibitor
of conjugation of 3-alpha 2-beta
pregnanediol
Criggler Najjar syndrome due to lack Hypothyroidism, Intestinal obstruction,
of conjugating glucuronyl transferase
enzymes, Pyloric stenosis,
Lucy Driscoll syndrome due to placental All causes <24 hrs, Metabolic causes-
transfer of inhibitor of conjugation-ortho Galactosemia, tyrosinemia,
-amino phenol hypothyroidism
Inspissated bile syndrome,
Intrauterine infections,
Gilbert’s syndrome due to mutation
of transferase enzyme gene,
Rotor and Dubin Johnson syndrome
due to excretory defects
Neonatal Reflexes
Neonatal reflexes are given in Table 35.22.
Table 35.22: Neonatal reflexes—age of onset and disappearance
Reflex Age of onset Age of disappearance
Moro Birth 12 weeks
Stepping Birth 6 weeks
Placing Birth 6 weeks
Sucking Birth 4–7 months
Rooting Birth 4–7 months
Palmar grasp Birth 4–6 months
Plantar grasp Birth 10 months
Tonic neck 2 months 4–6 months
Landau 3 months 24 months
Parachute 9 months Persists
544 Section 12: Pediatrics
Part–II: Specialties
SECTION
13
Geriatrics
CHAPTER
Examination of
36
1 Geriatric Patients
Aswini Kumar
General causes of morbidity in the elderly, Interrogation, Physical examination, Elderly women
e. A general increase in multiple symptoms have In many cases, they resort to self-medication with
been observed several drugs derived from different systems of
f. General fatigue, dizziness and tendency to fall, medicine.
leg ulcers, musculoskeletal pain, hypertension and Social factors like status in the family, income,
worsening of lung function. change of residence, interaction with family
g. Immune processes are diminished in the elderly members and neighbors should be recorded. Death
and hence they are more susceptible to infections, of a near relative especially of the spouse among an
particularly of the respiratory and urinary tracts. elderly couple is serious, resulting in severe
h. The incidence of cancer also increases considerably psychological trauma; and in many cases this may
as age advances. Prostate cancer in men, breast precipitate the death of the survivor.
cancer in women and cancer of the colon and
melanoma in both sexes show increased occurrence. PHYSICAL EXAMINATION
All these factors should be kept in mind while This is basically the same as in other age groups.
approaching an elderly patient. However, physical examination may require more
than one session because the patient may become
INTERROGATION fatigued and uncooperative.
History is often narrated by the patient himself or a Assessment of nutritional status is important,
relative or a social worker. It should be kept in mind since the elderly are more prone to suffer from
that the presentation of diseases may be atypical. malnutrition.
For example, acute myocardial infarction may often In general hemoglobin levels are lower in the
Part–II: Specialties
be silent and detected only by investigations, or the elderly group. The reasons for this are not completely
presentation may be atypical in that, the symptom understood. In an individual patient, it may be that
may be breathlessness or confusion rather than chest some decline in hemoglobin level occurs as part of
pain. Infections may not often present with fever but aging but anemia is not only a consequence of aging.
on the other hand, the presenting symptoms may be Malnutrition, loss of teeth, financial dependence,
disordered behavior, refusal of food or alteration in co-morbidities like chronic kidney disease, cardiac
the mental state. Due to the impairment in memory failure, COPD and drugs like NSAIDs, anti-
and defective hearing, the physician may have to be coagulants and others may be contributing to anemia.
patient while eliciting the history. Often repeated Senescence which is a decreased capacity of the bone
interviews may be required. marrow to proliferate and regenerate in response to
development of anemia may also contribute.
The past history should include details about
medical illnesses like cerebrovascular disease, Several age-related changes and pathological
coronary artery disease, obstructive airway disease, phenomena are common in the elderly. These include
acid peptic disease, infections, constipation, urinary the following:
obstruction, minor or major surgical interventions, Skin, hair and nails: The skin is often lax and shows
anesthesia and accidents. wrinkles, furrows, xerosis and evidence of pruritis.
Personal history should include details about the Petechiae and purpura over the extremities subjected
occupation, diet, physical activity, addictions, bowel to minor trauma are common findings.
habits and social behavior. In elderly female, Campbell de Morgan’s spots are commonly seen
patients’ history of postmenopausal bleeding should over the trunk and abdomen. These are non-
be particularly asked for. pathological. In bed-ridden or chair-bound patients,
Drug history should be elaborated and this pressure sores may be seen at pressure points such
should elicit details about both prescribed and self- as the sacrum, hips, heels and other regions.
administered drugs, the time of starting and stopping Grading of bed sores:
the drugs, dosages, side-effects, withdrawal i. Soft tissue swelling
syndromes and drug allergies. Immunization status ii. Skin ulcer
against influenza, pneumococcal infections, hepatitis iii. Skin and subcutaneous tissue ulceration
and tetanus should be ascertained. The elderly are iv. Skin, subcutaneous tissues and deep fascia
often non-compliant with prescribed medications. ulceration exposing underlying bone.
Chapter 36: Examination of Geriatric Patients 551
Malignancies: With advancement of age, the irreversible deafness. Full investigation is necessary
incidence and prevalence of cancers also increase. to provide corrective hearing aids.
Common sites for malignancy include the genital
Cardiovascular System
tract (especially the prostate), colon, stomach, skin,
lungs, intracranial structures, lymphatic tissues and The pulse rate decreases with increasing age. Sinus
others. Any bizarre symptom occurring in the elderly arrhythmia may not be present. Systematic palpation
should raise the suspicion of malignancy. of all peripheral pulses and auscultation over both
carotids should be done in order to detect occlusive
Nervous System and Special Senses vascular disease.
Physical examination should be directed to detect Blood pressure should be recorded in the lying,
special problems such as sensory deficits, musculo- sitting and standing positions in order to detect
skeletal dysfunction, urinary and fecal incontinence, postural hypotension. Fall in systolic blood pressure
gait problems and impairment of mental status. The of more than 10 mm Hg may be seen during standing.
mental state is rapidly assessed by using the modified Dysautonomia is the common cause for this. Systolic
minimental status examination. The senses of smell, hypertension over 160 mm Hg is more common. Age
taste, vision and hearing show age related impairment. related calcification of aortic and mitral valves may
Muscles show wasting. Muscle tone may be give rise to cardiac murmurs. Cardiac failure
increased. Superficial reflexes are less brisk. increases in frequency with age reaching up to 5 to
Ankle jerk and knee jerk may be diminished or 10% in people aged above 75 years.
lost even in the absence of any other major Respiratory System
Part–II: Specialties
neurological disease.
Primitive reflexes like glabellar tap, sucking The usual respiratory rate at rest is 15 per minute.
reflex, rooting reflex, snout reflex and palmo- Expansion of the chest is diminished due to
mental reflex may appear. This suggests the onset emphysema and changes in the thoracic cage.
of diffuse irreversible brain damage. Tobacco-related diseases, COPD and respiratory
infections are common. These increase the risk of
Sensory abnormalities include impairment of
morbidity and mortality due to acute infections such
pain sensation, paresthesia, anesthesia and diminution
as influenza, pneumonia.
of vibration and proprioception.
Involuntary movements are common. These Gastrointestinal System
include titubation (rhythmic head nodding) and Loss of teeth is common and this leads to nutritional
senile tremors of hands and legs. Parkisonism is problems. Glossitis, cheliosis, angulo-stomatitis,
more common. The gait is often short and shuffling. ulceration of the angles of the mouth caused by
Neurological disability and painful osteoarthritis of dentures and poor oral hygiene are all common.
the knees, hips and ankles adversely affect the stance Impairment of the senses of smell and taste lead to
and gait. They predispose to falls. further diminution of food intake.
Eyes Abdominal palpation may reveal loaded sigmoid
and rectum and distended urinary bladder. Rectal
Arcus senilis, enophthalmos and ptosis are common.
examination is mandatory to detect enlargement of
Cataract is a common age-related problem which
the prostate, colonic lesions and the presence of
is often accelerated by pathological processes.
inspissated fecal mass which may lead to spurious
Complete examination to assess the visual acuity,
diarrhea and fecal incontinence.
visual fields and ocular tension should be undertaken
in all patients, since eye problems are common ELDERLY WOMEN
causes of disability. The pupils are often small and
at times, may be irregular even without specific Many women in India can be expected to live
disease. for twenty to thirty years after menopause. Due
to hormonal changes and increase in risk of
Ears atherosclerosis, the incidence of coronary artery
Inspissations of wax is the most frequent cause of disease increases equal that in men after varying
reversible deafness. Presbyacusis is age related periods. Other common pathological conditions
552 Section 13: Geriatrics
14
Pregnancy
CHAPTER
37
1 Maternal Changes
in Pregnancy
V Rajasekharan Nair
General considerations, Hematological and cardiovascular changes, Pregnancy norms in Indian women
enlarge and contribute to the blood flow to the abdominal skin—linea alba—becomes especially
pregnant uterus. There is increased vascularity and pigmented, assuming a brownish-black color to form
hyperemia in the skin and muscles of the perineum the linea nigra. Due to the progressive stretching of
and vulva and softening of the connective tissue. the abdominal skin, stretch marks called striae
gravidarum tend to occur in all pregnant women.
Breasts
chloasma or melasma gravidarum—the so called
Breast tenderness is often the first symptom of mask of pregnancy are irregular brownish patches
pregnancy. There is enlargement of the breasts due of varying size that appear on the face and neck.
to glandular hypertrophy. The axillary tail enlarges Pigmentation occurs in the areolae and genital skin
and may become painful. Bluish dilated veins appear also. After delivery hyperpigmentation regresses
over the breasts. The nipples enlarge and become considerably. Angiomas or vascular spiders,
deeply pigmented, and erectile. Hypertrophic telangiectasis and palmar erythema are due to
sebaceous glands called glands of Montgomery are vascular changes and are more common in white
seen prominently in the areola. Thick, yellowish women (Fig. 37.3).
colostrum can be expressed from the nipples. Striae
may appear on the skin (Fig. 37.1). HEMATOLOGICAL AND CARDIOVASCULAR
CHANGES
Skin
Maternal blood volume begins to increase during
Cutaneous blood flow increases making the skin feel the first trimester and reaches 40 to 45% above the
warm. Striae gravidarum or stretch marks develop nonpregnant blood volume after 32 to 34 weeks. This
Part–II: Specialties
in the abdominal skin and sometimes in the skin over hypervolemia helps to protect the mother and the
the breasts and thighs. They appear as reddish, fetus, against impaired venous return in the supine
slightly depressed streaks. Later, they cicatrice and and erect positions and safeguards the mother against
become glistening, silvery lines. Occasionally, blood loss during parturition apart from meeting the
diastasis of recti is seen which can lead to ventral demands of the hypertrophied vascular system and
hernia, if severe. providing adequate nutrients to the rapidly growing
Hyperpigmentation is more common in placenta and fetus. Hypervolemia is mainly due to
those with darker complexion. The midline of the increased plasma volume than the erythrocyte volume
Fig. 37.2: Height of uterine fundus according to Fig. 37.3: Striae gravidarum and pigmentation of abdominal
period of gestation in weeks skin in pregnancy
Part–II: Specialties
and this leads to dilutional anemia. The increase in increases about 10 beats/minute during pregnancy.
the erythrocyte volume averages about 50 mL. Diaphragm becomes progressively elevated and the
Moderate erythroid hyperplasia is present in the bone heart is displaced to the left and upward and rotated
marrow and the reticulocyte count is elevated slightly on its long axis leading to slight left-axis deviation
during normal pregnancy due to the increase in in ECG. There is an exaggerated splitting of the first
maternal plasma erythropoietin levels. Hemoglobin heart sound with increased loudness of both
concentration and hematocrit decrease slightly components; no changes in the aortic and pulmonary
during pregnancy. Average hemoglobin concentration elements of the second sound and a loud, easily heard
at term is 12.5 g/dL. Hemoglobin concentration third sound. A systolic murmur may be present in
below 11.0 g/dL is usually due to iron deficiency. 90% of pregnant women and a soft diastolic murmur
Approximately 1000 mg of iron is required during in 20%. Continuous murmurs arising from the breast
normal pregnancy. vasculature can be heard in 10%. During normal
The iron requirement in the second half of pregnancy, mean arterial pressure and vascular
pregnancy averages 6 to 7 mg/day. Iron is actively resistance decrease, while blood volume and basal
transferred to the fetus even when the mother has metabolic rate increase. As a result, cardiac output
severe iron deficiency anemia. Serum iron and at rest, when measured in the lateral recumbent
ferritin concentrations decline. During normal position, increases significantly beginning in
pregnancy, both coagulation and fibrinolysis are early pregnancy and remains elevated during the
augmented. Concentrations of all clotting factors, remainder of pregnancy. There is increase in heart
except factors XI and XIII are increased and levels rate, stroke volume, and cardiac output. Systemic
of high-molecular-weight fibrinogen complexes are vascular and pulmonary vascular resistance both
also increased. Fibrinogen concentration increases decrease significantly, as also the colloid osmotic
approximately 50% to 300 to 600 mg/dL. The pressure. Pulmonary capillary wedge pressure and
average platelet count is decreased slightly during central venous pressure do not change appreciably
pregnancy. Arterial pressure usually decreases to a nadir at 24
Cardiac output is increased as early as the fifth to 26 weeks and rises thereafter. Diastolic pressure
week due to reduced systemic vascular resistance decreases more than systolic. Venous blood flow in
and increased heart rate. The resting pulse rate the legs is retarded during pregnancy. Supine
558 Section 14: Pregnancy
compression of the great vessels by the uterus causes and elevated pressure in veins below the level of
significant arterial hypotension. the enlarged uterus.
Respiratory System Total alkaline phosphatase activity almost
doubles but much of the increase is attributable
The diaphragm rises about 4 cm and the subcostal to heat-stable placental alkaline phosphatase
angle widens so that as the transverse diameter of isozymes. Serum aspartate transaminase (AST)
the thoracic cage increases approximately 2 cm
alanine transaminase (ALT), glutamyl transferase
and the thoracic circumference increases about
(GGT) and bilirubin levels are slightly lower
6 cm. Diaphragmatic excursion is actually greater
compared with nonpregnant values. The concentration
in pregnant than in nonpregnant women. The
of serum albumin decreases even though total
functional residual capacity and the residual volume
albumin is increased. During normal pregnancy, the
are decreased as a consequence of the elevation of
contractility of the gallbladder is reduced, leading
the diaphragm.
to an increased residual volume. Impaired emptying
Tidal volume and resting minute ventilation leads to stasis, which is associated with increased
increase. Peak expiratory flow rates decline pro- bile cholesterol saturation of pregnancy. There is a
gressively as gestation advances. Lung compliance propensity for intrahepatic cholestasis and pruritus
is unaffected by pregnancy, but airway conductance gravidarum from retained bile salts in pregnancy.
is increased and total pulmonary resistance reduced.
The maximum breathing capacity and forced or Metabolic Changes
timed vital capacity are not altered appreciably.
A smaller fraction of the increased weight is due to
Part–II: Specialties
Part–II: Specialties
levels of dehydroepiandrosterone sulfate are
Endocrine System
decreased during normal pregnancy. Andro-
The pituitary gland enlarges even though it is not stenedione and testosterone levels are increased
essential for maintenance of pregnancy. Serum during pregnancy.
CHAPTER
1
38 Antenatal Examination
V Rajasekharan Nair
History, General examination, Obstetric examination, Terms used to describe palpation findings, Pelvic
examination, Assessment of Cephalopelvic disproportion, Antenatal advice
Part–II: Specialties
Record the incidence of diabetes mellitus, hyper- is considered for assessing the individual’s risk. BMI
tension, other hereditary diseases, twinning and over 28 is associated with greater complications
congenital anomalies in the family members. during pregnancy and puerperium. Apart from
Personal History increase in medical complications like GDM, and
pre-eclampsia these women run a higher risk of
Find out details of addictions, contraception, allergies.
developing intrapartum, perioperative and anes
thetic complications also. Many of these women
What to Do during each Visit (Flow chart
require thromboprophylaxis, especially when they
38.1)?
undergo operative procedures.
All systems should be examined routinely to
Flow chart 38.1: Antenatal care
detect abnormalities, if any, and to assess the changes
induced by pregnancy.
Blood Pressure
Blood pressure should be recorded with the woman
in sitting posture with the arm at the level of heart.
BP is about 15 mm lower in lying down posture. In
normal pregnant women systolic remains between
100 to 120 mm and diastolic between 70 and 80
mm mercury. If the recorded blood pressure is 140/
90 mm or more on any occasion, it should be taken
as abnormal. In those on antenatal follow-up, a rise
of 20 mm in systolic or 15 mm in diastolic over the
first trimester blood pressure is considered as
hypertension.
562 Section 14: Pregnancy
OBSTETRIC EXAMINATION feel for the top of the fundus. Note the height of
fundus in relation to the umbilicus and symphysis
Vaginal Examination During First Trimester (Fig. 38.2). At 12 weeks uterus is just palpable
Vaginal examination is indicated if the patient above the symphysis. The distance between
presents before 12 weeks of gestation. It is done to umbilicus and symphysis is divided into 3 equal
confirm pregnancy and to ascertain whether it parts. The lower 1/3 is reached at 16 weeks, 2/3 is
corresponds to period of gestation, whether it is reached at 20 weeks and uterus is at the umbilicus
intrauterine or extrauterine and whether other pelvic at 24 weeks. After the twentieth week the uterus
pathology like fibroids or ovarian tumor is rises at the rate of 1 cm every week. The distance
associated with it (Fig. 38.1). between the umbilicus and xiphisternum is divided
If vaginal discharge is present, a specimen into three equal portions. Lower 1/3 is reached at
of the discharge is taken for bacteriological 28 weeks, lower 2/3 at 32 weeks and the xiphisternum
examination using a speculum. The cervix is next at 36 weeks. Thereafter, the height of the fundus
inspected for discoloration, erosion and growths and descends and at 40 weeks it occupies the height at
a Papanicolaou (Pap) smear may be taken for 32 weeks. This descent is due to engagement of the
cytological screening. fetal head and the falling forward of the uterus.
Symphysiofundal height and abdominal girth
Abdominal Examination also help to assess the normal growth and to rule
The patient should empty the bladder and is put on out conditions such as intrauterine growth restriction
the table in the dorsal position with the knees and (IUGR) or multiple pregnancy.
Part–II: Specialties
Fig. 38.1: Vaginal exam–early pregnancy showing Fig. 38.2: Measuring height of fundus after
elicitation of Hegar’s sign (due to softening of cervix) correcting dextrorotation of uterus
Chapter 38: Antenatal Examination 563
Part–II: Specialties
Fig. 38.3: Fundal grip–palpating for fetal parts Fig. 38.5: First pelvic grip
in the upper pole
Fig. 38.4: Umbilical grip-palpating fetal back and limbs Fig. 38.6: Second pelvic grip–noting relative
levels of sinciput and occiput
564 Section 14: Pregnancy
Part–II: Specialties
During pregnancy and lactation, the nutritional
Feel for the hollow of the sacrum. Identify the requirement increases. Extra allowance of calories
sacrosciatic notches and ischial spines. Look for and proteins are given with special emphasis on
cephalopelvic disproportion by pushing the head balanced diet. A model diet chart for pregnant
down and feeling whether it comes down to the woman is shown below:
level of ischial spines. Feel for over-riding of the
Time Meal Menu Amount
head by keeping the thumb over the symphysis pubic 6.30 am Early Tea/Coffee Sugar 10g
while the head is being pushed down. Subpubic morning Milk 150 mL
angle is assessed by placing two fingers under the 8.30 am Breakfast Idli/Dosa/Appam 3 nos
symphysis pubis. Normally, the subpubic angle Or Puttu/Upma 3 cups
should accommodate two fingers. Transverse Fruit seasonal 1
diameter of the outlet is assessed by placing the 11.00 am Mid morning Ragi/Rava 1 cup
knuckles in the widest part between the ischial 1.30 pm Lunch Rice (cooked) 3 cup
Veg curry 1 cup
tuberosities. Normally, four knuckles should be Dal curry 30 g of dry dal
accommodated. The anteroposterior diameter is Curd 60 mL
the distance from the tip of the sacrum to the Salad 1 plate (300 g)
undersurface of the symphysis pubic. 4.00 pm Evening Tea/Coffee I cup
Snacks 50 g
ANTENATAL ADVICE 8.00 pm Dinner Rice/Chappathi 3 cup/3 nos
Dal curry 1 cup
During each antenatal visit the pregnant woman
Veg curry 1 cup
should be instructed to adhere to certain general
Salad 1 cup (300 g)
norms. 9.00 pm Milk 1 cup (200 mL)
Iron and Folic Acid Supplementation N.B–Nonvegetarians can have one or two
Iron present in the food is insufficient to prevent servings of fish/meat or egg, replacing the dal curry.
anemia. Hence, the woman should take iron tablet If the woman is obese/diabetic or having renal
(60 mg elemental iron) daily. This is usually started disease, suitable alterations have to be made.
after 12th week as the woman may have nausea
Fish 150-200 g
and vomiting during the first trimester. A pregnant
woman need to take at least 100 iron tablets Meat 150-200 g per day
during pregnancy without which she is at risk of Egg 1-2
CHAPTER
39
1 Common Investigations
in Pregnancy
V Rajasekharan Nair
Pregnancy tests, Antenatal investigations, Ultrasound investigations, Amniocentesis, Chorionic villus biopsy,
Electronic fetal monitoring
Part–II: Specialties
of 75 g glucose and estimation of the blood sugar at
the end of 2 hr. This replaces the previous two stage
investigation of doing a 50 g glucose challange first
and the doing the OGTT if the blood sugar result
goes beyond 140 mg/dL. Fig. 39.2: Measuring abdominal circumference a sensitive
index in growth retardation
ULTRASOUND INVESTIGATION
insufficiency. Middle cerebral artery Doppler is
Ultrasound scan is an extremely useful tool to follow used for monitoring IUGR pregnancy.
the fetal development and detect abnormalities
(Figs 39.1 and 39.2) (Flow chart 39.1). AMNIOCENTESIS
Doppler velocimetry of the umbilical and Aspiration of amniotic fluid for genetic, bacterio-
uterine arteries is used to diagnose placental logical or biochemical studies is done between 14
to 16 weeks under ultrasonographic guidance for variability, presence of accelerations in heart rate
genetic studies. At later gestations it may be required during fetal movement (by15-20 beats and sustained
for monitoring of Rh sensitized pregnancy, for 15 to 20 seconds or more), any deceleration of
decompressing a hydramnios or for confirmation of fetal heart etc are noted. This is called a nonstress
fetal lung maturity. test (NST). A reactive NST is reassuring while a
nonreactive NST may indicate fetal compromise.
CHORIONIC VILLUS BIOPSY Electronic fetal heart monitoring can be used for
It is done at 10 to 13 weeks transabdominally or intrapartum monitoring of high risk pregnancies also
transcervically helps to detect genetic abnormalities (Fig. 39.3).
earlier. Percutaneous umbilical blood sampling
(PUBS) or cordocentesis is another invasive
technique for obtaining fetal blood sample for faster
genetic analysis. Fetal tissue biopsy is possible to
detect specific defects like muscular dystrophy or
epidermolysis bullosa.
40
1 Management of Normal Labor
V Rajasekharan Nair
Management of first stage, Management of second stage, Management of third stage, Fourth stage of
labor, Instrumental deliveries, Cesarean section
Labor is the process by which childbirth occurs and examination unless there has been bleeding in
represents the period from the onset of regular uterine excess of bloody show. The procedure is done with
contractions until expulsion of the placenta. It is all aseptic precautions. Examiner should wear mask
marked by regular uterine contractions that bring and gloves after scrubbing the hands as for a surgical
about demonstrable effacement and dilatation of the operation. The vulva is cleaned with antiseptic lotion
cervix. The first stage of labor denotes progressive and draped with sterile towels. Index and middle
effacement and dilatation of cervix until it is fully fingers of right hand lubricated with antiseptic
dilated. The second stage starts at this point and ends lubricant are introduced into the vagina. The
with delivery of the fetus. The third stage of labor effacement and dilatation of cervix are noted.
denotes the period from delivery of the fetus to Obliteration of cervical canal is termed cervical
expulsion of placenta and complete contraction and effacement and is expressed as a percentage
retraction of the uterus. compared with that of an uneffaced cervix. When
A patient may present at term with onset of labor fully dilated, the cervix is 10 cm in diameter. Next
pains, leaking or show (blood stained mucoid step is to find out details of the presenting part and
discharge). Duration of labor pains or leaking should its position. In normal vertex presentation with
be ascertained. Review the antenatal record and occipito-anterior position, the posterior fontanelle
confirm the gravidity, parity, and period of gestation. will be felt in the anterior quadrant of pelvis. The
Ascertain whether the gestational age is accurate posterior fontanelle is identified by the presence of
by referring for early ultrasound. Look for any three suture lines. The posterior fontanelle is in the
antenatal complications recorded in the antenatal posterior quadrant in occipito-posterior position.
chart. Vital signs including the pulse, blood pressure, Station or the relationship of the head to the pelvis
temperature and respiratory rate are recorded. is noted. Level of the ischial spine is considered as
Obstetric examination is done at this stage. O station. Look for caput formation or moulding
Abdominal palpation to ascertain the period of which may indicate cephalopelvic disproportion.
gestation, presentation and position of the fetus
MANAGEMENT OF THE FIRST STAGE
followed by assessment of frequency and intensity
of uterine contractions and recording the fetal heart The normal laboring woman need not be confined
is done. Admission test is a cardiotocographic to bed early in labor. She can assume any comfortable
recording of the fetal heart tracing in relation to the position. Prolonged supine position is to be avoided
uterine contractions and indicates fetal well-being. to prevent aortocaval compression.
Enema is given unless there is bleeding PV or leaking Fetal well-being: The fetal heart rate should be
with a mobile head. This is followed by a vaginal checked immediately after a contraction at least
570 Section 14: Pregnancy
Maternal vital signs: Temperature, pulse, and blood engagement of the shoulder. Gentle downward
pressure are evaluated at least every 4 hours. Food traction on the head may be necessary if the anterior
should be withheld during active labor and delivery. shoulder is not born spontaneously. Drawing the
Clear liquids can be allowed. Establish an intravenous head gently upwards helps delivery of the posterior
infusion line early in labor. Administration of shoulder. Rest of the body is born spontaneously.
glucose, sodium, and water to the laboring woman As soon as the baby is delivered, the face is
at the rate of 60 to 120 mL/hr prevents dehydration quickly wiped and the nares and mouth are aspirated
and acidosis. to clear the airway and prevent aspiration of blood,
Pain relief can be provided with opioid analgesics mucus and amniotic fluid. Then the cord is clamped
like pethidine, inhalation analgesia like nitrous at two points and cut in between. Delaying the cord
oxide with oxygen or by administration of epidural clamping until pulsations cease allow more blood
analgesia. to be transferred to the baby from the placenta. Then
the clinical status of the baby is assessed and the
If the urinary bladder gets distended the woman
Apgar score recorded taking into account the fetal
should be encouraged to void. Catheterization should
heart rate, respiratory movements, color, cry, and
be minimized. Periodic pelvic examinations are
attitude. Maximum score is 10.
performed to evaluate labor progress and amniotomy
may be performed once labor is well-established. Partogram
It is a composite record of all the events occurring
MANAGEMENT OF THE SECOND STAGE
during labor including the cervical dilatation, descent
When cervix is fully dialated, the woman starts of head, intensity of uterine contractions, details of
bearing down and has an urge to defecate. fetal heart sounds, liquor, drugs administered and
Contractions increase in frequency and intensity. The maternal status. This is ideally suited to follow the
maternal bearing down plays an important part in course of labor and to initiate interventions such as
the expulsion of the fetus. When the head descends augmentation including oxytocin acceleration,
to the outlet, the perineum bulges and skin is cesarean section and others. Partographic monitoring
stretched. Crowning of the fetal head indicates of labor is suitable for all settings, whether it is
imminent delivery. primary, secondary or tertiary (Fig. 40.2).
Chapter 40: Management of Normal Labor 571
Part–II: Specialties
Part–II: Specialties
as the result of uterine atony is more likely at this
time. Hence, the parturient should be closely
monitored. Monitoring the general condition of
woman by blood pressure and pulse rate, and
palpating for the level of uterine fundus and the
consistency of uterus and observing for any vaginal
bleeding forms the basis of the vigilance. Slow Fig. 40.4: Technique of delivering the baby during
cesarean section
trickle of blood occurring during this phase can cause
deterioration of the maternal condition, which could
fetal distress due to various reasons. Regional
be prevented by the above strategy.
anesthesia is preferred in most of the cases and the
INSTRUMENTAL DELIVERIES procedure is best done though a Pfannenstiel
incision. In ideal situations, the incidence of cesarean
In a small proportion of cases labor may not section should be only around 15% of the total
end spontaneously and this may necessitate number of deliveries. Every attempt should be taken
interventions. If the fetal head has negotiated the to reduce the number of primary cesarean sections
pelvis very well and the vertex is well below the (Fig. 40.4).
ischial spines, the delivery can be completed either
with vacuum extractor or forceps depending on the Who should Conduct a Delivery?
situation. After delivery, the vagina and cervix should There is a false belief that all deliveries should be
be inspected for any tears as this is more commonly conducted by specialists. Delivery is a natural
seen following instrumental deliveries (Fig. 40.3). process, and in the majority of cases if there are no
antenatal complications, it can be conducted by any
CESAREAN SECTION
trained person. Most problems occur during the
If conditions are not favorable for vaginal delivery, second and third stage of labor which can be reduced
then delivery per abdomen–cesarean section should by sticking on/to partograms and active management
be thought of. This can be an elective procedure as of third stage of labor. In India as a whole only 50%
in a case of placenta previa or abnormal presentation of deliveries are attended to by a trained personnel,
or can be an emergency procedure as in a case of whereas in Kerala state it is nearly 100%.
SECTION
15
Dermatology, Leprology
and Sexually Transmitted
Diseases
CHAPTER
General Considerations,
41
1 Clinical Examination and
Laboratory Investigations
Usha Vaidyanathan
Structure of the skin, Embryology, Microbial flora, Hair, Nail, Morphology of normal skin, History, Physical
examination, Laboratory investigation, Differential diagnosis
called reticular dermis with coarse bundles of it to the T-lymphocytes along with the class II
collagen. The dermis also contains fibroblasts histocompatability (HLA-DR) molecule. Now the
(which synthesize collagen, elastin and the ground T-cells get activated and release a variety of proteins
substance), dendritic cells, mast cells, macrophages called lymphokines, like Interleukin (IL) 1,2,3 and
and lymphocytes. 4, gamma interferon and B-cell differentiating factor
The dermis is supplied with a rich network of (BCDF). Gamma interferon enhances the DR
blood vessels, lymphatics, nerves, eccrine glands, expression on the antigen-presenting cell, thereby
apocrine glands, sebaceous glands and hair follicles. increasing the T-cell response to antigen.
Free sensory nerve endings are seen in the dermis, IL-2 binds to specific receptors on activated
also extending to the epidermis. These nerve endings T-cells, giving rise to expansion of the activated
detect pain, itch and temperature sensation. There clone of T-cells.
are specialized receptors called Pacinian IL-4 and BCDF are important in the growth and
corpuscles to detect pressure and vibration and maturation of antigen primed B-cells, which are
Meissner’s corpuscles in the skin of hands and feet, involved in the production of antibodies. Thus the
which detect touch. skin plays a major role in the recognition of an
Sebaceous glands are lipid-producing glands, antigen or an allergen and the activation of the
distributed over the entire surface of the skin immune system.
except the palms, soles and dorsum of feet. They
are more numerous on the scalp and face. The major MICROBIAL FLORA
components of sebum are triglycerides, wax esters,
Part–II: Specialties
3. The skin regulates the loss of body fluids by Scalp hair cycle is as follows:
altering the rate of perspiration. 1. Anagen phase (growing phase)—3 to 10 years.
4. Melanin pigment protects the skin from the 2. Catagen phase (involuting phase)—2 to 3 weeks.
harmful effects of ultraviolet rays. 3. Telogen phase (resting phase)—3 to 4 months.
5. Skin acts as a major sensory organ receiving all
superficial sensations. Hair as an Indicator of Systemic Disease
6. Vitamin D synthesis occurs in the skin, on The common hair disorders are hair loss (alopecia)
exposure to sun light. and excess hair (hirsutism and hypertrichosis).
7. Dendritic cells in the skin play a major role in Alopecia is classified as diffuse or localized and
immune surveillance. scarring and nonscarring.
8. Sebum has antimicrobial properties.
Alopecia
HAIR Diffuse nonscarring alopecia is due to male pattern
Hairs are found over the entire surface of the skin baldness (androgenic alopecia), hypothyroidism,
except the glabrous skin of the palms, soles, glans hypopituitarism, hypoadrenalism and iron or zinc
penis and vulval introitus. The density of follicles is deficiency. Malnutrition causes dry brittle hair (pale
greatest on the face. The fetus is covered by fine, or red in kwashiorkor).
soft long hair called lanugo hair. Postnatal hair Telogen effluvium is a condition where the hair
consists of soft, short unmedullated vellus hair over follicles are set in a resting phase and shed together
the body and large, coarse medullated terminal hair about 3 months later. It results from high fever,
Part–II: Specialties
on the scalp and eyebrows. With the onset of puberty, childbirth, surgery or other stress. Similarly
androgens initiate the change of vellus hair to cytotoxic drugs can arrest the hair growth abruptly
terminal hair in specific sites. The axillary and pubic leading to anagen effluvium.
hair in both sexes and the hair over the Localized nonscarring alopecia is due to
beard and moustache areas in males change into alopecia areata (Fig. 41.1), hair pulling, traction,
terminal hair. dermatophyte infection and secondary syphilis.
New hair follicles are not formed after birth. Scarring alopecia is uncommon and is asso-
Of the 100,000 hair follicles present on the average ciated with morphea, lichen planus (Fig. 41.2),
scalp, about 70 to 100 hairs are shed daily. Hair on tertiary syphilis, radiation, trauma and others.
the scalp grows at an average rate of 0.37 mm/day.
In men, scalp hair grows slower and hair on the Excess Hair
trunk grows quicker than women. Hair growth Hypertrichosis is excessive terminal hair growth in
occurs in a cycle of three phases. a nonandrogenic distribution. It is usually due to
Fig. 41.1: Alopecia areata Fig. 41.2: Lichen planus scalp-scarring alopecia
580 Section 15: Dermatology, Leprology and Sexually Transmitted Diseases
NAIL
Nail is a phylogenetic remnant of the mammalian Fig. 41.3: Psoriasis of nails. Note the destruction and
separation of the nail plate
claw. It consists of a nail plate made up of hard
keratin, which is derived from the nail matrix at the
base of the nail. It protects the finger tip, facilitates fold is swollen, with dystrophic and discolored
grasping and tactile sensitivity in the finger pulp. nails. Acute paronychia is usually bacterial
Part–II: Specialties
Part–II: Specialties
allergic contact dermatitis. aggravate psoriasis.
Aggravating factors should be enquired into:
Family history: A positive family history may be
• Sunlight exacerbates photodermatitis
obtained for diseases such as psoriasis. Atopic
• Seasonal variations (ichthyosis worsens in
dermatitis, asthma and other allergic diseases may
winter, Darier’s disease worsens in summer,
occur in several family members. Autosomal
psoriasis improves in summer)
recessive diseases like xeroderma pigmentosum and
• Allergic disorders may be aggravated by
allergens in diet or environment lamellar ichthyosis may reveal consanguinity among
• Emotional disturbances aggravate many the parents. Several members of the family,
dermatological disorders like psoriasis and especially children may show signs of scabies.
neurodermatitis. Drug history: Treatment received (both prescribed
Past history: History of similar illness in the past and self-administered, topical and systemic drugs)
gives helpful clue to the diagnosis of allergic and its effect has to be enquired. Partially treated
disorders, psoriasis, photodermatitis and others. lesions, especially with topical steroids, change their
History of diabetes, hypertension and bronchial morphology considerably. Cosmetics can also cause
asthma should be enquired. dermatitis and their use has to be asked for
Diabetics are more prone to candidal infections, specifically.
bacterial infections with Staphylococcus aureus, Personal history: This is particularly important in
erythrasma and serious infections like necrotizing cases of suspected contact dermatitis and several
fasciitis and pseudomonas infections. Acanthosis other skin disorders. The details of occupation,
nigricans, scleredema (thickening of skin of back habits, hobbies, diet, cosmetics, clothes and home
and neck) and Kyrle’s disease especially in surroundings help to diagnose many of them straight
diabetics with chronic renal failure. Kyrle’s disease away.
(Fig. 41.4) presents as follicular and extrafollicular
papules with central keratotic plug and may form PHYSICAL EXAMINATION
verrucous plaques, commonly on the legs
and arms. The whole skin surface should be examined under
Necrobiosis lipoidica diabeticorum (asympt- proper illumi nation, preferably natural light. Hair,
omatic red papules and plaques which resolve nails, palms, soles and mucous membranes of the
582 Section 15: Dermatology, Leprology and Sexually Transmitted Diseases
mouth, genitalia, nose and eyes should be Patch: A macule more than 1 cm is called a patch.
examined. Total absence of pigments leads to vitiligo
The morphology of the individual lesion, (Fig. 41.7).
configuration and distribution of lesions should Papule: A solid elevated lesion up to 1 cm in
be noted. diameter is a papule. (Figs 41.8 and 41.9). The
Morphology surface of the papule may be flat-topped, dome
shaped, verrucous, filiform (Fig. 41.10) or
Skin lesions are classified as primary or secondary.
umbilicated.
Primary lesions arise de novo from the skin.
Secondary lesions arise secondary to the primary Plaque: A solid elevated lesion larger than 1 cm is
lesions. called a plaque (Fig. 41.11).
Nodule: A nodule is a solid swelling situated within
Primary Lesions
the skin. It is better felt than seen.
Macule: An alteration of colour of the skin up to Vesicle: It is an elevated lesion containing clear
1 cm in diameter is called a macule. It is flush
fluid up to 1 cm in diameter (Fig. 41.12).
with the surface, e.g. hypopigmented macule.
(Fig. 41.5) and depigmented macule (Fig. 41.6), Bulla: Fluid filled lesion more than 1 cm is called a
hyper pigmented macule. bulla (Fig. 41.13).
Part–II: Specialties
Fig. 41.5: Macules of pityriasis versicolor Fig. 41.7: Depigmented patch of vitiligo
Fig. 41.6: Depigmented macule—vitiligo Fig. 41.8: Minute papules of lichen nitidus
Chapter 41: General Considerations, Clinical Examination and Laboratory Investigations 583
Pustule: It is an elevated lesion containing pus Wheal: It is an evanescent, edematous skin lesion.
(Figs 41.14 and 41.15). Usually pustules are small It may be erythematous, skin colored or pale
and less than 1 cm in diameter. (Fig. 41.16).
Abscess: It is a large collection of pus underneath Purpura: This is a circumscribed hemorrhagic
the skin. lesion up to 1 cm in diameter, which is flush
Fig. 41.9: Violaceous flat topped lesions of lichen planus Fig. 41.12: Herpes simplex infection—grouped
Part–II: Specialties
vesicles nasolabial fold
Fig. 41.10: Filiform wart Fig. 41.13: Vesicles and bullae in contact dermatitis
Fig. 41.15: Sterile pustules of psoriasis Fig. 41.17: Tunnel formed by larva migrans
Part–II: Specialties
Fig. 41.16: Urticaria causing wheal (arrow) Fig. 41.18: Acne comedones (arrow)
with the surrounding skin or mucous membrane. The people using cutting tools or lubricating oils under
lesion does not blanch on pressure. Palpable purpura high pressure.
is a feature of Henoch-Schönlein purpura. Larger Telangiectasia: Persistent dilatation of the post-
lesions are called ecchymoses and pin-point lesions capillary venules is called telangiectasia.
are called petechiae. Target lesion: (Iris lesion) has a central vesicle or
Cyst: A cyst is a sac that contains liquid or semisolid purpura, surrounded by a zone of edema and an outer
material. ring of erythema. Classically seen in erythema
Sclerosis: Sclerosis is hardening of the skin due to multiforme.
dermal or subcutaneous edema, cellular infiltration Secondary Lesions
or increased collagen, e.g. scleroderma. Scales: Visible dry exfoliation of the superficial
Special Primary Lesions layers of the epidermis is called scaling.
Crust: This is formed of dried up discharges such
Burrow: It is a tunnel produced by the movement as serum, pus or blood.
of a parasite within the tissue. It is seen as a straight Erosion: Loss of superficial skin leaving a raw
or zig-zag line that may be grayish. These are seen area is called erosion (Fig. 41.19). This is seen in
in scabies and larva migrans (Fig. 41.17). pemphigus when the bulla ruptures and in acute
Comedones: These are dark plugs seen inside the eczema.
opening of a hair follicle (Fig. 41.18). This is the Ulcer: Loss of whole thickness of skin due to
primary lesion in acne vulgaris. It is also seen in infection, ischemia or necrosis leads to ulceration.
Chapter 41: General Considerations, Clinical Examination and Laboratory Investigations 585
Fig. 41.19: Erosions, crusting and scaling in contact dermatitis Fig. 41.21: Atrophy of skin due to long-term topical steroid
Part–II: Specialties
Fig. 41.20: Lichenification—note the exaggeraged Fig. 41.22: Annular plaque of tinea faciale
skin marking (arrow)
Fissures: Fissures are linear cracks exposing the fashion and continue to increase in size for decades
deeper aspects of the skin. or may remain stable. It may be familial.
Lichenification: The skin markings become Hypertrophic scars originate at the site of injury
prominent. This is usually associated with only. It is confined to that site and does not extend
pigmentation and thickening (Fig. 41.20). beyond the original injury. It tends to regress with
Excoriation: Excoriation is superficial denudation time and flatten. There is no familial susceptibility.
of the skin covered by black crust. Combination of Lesions
Atrophy: Skin is thin, shiny and wrinkled.
More than one type may be combined in a single
(Fig. 41.21). Atrophy can occur in the epidermis,
lesion. A vesicle or pustule can occur on top of a
dermis or the subcutis.
macule or papule. The various combinations noted
Scar: Scar is an alteration in the appearance and are maculovesicle, maculopapule, papulovesicle,
texture of the skin which heals in areas of tissue papulopustule, papulosquamous, and so on.
destruction. A depressed scar is an atrophic scar.
Excessive scar tissue occurs in keloids and Configuration of Lesions
hypertrophic scar. After noting the type of skin lesion, see whether the
Keloids originate at the site of injury or even lesions tend to take any particular pattern.
without an injury, example, presternal region. It can Annular lesions (ring-like) are seen in
extend beyond the site of injury in a claw like dermatophyte infection (Fig. 41.22), granuloma
586 Section 15: Dermatology, Leprology and Sexually Transmitted Diseases
Distribution of Lesions
Elicit whether the lesions are generalized or
localized (Fig. 41.26), bilateral or unilateral and
symmetrical or asymmetrical. Look for areas of
greater involvement, e.g. sun-exposed areas and
Fig. 41.24: Gyrate pattern of lesions in erythema gyratum repens sparing of any region (Fig. 41.27). An extensor
distribution is common in psoriasis and flexor
distribution in lichen planus. Scabies lesions occur
annulare, and annular erythema. Grouping of lesions
in a particular distribution on inter digital spaces of
is seen in herpes simplex (See Fig. 41.12), herpes
fingers (Fig. 41.28), medial wrist, elbows, anterior
zoster and dermatitis herpetiformis. Linear pattern
axillary fold, nipples in females and genitalia in
is seen in some types of congenital nevi (Fig. 41.23),
males, completing an imaginary circle called “circle
lichen striatus, linear morphea and others.
of Hebra”.
Arciform lesions occur as incomplete rings or C-
shaped lesions. These are seen in some cases of Though dermatological diagnosis is largely
secondary syphilis. Gyrate pattern (circular or spiral) dependent on inspection, palpation of the skin helps
is seen in erythema gyratum repens (Fig. 41.24), a in certain situations like assessing the texture,
dermatological manifestation of internal malignancy. consistency, depth of lesions and tenderness.
Examine the mucous membranes of the
Zosteriform pattern (girdle pattern) is seen in
mouth and genitalia for discoloration, erosion or
herpes zoster, and some forms of nevi, vitiligo and
ulceration. Examine the hair for its color, texture
morphea which follow a dermatomal distribution
and alopecia. Examine the nails for pitting, ridging,
Generalized lesions are seen in specific patterns
discoloration, dystrophy, thickening and subungual
like ‘S’ shaped, linear and whorls in some verrucous
keratosis.
epidermal nevus and incontinentia pigmenti. These
do not follow segmental pattern (Fig. 41.25). Systemic Examination
Koebner phenomenon (isomorphic effect): This After the dermatological examination an appro-
is the phenomenon in which similar lesions can be priate general examination and systemic exami-
reproduced by physical trauma. For example, nation should be performed.
Chapter 41: General Considerations, Clinical Examination and Laboratory Investigations 587
Fig. 41.26: Allergic contact dermatitis to bangle—well Fig. 41.28: Scabies Lesions on interdigital space (arrow)
demarcated and localized
Part–II: Specialties
epidermolysis bullosa.
Common Clinical Tests Stroking the skin with a blunt object produces an
exaggerated triple response, the red line, flare and
Special tests are performed to elicit diagnostic signs. edema. This is positive in some types of urticaria
and also in mastocytosis. White dermographism is
Gruttage the one in which pallor develops instead of the flare.
Scraping the surface of a psoriatic lesion in a non- This is a feature of atopy.
hairy area with a glass slide releases silvery scales Darrier’s Sign
as if one is scratching the surface of a candle. This
is called “candle grease” sign. Once all the scales Rubbing the macular lesions in urticaria pigmentosa
induces a wheal.
are removed a thin membrane is exposed and on
removing this membrane multiple pinpoint bleeding Diascopy
is seen. This is called Auspitz’s sign and it is
The lesion is pressed with a flat transparent glass
pathognomonic of active psoriasis. It may not be
slide. This helps to differentiate between purpura
positive in a healing lesion.
and erythema. In purpura, the lesion does not blanch,
but in erythema the lesion blanches on pressure and
Nikolsky’s Sign
the color returns on releasing the pressure. In lupus
In cases of active pemphigus vulgaris, if tangential vulgaris a yellowish brown apple jelly appearance
pressure is applied with the thumb on a normal may be seen on diascopy.
588 Section 15: Dermatology, Leprology and Sexually Transmitted Diseases
Part–II: Specialties
DERMATOLOGICAL PROBLEMS 7. Pustules Folliculitis, pustular miliaria, pustular
psoriasis, subcorneal pustular
Generalized Itching (Syn: Pruritus) dermatosis
8. (a) Annular lesions Tinea corporis, granuloma annulare,
Skin Diseases annular erythema, secondary syphilis,
annular lichen planus, pityriasis rosea
Dry skin, scabies, drug eruptions, urticaria, (b) Linear lesions Nevus, scleroderma, lichen striatus,
dermatitis herpetiformis. lichen planus
9. Koebner Psoriasis, lichen planus, lichen
Systemic Diseases phenomenon nitidus, vitiligo, warts
10. Mucous membrane Lichen planus, leukoplakia,
Diabetes mellitus, uremia, anemia, liver diseases, lesions candidiasis, secondary syphilis,
obstructive jaundice, internal malignancy. erythema multiforme, malignancy
CHAPTER
42
1 Clinical Methods
in Leprology
Usha Vaidyanathan
Part–II: Specialties
hypopigmented or erythematous, ill-defined or well-
defined macule (never raised), commonly over the
covered areas of the body. Loss of sensation and
nerve thickening may or may not be present. The
lesions heal spontaneously in 70% of patients. The
rest 30% progress to a determinate type of leprosy,
more commonly to lepromatous spectrum.
Fig. 42.2: Leprosy—large bizarre lesions (BB) Cardinal Signs of Leprosy
1. Alteration of sensation in a lesion characteristic
of leprosy, or in an area supplied by one or more
of the peripheral nerves.
2. Thickening and/or tenderness of peripheral nerve
trunks.
3. The finding of acid-fast bacilli in smears from
skin lesions or normal looking skin.
At least two out of these three signs must be
present for a diagnosis of leprosy.
Lepra reactions, which occur during the course
of leprosy cause many symptoms that often compels
the patient to seek medical advice. There are three
types of reaction.
Type I lepra reaction (delayed hypersensitivity
Fig. 42.3: Leprosy—multiple lesions of BL reaction) is common in borderline leprosy. An acute
exacerbation of existing lesions (erythema, edema,
They contain numerous lepra bacilli. Nasal tenderness) or occurrence of new lesions, edema of
scrapings are negative. Nerve thickening (bilateral hands and feet and acute neuritis are the features of
and asymmetrical) with or without muscle paralysis Type I reaction.
592 Section 15: Dermatology, Leprology and Sexually Transmitted Diseases
Type II lepra reaction (immune complex 4. Loss of sensations in lesions is marked in TT,
mediated) is seen in lepromatous leprosy. It is but not so in LL
characterized by erythema nodosum leprosum 5. TT lesions are bacteriologically negative,
(ENL), which presents as erythematous, small whereas LL lesions team with lepra Bacilli
nodules or plaques, bilaterally symmetrical, tender, 6. Lepromin test, which is strongly positive in TT,
warm and evanescent (lasts for only 2–3 days). ENL becomes negative in BB, BL and LL (This is
lesions are commonly seen over the face, arms and seldom done in practice).
thighs. Other features include fever, malaise, joint
pain, iritis, epididymo-orchitis, neuritis, epistaxis, Examination of Peripheral Nerves
proteinuria and bone pain. The following nerves should be inspected and
Type III lepra reaction (Lucio phenomenon) palpated for thickening, tenderness and nodularity
occurs in Lucio leprosy, which is rare in India. which suggest nerve abscess:
1. Supratrochlear and supraorbital nerves on the
HISTORY forehead
Important points to note in history are: 2. Zygomatic branch of the facial nerve on the
1. When, where and how the lesions started face
2. The evolution of lesions 3. Great auricular nerves over the sternomas-
3. Onset (whether insidious or sudden) toids
4. Any symptoms (leprosy lesions are usually 4. Supraclavicular nerves over the clavicle
asymptomatic). Details of hyperesthesia, 5. Radial nerves in the radial grooves in the arms
Part–II: Specialties
paresthesia or anesthesia of any part should be 6. Ulnar nerves behind the medial epicondyles
elicited. Anesthesia leads to blistering, ulceration 7. Lateral cutaneous nerve in the anatomical
and loss of tissues, particularly fingers and toes snuffbox
5. Sudden or insidious onset of muscle weakness 8. Median nerves in the middle of the flexor
or paralysis aspect of the wrists
6. Nasal symptoms (nasal stuffiness, crust 9. Common peroneal nerves lateral to the head
formation, blood stained discharge), bilateral of the fibulae. Finger should be rolled upwards
pedal edema—these are features of early and forwards
lepromatous leprosy. 10. Sural nerves in the middle of the posterior
7. Systemic involvement is common in lepromatous aspect of the lower part of the legs
leprosy. These include fever, iridocyclitis, 11. Superficial peroneal nerves in the lower third
epididymo orchitis, renal involvement and others. of the lateral aspect of the legs and crossing in
These aggravate during lepra reactions. front of the ankle to the dorsum of the feet
12. Posterior tibial nerves behind the medial
PHYSICAL EXAMINATION malleoli
In addition to a routine examination of the skin, 13. Any cutaneous nerve near a skin patch.
superficial sensations should be looked for. The most Sensation should be tested over the cornea,
obvious abnormalities are diminution or loss of hands and feet. Deformities such as claw hand and
sensations of temperature, touch and pain. It should foot drop should be looked for. Muscle power should
also be noted whether there is infiltration of the face, also be tested in the distribution of the affected
ear lobes or other parts of the skin. nerves.
Specific points to note in order to classify the
spectrum are: INVESTIGATIONS
1. Number of lesions increases through the spectrum
from TT to LL Slit Skin Scraping for AFB (Skin Smear)
2. Size of lesions is bigger in borderline and In all cases of suspected leprosy, skin smears
decreases in LL should be examined to demonstrate Mycobacte-
3. Surface of lesions is dry in TT and shiny in LL rium leprae. In positive cases this should be
Chapter 42: Clinical Methods in Leprology 593
repeated every 6 months to assess the progress. It or not. MI reduces with treatment and falls to zero
should ideally be taken from 4 sites, one from the in 4 to 6 months.
patch, both the ear lobes and normal looking The density of bacilli in smears is known as
skin. the bacteriological index (BI) and includes both live
Hold the skin or the ear lobe firmly between the and dead bacilli. BI is high in lepromatous and few
thumb and the index finger. Make a slit 0.5 cm in or no bacilli in TT. BI remains the same for 12 months
length. If there is any bleeding, wipe off the blood and then steadily falls over the next 5 to 10 years.
and then scrape out some tissue with a pointed Skin Biopsy
scalpel, make a smear, fix it over the flame, stain
Biopsy is indicated for confirmation of diagnosis
by modified Ziehl-Neelsen’s method. Examine in cases of doubt and also for proper classification
under the oil immersion microscope. Note the of the type of leprosy.
presence and morphology of the acid fast bacilli,
whether they are uniformly stained, fragmented or Lepromin Test
granular and also the approximate number of bacilli It is an intradermal test in which 0.1 mL of antigen
in an average field. is injected intradermally on the forearm. The
Fernandez reaction is read after 48 hours and the
Live and dead bacilli should be differentiated to
Mitsuda reaction after four weeks.
know the progress during treatment. Live bacilli are
The Fernandez reaction is a delayed type of
solid rods and stain uniformly. Dead bacilli are hypersensitivity reaction to the bacillary antigen.
fragmented or granular and stain irregularly. The The mitsuda reaction is indicative of cell-mediated
Part–II: Specialties
percentage of solid stained bacilli, calculated after immune response and is more valuable in assessing
examining 200 red-staining elements lying singly the immune status. Lepromin test is not commonly
is called morphological index (MI). This gives performed, but is done for research purposes rarely
valuable information on whether the disease is active at times.
CHAPTER
Sexually Transmitted
43
1 Diseases: Genitourinary
Medicine
Usha Vaidyanathan
Recording of history and physical examination patient had only one exposure prior to the onset,
follows the general pattern. As these diseases are the incubation period can be inferred correctly.
sexually transmitted, they carry social stigma and Attempts should be made to trace all the contacts
the patients are usually hesitant to divulge the so that they can be summoned and treatment offered.
correct history due to fear of ostracization. Hence, Enquire into the past occurrence of STD and
these patients should be given enough privacy and treatment taken by the patient and the sexual partner.
confidence. Presenting complaint: Males with urethritis complain
Medical fraternity should change their attitude of pain during micturition and discharge per
towards these patients and be kind and courteous to urethra.
them. They should not be discriminated upon. They
deserve all respect and hospitality. PHYSICAL EXAMINATION
Suppressing the illness causes harm to the
patient and favors spread to others. Therefore, the In males examine the genitalia, look for any
aim of the doctor should be to cure all cases and discharge. Retract the prepuce, examine the glans
trace all contacts from the index case. It should be penis, coronal sulcus and the undersurface of the
remembered that the same patient may suffer from prepuce. If ulcers are present note their number, size,
multiple STDs. shape, surface and surrounding area. With gloved
hands, palpate the ulcer for tenderness and
SPECIAL POINTS IN INTERROGATION induration. Examine the scrotum and testes. Lift the
Sexual exposure: History of premarital, extramarital scrotum and examine its under surface also.
or marital exposure, the frequency of exposures, Examine the anal region for discharge, ulcers, moist
the type of sex practiced (genital, oral, anal, etc.) papules or verrucous lesions.
and the date of last exposure should be asked for. Note the nature of the discharge, whether it is
Nature of sexual partner: The nature of the sexual purulent (gonorrhea), mucopurulent, mucoid (non-
partner such as prostitute, call girl, casual specific urethritis), or blood stained.
acquaintance, neighbor, relative, foreigner, etc. In females with history of excessive vaginal
and also the place of exposure are important. The discharge, the nature of the discharge—whether
sexual practices-whether heterosexual, bisexual it is purulent (gonococcal), white and curdy
or homosexual should be ascertained. (candidiasis) or yellowish and frothy (tricho-
Personal history: Marital status and occupation moniasis), should be determined. If ulcers are
should be asked for. In females with suspected late present, their onset and presence of any vesicles or
syphilis obstetric history should be recorded. If the trauma prior to the ulcer should be ascertained.
Chapter 43: Sexually Transmitted Diseases: Genitourinary Medicine 595
Syphilitic chancre is usually single, indolent, there is acute tenderness. Bring the finger first to
painless and indurated with bilateral painless the right lateral lobe and press it from above
lymphadenopathy of rubbery consistency. downwards. Then repeat the same procedure
The ulcers of chancroid are usually multiple, medially twice. The same is done on the left
shallow, painful, sharply circumscribed with ragged lateral lobe. This brings the prostatic secretions into
undermined edges, floor covered with vascular the urethra. Then bring the finger in the midline and
granulation tissue and bleeds easily on touch. press downwards. This will express the discharge
Usually unilateral, tender, matted, lympha- from the prostatic urethra to the penile urethra.
denopathy occurs in a few days to weeks and it Examine the nature of the secretion and do a gram
suppurates to form a unilocular abscess. stain. Clumps of pus cells indicate prostatitis.
In lymphogranuloma venereum (LGV), the
INVESTIGATIONS
primary lesion is small, herpetiform, painless,
nonindurated, usually single and frequently Urethral Smear
unnoticed by the patient as it heals very quickly.
It should be examined for gonococci by Gram stain.
Lymphadenopathy follows in a few weeks, which
In females, the urethral and cervical smear should
is unilateral (in two-thirds of cases), tender and
be examined. A wet smear in normal saline should
matted. Enlargement of nodes above and below the
be examined for Trichomonas vaginalis and
inguinal ligament gives a characteristic grooved
Candida albicans. If there is no frank urethral
appearance called the ‘sign of the groove’.
discharge the urethra should be milked by applying
Part–II: Specialties
Examination of Lymph Nodes pressure from the posterior aspect.
The inguinal, external iliac, epitrochlear, posterior Two-Glass Test for Urine
cervical and axillary lymph nodes should be
The patient should hold the urine at least for
examined.
2 hours, and it is passed into two glasses—the first
Mucous membrane of the mouth and throat half in one glass and the rest in the second. If only
should be examined for mucus patches, erosion or the first glass is turbid or hazy it indicates anterior
ulcers. Skin lesions, alopecia, ocular lesions and urethritis. If both glasses are hazy or turbid it shows
hepatomegaly should be positively looked for. that there is involvement of posterior urethra or
Examination of Females higher up. Look for any threads which consist of
shed epithelium lining Littre’s ducts.
Lithotomy position is ideal for examining the
In case of ulcers, Gram stain should be done
genitalia. The external genitalia, vagina, urethra and
cervix should be examined. Except in virgins with from the discharge or slough.
intact hymen speculum examination should be done. Dark Field Examination
Further examination is similar to that in males.
Clean the ulcer with normal saline, press the ulcer
Proctoscopy and the serum should be collected on a cover glass.
This should be done and any discharge, ulcer, Invert the cover glass on a slide, smear the edges
growth or stricture should be looked for. If there is with vaseline. Put oil on the cover slip and also on
discharge it should be examined for gonococci, the condenser and examine under the dark field
ameba, and other organisms. microscope. Spirochetes and Trichomonas can be
seen.
Prostatic Massage Tissue smear: In case of suspected donovanosis, a
It is indicated in males with chronic prostatitis for tissue smear should be taken with a toothed forceps.
diagnosis as well as for therapy. The gloved index Forceps, crushed on a slide with another slide and
finger is introduced into the anal canal and the both slides should be fixed and stained with
prostate is palpated for its size, consistency and Leishman’s stain. The organisms are seen inside the
tenderness. Prostatic massage is contraindicated if monocytes. The organisms may be coccoid, cocco-
596 Section 15: Dermatology, Leprology and Sexually Transmitted Diseases
bacillary or with a bipolar staining giving the usually remains positive life long, even after full
appearance of a closed safety pin. treatment.
In cases of amebic ulcer, a wet saline prepara- FTA-ABS IgM test is indicated in case of
tion from the edge of the ulcer may show actively congenital syphilis to differentiate between infection
motile amebae. If tuberculosis is suspected, a smear in the baby and the transmission of maternal
should be examined for M. tuberculosis by Ziehl- reagenic antibodies without actual infection.
Neelsen method. Presence of FTA-ABS IgM antibodies suggests that
the baby is infected.
Biopsy of the Ulcer
This helps to differentiate syphilis, chancroid, Cerebrospinal Fluid (CSF) Examination
donovanosis, tuberculosis, malignancy and others. The cell count, proteins and VDRL should be done
to exclude neurosyphilis. In neurological involvent
Serological Tests in AIDS the CSF may show diagnostic abnormalities.
Venereal Disease Reference Human Immunodeficiency Virus
Laboratory Test Infection and Skin
Venereal Disease Reference Laboratory (VDRL) Human immunodeficiency virus (HIV) pandemic is
test should be done in all STD cases to diagnose continuing for nearly 30 years. Heterosexual contact
syphilis. If the test is negative, it should be repeated is the main mode of transmission. Certain skin
after 10 days since the test may be nonreactive in disorders are highly associated with HIV infection.
Part–II: Specialties
early primary stage. The test should be done in serial Serotesting is indicated in acute retroviral syndrome,
oral hairy leukoplakia, eosinophilic folliculitis,
dilutions in case of suspected secondary syphilis to
Kaposi’s sarcoma, bacillary angiomatosis, proximal
exclude a prozone phenomenon. In all other cases
subungual onychomycosis and occurrence of any
the test should be repeated after 3 months. It is a
STD. Viral infections like herpes zoster and
nonspecific test. VDRL becomes negative after molluscum contagiosum, fungal infection like
treatment. candidiasis, recurrent aphthae and seborrheic
Specific Tests for Syphilis dermatitis are common associations.
In the early course of HIV, most dermatological
Specific tests are done to differentiate from a false manifestations are typical and respond to treatment.
positive reaction and to know whether the patient With progressive immunodeficiency, atypical
had a previous treponemal infection. Treponema presentations occur. They are usually extensive,
pallidum immobilization test (TPI), fluorescent recurrent and resistant to treatment.
treponemal antibody absorption test (FTA-ABS)
and Treponema pallidum hemagglutination test ELISA Test for Human Immunodeficiency
(TPHA) are the specific tests used. Of these three Virus I + II Antibodies
specific tests, TPI is very specific, FTA-ABS is very ELISA for HIV should be done in all STD patients,
sensitive, but the commonly performed and those with multiple partners, homosexuals and those
available test is TPHA. In biological false positive with high-risk behavior. If positive, it should be
VDRL test, TPHA test will be negative. TPHA confirmed by Western blot test.
SECTION
16
Psychiatry
CHAPTER
44
1 General Considerations
N Krishnankutty
Psychosis, Neurosis, Mental functions, List of signs and symptoms of mental disorders, Classification of
mental disorders, Organic and functional mental disorders
• Abnormal memory
Signs and symptoms of mental disorders are Amnesia – immediate, recent. and remote;
described in Table 44.2. anterograde, retrograde confabulation
• Abnormal intelligence
Table 44.2: Signs and symptoms of mental disorders Dementia, mental retardation
• Abnormal psychomotor activity Abnormal Judgment – impairment
Acceleration Retardation Perseveration
Table 44.3: Classification of mental disorders
Agitation Stupor Catatonia
Restlessness Stereotypy Waxy flexibility • Organic mental disorders
Excitement Echopraxia Negativism Delirium, dementia
Retardation Perseveration Posturing • Mental disorders due to
• Abnormal mood psychoactive substance use, e.g. alcohol, tobacco, cannabis opiods
Apathy Euphoria Anxiety • Schizophrenia
Incongruous mood Exaltation Irritability • Mood disorders: Manic episode, depressive episode
Blunted affect Ecstasy LaBella indifference • Neurotic and stress related
Elevation Depression mental disorders
• Abnormal thoughts Generalized anxiety disorders
Formal thought disorders Panic disorder
Loosening of association, flight of ideas, neologism, perseveration. Phobic anxiety disorders
Abnormal streams Obsessive – compulsive disorder
Pressure of thought, poverty of thought, thought block, tangentiality, Dissociative (conversion) disorders
circumstantiality Somatoform disorders
Abnormal contents • Sexual dysfunctions – impotence
• Personality disorders
Delusions Types of delusions
Part–II: Specialties
1
45 Clinical Aspects of
Mental Disorders
N Krishnankutty
Examination of psychiatric patient, Mental status examination, Examination of psychomotor activity, Brief
clinical features of common mental disorders
obtained. The present illness may be either an the consultation room and goes hand-in-hand with
exacerbation or another episode of the previous history taking. Some cases may require more than
disorder. one sittings for the completion. It is done according
Previous physical illness may bear relation to to the scheme.
the present mental disorder. Epilespy and head injury
may have psychiatric sequlae. Treatment with General Appearance and Behavior
steroids can produce mood disorder. Cushing’s The description should be as complete, accurate and
disease, thyroid dysfunction and Huntington’s chorea life-like as possible. Look at the way of dressing,
have their psychiatric counterparts. Encephalitis in cleanliness in general, self-care, hair dressing, and
childhood can cause mental retardation. behavior towards others.
Note:
Family History
1. Is he in touch with the surroundings?
All details of the family members, their inter- 2. Is he restless or slow?
relationship, the family structure, the attitude of other 3. Is the patient violent and aggressive?.
family members towards the patient and the 4. Are there abnormal responses to external
occurrence of psychiatric illness, alcoholism, events?
suicide, and mental retardation in the family have 5. Is he cooperative?
to be elicited. Drawing a family tree is useful for 6. Is he communicative?
recording. 7. Does the patient’s behavior suggest that he is
Socioeconomic Status disoriented?
Socioeconomic conditions of the patient and the Note the presence of any catatonic phenomena,
social support he is likely to get are to be enquired tics, mannerisms or hallucinatory postures.
into. His source of income and accessibility to
EXAMINATION OF PSYCHOMOTOR ACTIVITY
treatment and affordability to costly drugs is also
important. It is the mental activity manifested in his physical
activity. It is not the same as neurological motor
Personal History function. Observe the speed or rate of talk, writing
Get a biographic scheme of the person. Prenatal or any other activity. The rate may be abnormally
and postnatal history, trauma and illness during low or high. When the rate is high, it is called
Chapter 45: Clinical Aspects of Mental Disorders 603
Part–II: Specialties
speech) Similarly repetition may occur in carrying
inappropriate or incongruous. It is also incongruous
out an activity (perseveration of action).
if the mood and ideas are not in harmony. For
Catatonia refers to the widespread muscular
example, the patients may be telling his sad news,
rigidity expressed as waxy flexibility, posturing,
but he may appear happy. The face may appear mask
negativism, excitement or stupor. Ask the patient to
like with no emotional response to anything
do some deed. He may automatically resist it or
(apathy).
may do the opposite of expected one (negativism).
Examine the degree of intensity of mood. An
The limb of the patient may show wax like rigidity
so that it can be placed in any awkward posture for obvious reduction in the intensity may be seen
any length of time. (Waxy flexibility/catalepsy/ (flattened/blunted affect). The patient may appear
flexibilitas cerea). Posturing is the maintenance of persistently happy and overjoyous for no obvious
bizarre, fixed, strange, rigid body position for reason elevation of mood. When the mood is
prolonged periods. Violent and aggressive activity elevated, find whether it is euphoria, elation,
may be found in excitement. exaltation or ecstasy. Euphoria is a mild degree of
elevation with exaggerated physical and
Clinical Importance of psychological well being. Elation is moderate
Psychomotor Activity degree of cheerfulness with increased self-
Mild increase in PMA is called restlessness which confidence and grandiose ideas. Exaltation is
is found in generalized anxiety disorders and early severe degree of elation with grandiose delusion.
delirium. Psychomotor activity (PMA) is very high Ecstasy is the highest degree of happiness, a
in manic excitement, schizophrenic excitement, feeling of rapture where one may forget oneself.
alcoholic intoxication, delirium, panic attacks and Usually it is short lived. The mood may be lowered
agitated depression, attention deficit hyperactivity or depressed as seen by the feeling of sadness, the
disorder. Echolalia stereotypy, echopraxia, negativism, facial muscles are devoid of tone and become loose,
waxy flexibility are more common in schizophrenia the angle of month sags down, the eyelids tend to
than in organic disorders. Perseveration is more fall down. A fearful facial expression appears in
common to organic disorders. The PMA is retarded anxiety mood; where the eyes are widely open,
in depressive illness. Stupor may be found in pupils dilated, the facial muscles are tight with
depressive disorder, catatonic schizophrenia, organic prominent grooves. Some patients may show
(physical) disorders and dissociative disorders. excessive reaction in unpleasant manner to external
604 Section 16: Psychiatry
stimuli (irritability). The patient may not show any The patient may have the delusion that he is
type of emotional concern towards the disability very powerful, can do anything for others and has
which he is suffering (La-Belle indifference). close company with persons of high positions—
Examination of thought/thinking: The thought is scholars, scientists, ministers, film stars and the
manifested as talk, writing and gestures. Normal like (grandiose delusion). Paranoid delusion is a
thought is relevant to the context and coherent. It common term in use. It includes both persecutory
follows a logical sequence pattern and grammatical and grandiose delusions. A patient in depression may
alliance. To find the abnormalities in thought, have the delusion that they lost everything and has
examine how the thought (talk) is formed, how is become too poor (delusion of poverty). In delusions
the flow (stream), what abnormal contents are there, of guilt, the patient accuses himself as a sinner,
and if there is any denial of ownership (possession). having done many sinful deeds in the past and
Loosening of association, flight of ideas, wishes to get punishments. Depressives often say
neologism and perseveration are formal thought that part of their body or the whole body or the world
disorders. In loosening of association the logical itself is not existing (nihilistic delusion). Delusion
sequence pattern is lost and so the thoughts of infidelity is found among couples where the
become meaningless and ununderstandable. The opposite partner is accused of extramarital sexual
grammatical alliances are not held properly. In- relation. Some patients may come with delusion that
flight of ideas there is rush of thought and the they suffer from serious physical disease (somatic/
thought jumps rapidly from one topic to another. hypochondriacal delusion) The delusion may be
They are related to one another and the meaning that their mood, thought and actions are controlled
Part–II: Specialties
can be gathered. The patient may use new words by other people outside, (delusion of control/
not found in the dictionary (neologism). The patient passivity/influence).
may continually repeat the same answer given to a
Delusion may appear suddenly out of the blue,
previous question, without responding to further
not preceded by, any other psychological events
fresh questions (perseveration).
(primary delusion). Delusion may occur secondary
Examine the stream of the talk. Too many ideas to some other psychological events such as mood
may be rapidly rushed out of the mind (pressure of change or hallucination (secondary delusion).
thought). On the other hand the talk may be scanty
Thought insertion, thought withdrawal and thought
and the flow is slow (poverty of thought). The
broadcasts are other kind of delusions. Thought
stream of talk may stop abruptly by itself and fails
insertion is the experience that thoughts are not his
to proceed further, however they may try (thought
own but placed in the mind by persons outside.
block). The talk may deviate away from the matter
Thought withdrawal is the experience that his
discussed and fails to reach a final goal (tangential
thoughts are taken way or stolen from his mind as
thinking). But in circumstantiality after lengthy
the thought disappears as soon as it comes to the
narration the original goal is reached finally.
mind. Thought broadcast is the experience that
Look for abnormal contents such as delusions
others are participating in his thinking so that
suicide ideas, obsessions, phobias and other.
unspoken thought are known to other persons.
Delusion is an abnormal belief which cannot be
shared by others. The notion is false, fixed and Ideas of suicide are not generally expressed they
cannot be corrected by arguments and evidence to have to be tactfully elicited. Enquire about the life
the contrary. It is culturally unacceptable. Usually in general and its importance. Ask about the present
delusion is reported by the informant of the patient. state of life of the person and his desire to live long.
Some may have persecutory delusion that the food Further it can be asked whether he had wished death
given is being poisoned; secret plot is being made at any time. In positive cases enquire about the plans
to kill him or to take away his wealth; he is spied made and of the desuading factors.
upon and so on. A news in the media, a gesture Obsessive ideas may be there as part of
observed, a conversation heard, a spitting out seen symptom of OCD, schizophrenia, depression or
may be construed as referring to him only and done brain disease. Phobia is a symptom of phobic
deliberately by his enemies. (delusion of reference). anxiety disorders.
Chapter 45: Clinical Aspects of Mental Disorders 605
Part–II: Specialties
Some patients may have complaints that bugs or
to end life and made fun of. Further they may be
insects are crawling under the skin. To some,
seen reacting to it by retorting in the same coin,
X-rays, electormagnetic waves or cosmic rays
start quarrelling and even petition to police. When
and vibrations falling on their skin may be
voices are there ascertain the contents of the
experienced. But the examiner will not find any
hallucination and the type of person—I, II, or III.
evidence. This is the nature of tactile/haptic
Hearing one’s own thought spoken aloud are of first
hallucinations.
person type. Voices arguing or addressing as “you”
and yours are of second persons and voices of Clinical Importance of Hallucination
running commentary, making statements or
Hallucinations are pathological, but not always.
conversations about the patient are of third person
type. Instead of voices there may be noises of any Hearing divine voices in the air once in a while is a
kind in many cases. culturally accepted premonition. Visual hallucinations
and rarely auditory hallucination occurring as one
Case Reports falls asleep (hypanagogic hallucination) and wakes
A mother sleeping with her schizophrenic daughter up from sleep (hypnopompic hallucination) are not
was woken up at night hearing the loud laughter of abnormal. Second and third person auditory
the patient. The patient said the reason; “Cannot hallucinations and hearing one’s own thought
you hear? They are calling me. Come, come out. spoken aloud are suggestive of schizophrenia.
We are here outside. “The mother said angrily.” Auditory hallucination of derogatory contents favors
Your madness has come again.” depressive disorder. Olfactory hallucination of burnt
materials are characteristic of temporal lobe
Visual Hallucinations epilepsy. Hallucination of bad odor entering the body
It is common in delirious patients. They may is experienced in schizophrenia where as passing
be startled with complaints that worms, spiders, out foul gas from the body is experienced in
snakes, millipedes and such insects are crawling depressive disorders.
over the body. They may try to pick them out. Visual Tactile/haptic hallucination of worms, creeping
hallucinations may be there in migraine and in LSD under the skin is a feature in cocaine psychosis.
and cannabis intoxication. Tactile hallucination of X-rays, electromagnetic
606 Section 16: Psychiatry
waves, cosmic rays falling on the skin is symptom Test the Orientation
of schizophrenia. Gustatory hallucination occurs in Ask the patient to give the time of the day without
temporal lobe epilepsy (TLE) and depression. looking into the wrist watch and also the day of the
Illusion weekmonth and year. Wrong answers convey
disorientation in time. Ask the patient to name the
It is the phenomenon of misinterpretation of sensory place where he is now, the name of his locality and
experience under certain circumstances. A rope may the place where the hospital is situated. Errors points
be mistaken for a snake and a tree for a ghost. out disorientation in place. Find whether the patient
De-reality Feeling (De-away) can identify persons previously known or persons
in traditional uniform such as policeman, nurse or
Some patients may come with an experience to their doctor. Disorientation to person is indicated by the
body as if the body or part of the body is not real mistakes committed.
and changed some way—depersonalization. In a
similar way the patient may have the feeling as if Tests for Attention and Concentration
the surroundings are not real and has changed in some These terms indicate the ability to focus to a particular
way— derealization. stimulus and to sustain it. Attention can be assessed
Clinical importance: Both depersonalization during interrogation. Normally, attention is prompt
and derealization are found in cases of anxiety and sustained as long as the stimulus continues. Test
disorder, depressive disorder, epilepsy, organic brain whether the attention is normal or abnormal.
disorders and schizophrenia. Attention and concentration can be tested by:
Part–II: Specialties
The object appears much reduced in size. The patient is made to count 1 to 20 forwards and
then backwards. Errors occur when attention is
Macropsia impaired.
The object appears much magnified. Serial Deduction Test
Both micropsia and macropsia are found in TLE
To deduct serially 3s from 40 or 9s from 100.
and schizophrenia. The rate of performance and the errors committed
Examination of Level of Consciousness will give an idea of the state of attention and
concentration. These factors also depend to great
These affect the clarity of the sensorium. The deal on the level of his education.
disorder of consciousness includes clouding,
confusion, stupor and coma. Functional psychiatric Digit Span Test
symptoms develop in a clear conscious setting. On The patient is seated in front of the examiner. In the
the other hand if the symptoms are found to digit forward test the patient is asked to repeat digits
supervene on an impaired state of consciousness, given by the interviewer containing three, four, five,
an organic illness has to be considered. In hysterical six, seven or eight digits (e.g. 729, 3194, 27106).
fainting there is no real loss of consciousness, and In the backward digit test, the digit given by the
they will be aware of the surroundings. The level examiner have to be repeated in the reverse order
of consciousness has to be carefully assessed by (i.e. 8139 as 9318). 7 digits forward and 5 digits
inspection and interrogation. backward constitute normal ability. It is lowered
when the attention or immediate memory is
Examination of Orientation impaired.
Orientation is the appreciations of one’s own Impaired attention is called distractibility.
temporal, personal, and spatial relations at a given Fluctuating attention is found in delirium. Lack
moment. Disorientation is the disturbance of of concentration occurs in generalized anxiety
orientation. Disorientation may pertain to time, disorders, depressive disorder, schizophrenia,
place or persons. It may occur in delirium. dementia and delirium.
Chapter 45: Clinical Aspects of Mental Disorders 607
Part–II: Specialties
are hidden. Incorrect answers indicates impairment
Intelligence is the global capacity of an individual
in immediate memory.
to think rationally, to act swiftly and to adjust
Recent Memory/Short-term Memory adequately to the surroundings. Intelligence can be
assessed clinically by knowing his adaptive skills,
It subserves the function of retention for short period
general knowledge, occupational adjustments,
and the ability to acquire new knowledge. Ask the
educational achievement, motor skills, management
patient what items of food he had for the previous
of finance, household and others. It can also be
lunch, persons who has visited him the previous day
assessed during the interview. Intelligence can
and what important news were there recently in the objectively be measured by scales of intelligence.
press or in the TV. Many such recent information Intelligence is expressed as intelligence quotient—
can be checked. Errors indicates amnesia for recent IQ and the normal is 100 + or – 16 – a whole
events. The truth has to be verified by the bystanders. number. See whether the intelligence is average or
Remote Memory subaverage or whether it is subnormal due to brain
pathology in dementia. Subaverage intelligence,
This term refers to the recollection of events of the due to failure in development is called mental
long past. Ask the patient to give his date of birth, retardation. Milestones of development will be
the name of school where he has studied, date of delayed in such cases.
marriage, the name of the siblings. Mistakes are
suggestive of loss of remote memory. It has to be Examination of Judgment and Reasoning
corroborated by relatives. Loss of remote memory Judgment is the ability to make right decisions in
is a late event in the disease process. specific situations. See whether the judgment is
normal or impaired. To test judgment certain
Clinical Importance of Memory hypothetical situations are selected. Examples:
Loss of memory is called amnesia. Amnesia occurs “What will you do when you see a house on fire?
in many CNS diseases and psychiatric disorders. What will you do when you get a wound on your
Easy forgetfulness is a problem among school finger? What will you do if you find a stamped,
children. Basically, it is due to poor attention causing addressed envelop on the road”? Subaverage
failure of registration. Anxiety disorders can also answers suggest impairment in judgment.
608 Section 16: Psychiatry
Retarded psychomotor activity or stupor. Poverty mad lasts for a few minutes. Mitral valve prolapse
of ideas, guilt feeling, hopelessness and worth lessness. is an important differential diagnosis.
Pessimistic, suicidal ideas, attempts and other self-
Phobic Anxiety Disorders
harming behavior.
Aches and pains and other vague somatic Anxiety attacks provoked by certain specific
symptoms. Early morning awakening to total innocuous objects or situations. At other times
insomnia. Loss of appetite, loss of weight and lack they are asymptomatic. Symptom ceases when the
of sexual feeling or impotence. object or situation is avoided, e.g. mysophobia (fear
of contamination), agoraphobia. In agoraphobia, the
Generalized Anxiety Disorders fear is to go to public places, crowds, crowded
Anxiety is very prominent. This leads to symptoms buses, traveling alone and to distant places.
characteristics of autonomous arousal. Mental and Obsessive Compulsive Disorders
physical symptoms affecting all systems are
manifest. Different manifestation may occur in The main features are obsessive thoughts and
different persons. compulsive behavior and the anxiety associated with
Mental symptoms: Unpleasant feeling of fear, it. Obsessions are the recurrent intrusion into the
tension, worries, feeling of impending danger and mind of unwanted ideas, doubts, impulses or images
disaster. Fleeting attention, poor concentration, despite the effort to avoid it and despite knowing
difficulty in getting into sleep and fretful sleep. that it is absurd. Compulsions (rituals) are repeated
activity due to the obsessive thoughts. Voluntary
Part–II: Specialties
CNS efforts to resist the activity produce mounting
Dilated pupil, wide open eyes, marked facial grooves, anxiety. Examples: That the hand is contaminated
headache and numbness. by dirt or germs may be an obsession. In order to
get rid of it, the hand is repeatedly washed
CVS (compulsion). The door may be locked. An obsessive
Chest pain, palpitation, tachycardia, high systolic BP. doubt may arise whether it is locked or not. To verify
it, checking behavior is carried out repeatedly
GIT (compulsion).
Dryness of mouth, anorexia, abdominal distention,
Dissociative (Conversion) Disorders
gas, constipation, diarrhea, hot flushes at anal orifice.
The features are loss or disturbance of function of
Respiratory sudden onset. Psychological stress (unconscious
Tachypnea, breathlessness, chest pain, choking. conflict) may be in the background. There are
psychic (dissociative) symptoms and physical
Genitourinary
(conversion) symptoms. The usual psychic
Increased frequency of micturition, hesitancy, symptoms are psychogenic amnesia, fugue, trance,
failure of erection. possession state and stupor. The common physical
Musculoskeletal symptoms are motor (paralysis of any type), sensory
(anesthesia, hyperesthesia, blindness, deafness)
Restlessness, tremors, tight feeling of muscles
and visceral (vomiting, retention of urine). The
(tension) and inability to relax, fear to go into public
symptoms of the disorder may mimic any disease
places, crowds, crowded buses, and to travel alone
or disorder. No physical pathology may be found.
to distant places.
The patient is emotionally unconcerned about the
Cutaneous disorder (La Belle indifference) is significant.
Increased perspiration, hot flushes, especially at anal Patient gets personal benefits out of the disorder
orifices. (secondary gain).
Panic Anxiety Disorders Dissociative Amnesia (Psychogenic Amnesia)
Sudden episodic attacks of severe anxiety with Sudden onset of forgetfulness for circumscribed or
feeling of impending doom or disaster or turning selective events which are traumatizing to the
610 Section 16: Psychiatry
person. Nonprogressive—no organic lesions can be true paralysis. The patient lies supine. Place the
detected. Complete recovery is the rule. palms of the examiner under the heels of the patient.
Ask the patient to raise the paralyzed limb. No
Dissociative Fugue movement may be noted. Next, ask the patient to
The patient may be wandering away to distant places raise the nonparalyzed limb. A downward thrust
under a new personal identity. Everything about the may be felt over the palm placed under the paralyzed
past is forgotten including the personal identity. limb (Hovers sign).
Original identity could be regained spontaneously
Dissociative Convulsion
or by hypnosis.
The patient may present with seizure like movement
Trance and Possession Disorders (Table 45.1).
The personality is affected by an alien spirit—either Dissociative convulsions (pseudoseizures)
a devil, divine force, or an expired close relative. mimic epilepsy. It should be distinguished from
genuine seizures, but both may coexist.
Sensory Disturbance
Hand Drop Test
Any kind of sensory loss may occur. In anesthesia,
The patient is supine. Passively raise the paralyzed
there is loss of sensation is over well defined areas.
hand straight above the face and allow it fall down.
It is marked by sharp boundaries. Mark the
In genuine paralysis the hand ought to fall on the
boundary of anesthesia repeatedly by drawing a line
face. But in conversion disorder somehow the face
with the pointed end of knee hammer from a
in evaded by the patient.
sensitive area. It also varies with suggestions. The
Part–II: Specialties
patient to look forward. Drop down a few coins 9. Lethargy may last for about Active and energic after the fits
48 to 72 hours
without the knowledge of the patient. The patient 10. Corneal reflex absent and Corneal reflex present and
turns the head backwards due to the auditory reflex plantar reflex is upgoing in the plantar is down going
which excludes organic lesion. post-ictal unconscious phase
11. Post-ictal rise of prolactin Nil
Motor Disturbances 12. EEG abnormalities occur EEG normal
Monoplegia, hemiplegia and quadriplegia are usual in inter-ictal period and
ictal period
common. They can be clinically differentiated from
Chapter 45: Clinical Aspects of Mental Disorders 611
Mild compression with the thumb over trachea may Anxiety Symptoms
also evoke cough reflex. Hyperthyroidism, pheochromocytoma,
hypoglycemia, withdrawal of sedative drugs.
Physical Illness Manifesting with
Psychiatric Symptoms Fatigue Syndrome
Physical illness may coexist not only in organic Anemia, sleepdisorders, chronic infections like
mental disorders but also in other mental disorders. tuberculosis, diabetes mellitus, hypothyroidism,
In addition, many drugs used in therapeutics may Addison’s disease, carcinoma, Cushing’s syndrome.
induce psychiatric symptoms. Common psychiatric Weakness
symptoms caused by systemic diseases are given Diabetes mellitus, hypothyroidism, malnutrition,
below. anemia, myasthenia, peripheral neuropathy, other
Depressive Symptoms neurological disorders.
Carcinoma infections, neurological disorders Episodes of Paroxysmal Disturbed Behavior
including dementia, hypothyroidism, Addison’s Epilepsy, hypoglycemia, pheochromocytoma,
disease, systemic lupus erythematosus, diabetes porphyria, early dementia, toxic states, or panic
mellitus, hyponatremia. disorders.
Part–II: Specialties
CHAPTER
46
1 Investigations in Psychiatry
N Krishnankutty
Part–II: Specialties
suppression of endogenous glucocorticoids in out the vascular anatomy more clearly.
response to externally administered dexamethasone Magnetic resonance imaging (MRI) is very
does not occur. False positives tests may develop at useful to study lesions which are not clearly brought
times. out by CT. MRI is more useful to visualize small
lesions, lesions in the white matter and those in the
Prolactin Level
posterior fossa. MRI also gives clues about the
Increase in the prolactin level may develop as an pathological nature of the lesion.
adverse effect of antipsychotic drugs. This may Positron emission tomography (PET) gives
produce gynecomastia, amenorrhea, and loss of information about the cerebral blood flow and
libido. metabolism. Its use in clinical settings is limited,
Prolactin levels may be used to distinguish as it is most expensive and is available only in a
between genuine seizures and pseudoseizures. few centers.
Elevation of prolactin levels occurs soon after
genuine seizures, not in pseudoseizures. PSYCHOLOGICAL INVESTIGATIONS
Body Weight Psychological investigations are done under special
circumstances in order to help the clinical diagnosis
Increase in body weight is observed in the case of
and assess the outcome of treatment.
the psychotropic drugs. Hence, regular weight
monitoring is indicated. Increase in body weight is Commonly used tests can be classified as:
a good prognostic sign in the treatment of anorexia 1. Ability tests
nervosa. 2. Personality tests.
X-ray skull can help to diagnose rise in Ability Tests
intracranial tension, secondary deposits and
intracranial calcifications. These test the mental ability or potential of a person.
These include:
Electroencephalogram 1. Intelligence tests, and
This may help to distinguish metabolic stupor 2. Aptitude tests.
and coma. Electroencephalogram (EEG), taken with The former is used more often in clinical
sphenoidal electrodes might help to identify complex settings.
614 Section 16: Psychiatry
Bhatia’s short scale of intelligence is a used in conjunction with an informative history and
modification of Binet-Simon intelligence test and mental state examination.
this is widely used in India. The intelligence scales
are individual tests with two categories of sub Thematic Apperception Test
tests—verbal and performance. It is a projective test that gives an idea about the
Verbal sub-tests reveal the ability to handle interpersonal relationships of an individual and his
language. Performance sub-tests assess the ability inner psychological world. The test kit consists of
to handle motor skills. In early stages of dementia thirty cards, each depicting a social situation—a
performance intelligence is impaired much more theme. The individual is asked to tell a story with a
than the verbal intelligence. Performance subtests beginning, theme and ending, based on the picture
are more helpful in people with limited verbal skills, in the card. For example, card No. 3 M shows the
foreign backgrounds or poor education, provided picture of a man in middle age and a teenager
they can understand the instructions. Such standing by his side. The boy’s face is quite grim
individuals frequently do better on performance tests and the man’s face is serious. One patient may
than on verbal tests. interpret this as a father scolding the son for a wrong
deed. Another one may think that both the father
Personality Tests
and son are worried about a common domestic
1. Projective tests, and problem. A third interpretation would be that both
2. Nonprojective tests. are plotting a scheme against a hostile neighbor or
Projective tests reveal the manner in which a undesirable relative. In other words, the individual
person responds to a vague or ambiguous stimulus projects his inner psychological conflicts or
and this is often a projection of his underlying mental concerns and interpersonal stresses into the
process and motives. ambiguous social situation depicted in the card and
Common projective tests are Rorschach Ink Blot makes a story accordingly. Thematic apperception
test, Thematic Apperception Test, Sentence test (TAT) is useful to understand the dynamics of
Completion Test and ‘Draw-A- Person’ Test. behavior and in planning psychotherapy.
Chapter 46: Investigations in Psychiatry 615
Part–II: Specialties
1. Minnesota multiphasic personality inventory • Global assessment of functioning (GAF) scale
(MMPI): Inventory is a written list of several • Abnormal involuntary movement scale (AIMS).
SECTION
17
Ophthalmology
CHAPTER
47
1 Ophthalmology: General
Considerations
ANATOMY AND FUNCTIONS OF receives motor fibers from third and sensory from
OCULAR STRUCTURES fifth cranial nerves and sympathetic fibers from
carotid plexus. It gives off short posterior ciliary
Anatomy of the Eye nerves which enter the posterior part of the eyeball.
The eye is lodged in the orbit which is almost
pyramidal in shape with the optic foramen at its The Eyeball
apex. Posteriorly the bony orbit has three openings— The eyeball is made up of imperfectly elastic tissue
the optic foramen, the superior orbital fissure, and consisting of the transparent cornea in front and
the inferior orbital fissure. The optic nerve and opaque sclera behind. The cornea is 11 mm in
ophthalmic artery pass through the optic foramen. diameter, it is avascular and its sensory supply is
The superior orbital fissure transmits the ophthalmic by the trigeminal nerve. Cornea has the richest
veins, the third, fourth and sixth cranial nerves sensory nerve supply in the body. The portion
which supply ocular muscles and the ophthalmic bounded by the two eyelids is the palpebral fissure.
branch of the trigeminal nerve. The infraorbital The palpebral conjunctiva which is a transparent
nerve and artery pass through the inferior orbital membrane covers the anterior part of the sclera. The
fissure. In addition to the eyeball, the orbit contains junction of cornea and sclera is the limbus. The
extraocular muscles, lacrimal gland, blood vessels, angle formed by the bulbar conjunctiva and the
nerves, fat and fascia. The ophthalmic artery and tarsal conjunctiva is the fornix. The optic nerve
its branches supply ocular structures. Orbital veins pierces the sclera 2.5 mm internal to the posterior
empty into the cavernous sinus through ophthalmic pole. The retina and the uveal tract line the inner
veins. aspect of the sclera. The uveal tract consists of the
iris and ciliary body anteriorly and the choroid
Nerve Supply to Orbital Structures posteriorly. The sphincter pupillae and the dilator
Third, fourth and sixth cranial nerves supply the pupillae regulate the pupillary aperture.
external ocular muscles. The third also supplies Ciliary body secretes aqueous humor and the
motor fibers to the sphincter pupillae and ciliary ciliary muscle acts on the ligaments of the lens to
muscles. Dilator pupillae is supplied by sym- control its convexity during accommodation for near
pathetic fibers derived from C8 to T3 spinal vision. The retina consists of seven neural layers
segments. Sensory supply to the eyeball and orbit formed by three strata of cells and their synapses.
is derived from the ophthalmic and maxillary The fovea centralis which contains only cones is
divisions of the fifth cranial nerve. Ciliary gang- situated 3 mm to the temporal side of the optic disk
lion, which lies to the outer aspect of optic nerve and it can be distinctly seen on ophthalmoscopy.
620 Section 17: Ophthalmology
Fovea centralis is the most sensitive part of the elastic and connected to subjacent muscles by loose
retina. It is surrounded by the macula where areolar tissue. Eyelids are free of fat. Anterior lips
ganglion cells and plexiform layers are heaped up of the lids are rounded and eyelashes arise from
and nuclear layers are thinned out. The nerve fibers them. The posterior margins are sharp. The
of the retina converge towards the optic disk and Meibomian glands open in front of the posterior
form the optic nerve. Fibers of the optic nerve pass margin. The upper eyelid is elevated by levator
backwards through the lamina cribrosa, which is palpebrae superioris and both the eyelids are closed
formed by interlacing connective tissue fibers. by the orbicularis oculi. In addition, the upper eyelid
contains Mueller’s muscle which maintains a tonic
The Lens upward pull.
The lens is biconvex and transparent. It is developed Lymphatics from eyelids drain into preauri-
from ectoderm. Central part contains the oldest cells cular, submaxillary and submandibular nodes.
and the periphery, the youngest. Anterior surface is Oculomotor nerve supplies the levator and facial
less convex than the posterior. The lens is suspended nerve supplies the orbicularis. Sympathetic nerves
behind the iris and in front of vitreous by suspensory supply the Mueller’s muscle. The lids protect the
ligament. The lens is an unique organ in that the eyes from injury and excessive light. Blinking of
cells and proteins once formed, are never turned the eye lubricates the eyeball regularly with tears
over. The center of the adult lens contains cells and and glandular secretions.
molecules formed in utero. The lens continues to Lacrimal Apparatus
grow throughout life. Newly formed cells elongate
Part–II: Specialties
and lose their nuclei and organelles and become It consists of the lacrimal puncta, canaliculi, sac
fibers added to the outermost layers of the cortex. and the nasolacrimal duct. Excess tears drain into
Aging is an inevitable process that continues, the inferior meatus of the nose.
but under optimum conditions the lens is Extrinsic Muscles of the Eye
programmed to remain transparent even up to
120 years. Cataract is the single most frequent Six muscles—4 recti and 2 obliques move the
cause of blindness. eyeball. Arising from the orbit they are all attached
to the sclera. The four recti—superior, inferior,
Anterior Chamber medial and lateral arise from the apex of the orbit.
It is the space bounded in front by the cornea and Their anterior attachment to the eyeball is 7.7, 6.5,
behind, by iris and the portion of the anterior surface 5.5. and 6.9 mm respectively behind the corneal
of the lens exposed at the pupil. It is about 2.5 mm margin. The superior oblique arising from the upper
deep in the center. It is filled with aqueous humor. and inner margin of the optic foramen, runs
Angle of the anterior chamber is the peripheral forwards, passes through the fibrous pulley and gets
recess of the anterior chamber bounded posteriorly attached to the upper and outer portion of sclera
by the root of the iris and ciliary body and anteriorly behind the equator. The inferior oblique has its
by corneosclera. origin from the lower and medial wall of the orbit.
Like the superior oblique, this is also inserted behind
Posterior Chamber the equator into the outer aspect of sclera.
It is the triangular space between the back of the In the primary position, the axes of the vertical
iris and anterior surface of the lens. recti make an angle of 25º and those of obliques,
51º with the visual axes. The superior oblique is
Eyelids supplied by the 4th cranial nerve and the lateral
Eyelids consist of skin, loose connective tissue, rectus by 6th. All the other muscles are supplied by
muscles, tarsus, fascia and conjunctiva from before the 3rd cranial nerve. The action of these muscles
to backwards. They contain numerous glands, blood and testing their function is given along with
vessels, lymphatics and nerves. The skin is thin and neurology.
CHAPTER
48
1 Examination in Diseases
of the Eyes
History, Subjective examination, Visual acuity, Field of vision, Squint, Examination in focal lights, Eyelids,
Conjunctiva, Cornea, Anterior chamber, Iris, lens, Ophthalmoscopy, Fundus changes in a systemic diseases,
Refractive error, Proptosis
causes like optic neuritis, optic atrophy and retinal downward. Normal subjects can read the upper line
degenerations. at 60 meters and the lowermost at 6 meters distance.
Night blindness is defective vision, often Other lines should be read at 36, 24, 18, 12 and 9
experienced when the level of illumination is low, meters from above downwards. The subject is made
as occurring at dusk. In India, the most common to read the lines first with the right eye and then
cause is deficiency of vitamin A. Other less common with the left, the other eye being covered. The line
causes include retinitis pigmentosa, late stages of up to which he can see distinctly is recorded. If there
glaucoma and various types of retinal degenerations. are refractive errors, the lenses required to correct
Alteration in the Perception of Color the same are also determined by trial and error
method. The acuity of vision is expressed as
Xanthopsia is the phenomenon of seeing objects as
a fraction, the numerator being the distance at
yellow. This is a common complication of drug
which the patient clearly sees the letters and the
toxicity, especially digoxin.
denominator being the distance at which normal
Indistinct Images and Distortion of Images eyes should see clearly. Normal eye can read the
smallest row of letters at 6 meters, i.e. the visual
Indistinctness of the images is usually caused by
acuity is 6/6. If he can see only the top line at
refractive errors of the eye such as hypermetropia,
6 meter distance vision is 6/60.
myopia or astigmatism. Distortion of the object, its
size and shape is caused by macular lesions such Ordinary test types cannot be used for young
as macular edema or macular bums often resulting children who cannot read. Simple pictures
from watching eclipses directly. Cataract is one of constructed on Snellen’s principles may be used.
the more common causes of loss of vision above For illiterates ‘E’ tests may be employed.
the age of 50 years. Examiner holds letter ‘E’ of various sizes and
patient is asked to identify the direction to which
Pain the limbs of the letter point or to hold similar letters
It may be felt in the eye due to ocular lesions such in the same position (Fig. 48.1).
as glaucoma, iritis, optic neuritis, orbital cellulitis If the patient cannot read even the top line, he
or herpes zoster ophthalmicus. Sometimes pain is brought closer to the chart and the distance at
arising from ocular causes may be referred to other which he can see clearly is measured. If he can read
parts of the head as headache. at 3 meters, the vision is 3/60. If he cannot read the
Chapter 48: Examination in Diseases of the Eyes 623
Tests of visual function the field of vision. A simple but useful bedside
method is the confrontation test in which the
examiner compares the patient’s visual field with
his own.
Method
Patient and the examiner sit facing each other at a
distance of about 1 m, the eyes being at the same
level. Both eyes are tested separately. To test the
right eye, the patient keeps his right eye open and
the examiner looks with his left eye. The other eye
Fig. 48.1: Various types of Snellen’s charts to is kept closed. The examiner brings his outstretched
suit literate and illiterate patients and children left index finger or any test object from periphery
letter even at 1 meter, he is asked to count the inwards, always keeping the object equidistant
examiner’s fingers held at 30 cm in front. If he can between the patient and himself. Patient is instructed
count, the vision is: V = counting finger (CF). to indicate as soon as he sees the examiner’s fingers
or the object. The field is tested in all directions, i.e.
If this is not possible, the examiner’s hand is
lateral to medial, medial to lateral, above downwards
moved in front of the patient’s eyes. If he can
and below upwards. After testing the right eye the
appreciate this movement V = hand movements
examiner tests the patient’s left eye, this time the
(HM). If vision is less than HM, the visual acuity
examiner’s right eye and right hand are used.
is perception of light (PL). When vision is reduced
Part–II: Specialties
Normal visual field extends 100° to the temporal
to PL, the next step is to throw light from different
side, 55 to 60° nasally, 60° upwards and 70°
directions. If the patient can indicate the direction
downwards. Defects in the visual field are called
of the source of light his vision is expressed as
scotomas. Confrontation method can detect gross
“PL with projection of light accurate”.
defects such as constriction of visual field,
Pinhole Vision hemianopia and quadrantanopia and scotomas
Pinhole vision is tested when visual acuity is better (Refer Figs 32.2 A to D).
than 6/60. A pinhole aperture is placed in front of Perimetry
the eye to ascertain any improvement in acuity. Accurate charting of the visual field is done by
A pinhole admits only central rays of light that perimetry. Perimeter consists of a half sphere
require refraction by cornea or lenses. Through the within which a spot of light or test object can be
pinhole, patient’s visual acuity should improve moved. A chart which has concentric circles marked
2 or 3 lines if the cause of diminished vision is upon it is fixed at the back of the perimeter. The
refractive error and not in eye diseases like cataract patient’s head is supported on a chin rest. One eye
or macular degenerations. is covered and the other is fixed upon an object
Contrast Sensitivity Test placed at the center of the arc which is about 1/3
This is used to test the visual acuity at various meter away. Different test objects which may be
special frequencies and contrast levels. The patient white or colored, with diameters of 1, 3 or 5 mm
is made to identify letters of the same size are moved from periphery to center along the radius
with diminishing contrast relative to the white of the arc up to the point of fixation.
background. This test is more sensitive in detecting The points at which the object is first seen in
visual defects caused by lesions of the visual the different meridians are recorded upon the chart.
pathway as in optic neuritis Scotomas are recognised by the patient losing sight
of the object when moved further. Graphic record
Field of Vision of the visual field is made by connecting all these
Field of vision represents the limits of peripheral points and the scotomas if any. At least two objects
or indirect vision. It is the area within which an of different sizes and eight meridians must be
object can be seen while the eye fixes on a spot of employed. The fields for different colors are
light or object. There are several methods of testing different. The fields for blue and yellow are about
624 Section 17: Ophthalmology
10° less in all directions than that for white. Fields common tests done to identify and measure degree
for red and green are smaller by another 10°. While of squint are:
expressing the result of perimetry, size and color of • Bruckner or red reflex test
test object, the nature of illumination used and the • Corneal light reflex test
distance of the eye from the fixation point should • Cover test
be mentioned. For detecting central and paracentral
defects within the central 30° radius, i.e. central Bruckner Test
field, Bjerrum’s screen is used. A direct ophthalmoscope light is thrown into the
These simple methods of kinetic perimetry have patient’s eyes and observe for red reflex in both the
been replaced by static perimetry in modern eyes. The reflex in the strabismus eye will be
instruments. For example, in Rubinger perimeter brighter than the nondeviated eye.
stationary test objects are projected with variable
Corneal Reflex Test
light intensity. Friedman’s visual field analyzer is
a semiautomated perimeter in which the central The reflexion of light on the cornea is observed in
25° field is studied at specific points by suprathre- primary gaze. In normally aligned eyes the image
shold testing. should be central and symmetric on both the corneas.
Automated perimetry is more popular in ophthal- Hirschberg’s Test: Patient is asked to look directly
mology and neurology at present. It consists of at a flash light held ½ m in front of the eye.
computerized visual field testing. Static threshold Asymmetric position of light reflection on cornea
of retinal sensitivity is estimated by presenting indicates deviation. Nasal position of reflection in
Part–II: Specialties
randomized stimulus. The field plotted is reproducible one eye denotes exodeviation and temporal position
and more sensitive. Octopus and Humphery field of reflection denotes esodeviation. The angle of
analyzers are examples of modern computerized deviation can be roughly measured by the amount
static perimeters. of deviation of reflection from the center of pupil.
Abnormalities of Visual Fields Each mm deviation equals 7° (degree) or 14 prism
dioptres. A light reflection at pupillary border
See Section 11—Chapter 32 Neurology.
corresponds to 15° degrees, between the limbus and
Color Vision pupillary border 30° degrees and at limbus 45°.
See Section 11—Chapter 32 Neurology. Krimsky’s Test: It is same as Hirschberg test, but
in this prisms of increasing or decreasing power are
SQUINT held in front of the fixing eye until the corneal reflex
Squint (strabismus) is the condition in which the in the deviating eye is centered. Strength of final
visual axes of the right and left eyes do not bear prism gives the amount of squint in prism dioptres.
toward an objective point simultaneously. The
patient is unable to direct both eyes simultaneously Cover Test
toward a point. Method: A spot of light or a fixation object is held
Though gross squint may be detected on inspec- 50 cm in front of the eyes and the patient is
tion, lesser degrees escape attention. An approxi- instructed to focus on it. If one eye is suddenly
mate estimate of the degree of squint can be made occluded the other eye does not show any deviation
by noting the corneal reflection, i.e. images of in normal subjects. In the presence of squint the
objects held in front of the cornea. Normally, the seeing eye will exhibit deviation. This movement
images falling on the cornea should be symmetrical is noted. This test is repeated for the other eye also.
and at the center of the pupils. In squint the images The direction of movement of the unoccluded eye
are seen asymmetrically. If the corneal reflection gives the nature of squint. If the movement is
on the squinting eye is at the edge of pupil, the angle outwards, obviously the eye must have been in a
of deviation is 20°, if it is at the edge of the cornea, convergent position before occlusion, i.e. convergent
the angle is approximately 45°. Presence of squint squint. If the movement is inwards the eye was in
is confirmed and quantitated by the cover test. Three divergent squint.
Chapter 48: Examination in Diseases of the Eyes 625
Part–II: Specialties
eyeball and Figure 48.3 represents various types of
This is a very important step of examination of
squint.
the eyes. Focal light could be a flash light from a
torch, condensing lens focusing light from a distant
source of light in to the eye. Simple magnifiers
like a corneal loupe can give better visualization
under magnification. Examination of eyes using
slit lamp gives good magnification, illumination and
stereopsis (Fig. 48.4).
Slit lamp is a clinical microscope having 2 parts
mainly. One giving magnification, illumination and
resolution and the other, giving adjustments to alter
the angulation, width, and height of the slit lamp
beam. Commonly used magnification are 10x, 16x
and 25x. Modern slit lamps provide high degree of
precision. Several accessories can be used in the
Fig. 48.2: Normal movements of the eyeball. Note: RSR, instruments. They are:
LIO, etc. give the extraocular muscle affected
Fig. 48.3: Various types of squint Fig. 48.4: Slit lamp in use
626 Section 17: Ophthalmology
Fig. 48.5: Left eye shows ptosis Fig. 48.6: Third nerve paralysis–left with ptosis left.
Note: Overaction of left frontalis raising the eyebrow
Fig. 48.7: Third nerve palsy left. Note: Divergent squint of Fig. 48.9: Method to evert the upper lid
left eyeball due to unopposed action of left lateral rectus
Part–II: Specialties
Fig. 48.8: Third nerve palsy left on testing eye movements Fig. 48.10: Grade IV senile ectropion left eye. Note: Everted
adduction of left eye is absent punctum (arrow)
Entropion: Lid margin is turned inwards carrying away. This may reveal redness and swelling of lid
along with it, the eyelashes. The lashes rubbing the margins with ulceration in the root of eyelashes.
eyeball causes continous irritation and corneal When there is inflammation of meibomian glands,
ulceration. gentle pressure on the lid leads to extrusion of pus
Ectropion: Evertion of lid margin carries along with from their ducts. In seborrheic dermatitis affecting
it puncta also and the presenting symptom is the scalp, the lid margin may show scales and signs
persistent watering from the eye-epiphora. Severe of irritation. This is known as squamous blepharitis.
ectropion causes lagophthalmos (incomplete closure As blepharitis progresses the eyelashes fall off
of eye lids and exposure of the cornea). This can leading to madarosis, i.e. loss of eyelashes.
lead to dryness of the eye and corneal ulceration
Condition of Eyelashes
(Fig. 48.10).
Normal eyelashes curve upwards smoothly.
State of Lid Margins Trichiasis is turning in of eyelashes, so as to rub
Blepharitis is inflammation of lid margins. The the eyeball. The eyelashes may undergo graying in
eyelashes are glued by inspissated discharge. elderly subjects. Pathological greying may develop
To expose the lid margin the crusted discharge in some cases of chronic uveitis occurring in
should be soaked with wet cotton and wiped sympathetic ophthalmitis and Vogt-Koyanagi-
628 Section 17: Ophthalmology
Harada syndrome. It may also be part of vitiligo. trigeminal nerve may be associated with intracranial
Presence of extra row of eyelashes is known as hemangioma and epilepsy Sturge Weber syndrome.
distichiasis. This can give rise to foreign body
CONJUNCTIVA
sensation due to the inturned eyelashes. Pediculosis
may affect the eyelashes and give rise to intense Tarsal conjunctiva of lower lid is examined first by
pruritus. Lice and their nits must be looked for in pulling down the lower lid. It is normally smooth
such cases. and red. Lower fornix comes into view when the
patient looks up with the lower lid gently everted.
Swelling along the Lid Margin It is hyperemic in conjunctivitis. Presence of follicles
Painful swelling in the lid with edema is seen in which are small elevated nodules, foreign bodies,
hordeolum externum which is caused by acute membrane and discharges are looked for. Adhesions
inflammation of Zeiss glands and hordeolum between tarsal and bulbar conjunctiva may be
internum which is caused by inflammation of seen as small bands connecting them—synechia
meibomian glands (tarsal glands). The former tends (Fig. 48.13). Tarsal conjunctiva of upper lid can be
to form abscesses close to the roots of eyelashes exposed by everting it. For this the patient is asked
and the latter tend to burst through the conjunctival to look down and the upper lid is gently grasped
aspect of tarsus. Small painless swellings in the lids and pulled forward between the thumb and index
which are better felt than seen are suggestive of finger. While pressing downwards at the upper
chalazion which is chronic granulomatous border of tarsus with the index finger or a rod the
inflammation of the meibomian glands. Meibomian lid is quickly everted (Fig. 48.9).
carcinoma presents as painless slow growing
Part–II: Specialties
Fig. 48.11: Advanced meibomian gland carcinoma Fig. 48.12: Left eye hordeolum internum
Chapter 48: Examination in Diseases of the Eyes 629
Fig. 48.13: Symblepharon: Adhesion between conjunctiva Fig. 48.15: Bitot’s spot—shiny white spots on the
of lid and eyeball often traumatic or burns conjunctiva in vitamin A deficiency
Part–II: Specialties
Fig. 48.14: Spring catarrah—gelatinous thickening- Fig. 48.16: Left eye anterior staphyloma. Staphyloma is
conjunctiva protrusion of the cornea or sclera often due to penetrating
injury
indicative of active uveitis. It is confirmed by Note the size, shape and contour of pupil.
slitlamp examination. Presence of blood in the To elicit direct reaction to light: A focused and
anterior chamber is known as hyphema and usually bright light is used to elicit the reaction. By slight
it follows trauma. It can also result from rupture of lateral movements the light can be moved on and
fragile vessels in cases of rubeosis iridis and tumors off the pupil—observe the pupillary reaction. Pupil
of the iris. Presence of pus in the anterior chamber remains contracted as long as the light is on.
is called hypopyon. It results from corneal ulceration
To elicit consensual reaction: The observer keeps
and uveitis. The angle of the anterior chamber is
his hand over the nose in such a way as to separate
examined in detail by gonioscopy.
the two eyes—throws light in one eye bringing it
IRIS from side to the pupil and observes the other pupil
for contraction. Normally both pupils contract on
Iris is a circular vascular diaphragm pierced in the throwing light in one eye—this is consensual
center by round opening the pupil. Abnormalities reaction.
that we may see are:
To elicit reaction to convergence and accomm-
• Structural abnormality of the iris
odation: Patient is asked to look at a distance. A
• Abnormal pupillary reactions
small object like pen is held 15 cm from the patient‘s
Structural Abnormalities of the Iris nose and he is instructed to look at this object
Congenital abnormalities: Coloboma iris–Full suddenly. The pupillary reaction is noted. Both
thickness defect in the iris tissue reaching up to the pupils should normally contract.
pupil. Usually seen in lower part, often associated Swinging flash light test: This is to detect unilateral
Part–II: Specialties
with coloboma of ciliary body, retina, optic nerve, optic nerve disease. A bright focused light is thrown
etc. into one eye, note the constriction—keep the light
Aniridia: Iris tissue absent except for a tiny rim on for 2 to 3 seconds and suddenly transfer it to the
often associated with glaucoma and Wilm’s tumor other side. This is repeated several times-note the
of the kidney. state of the pupil. Normally both pupils remain
contracted. In case of optic nerve disease (because
Aquired abnormalities: Inflammation of iris is
of less input through the nerve to the midbrain) when
usually associated with inflammation of ciliary body
the light is thrown into the affected side both the
called iridocyclitis. Iridocyclitis causes many
pupils will dilate and swinging back to the normal
abnormalities like muddy iris (loss of anatomical
side both pupils will contract. This is called Marcus
markings), nodules in iris, irregular pupil due to
Gunn pupil.
inflammatory adhesion of pupillary margins to the
lens (See Fig. 48.18). Abnormal Pupillary Reaction
Pupillary reflexes: There are three normal pupillary 1. Absent light reflex: Pupil fails to contract to light
reflexes (See also Figs 32.9 and 32.10 A and B). and is usually dilated also. It is seen in advanced
1. Light reflex: Pupil contracts when light fall on stage of diseases like optic atrophy, total retinal
the eye actively. This is the direct light reflex. detachement.
Pupil of the other eye also contracts (consensual 2. Hemianopic pupil (Wernicke’s pupil): Absence
light reflex). of pupillary reaction when light is thrown from
2. Near reflex: Contraction of pupil occurs on hemianopic side.
looking at a near object—reaction of convergence 3. Argyll Robertson pupil: Classically seen in
and accommodation. cerebral syphilis where the pupil is miotic and
3. Pschycosensory reflex: Psychic and sensory irregular, does not react to direct light, reacts
stimuli (fear, anger and others) causes dilatation to convergence and accommodation. Rarely, it
of pupil. can occur in diabetes, multiple sclerosis and
How to test the pupillary reaction? ciliary ganglion lesions.
Patient is comfortably seated in a low illuminated 4. Tonic pupil (Adie’s pupil): Seen in young women,
room. Patient is asked to look at distance to prevent usually unilateral, slightly dilated. Reaction to
accommodative constriction of pupil. light and accommodation sluggish.
632 Section 17: Ophthalmology
5. Hutchinson’s pupil: Bilateral dilated pupil seen Rubeosis iridis: Abnormal new vessels are seen in:
in severe head injuries due to tentorial herniation 1. Long standing diabetes mellitus,
and brainstem compression. 2. Neovascular glaucomas,
6. Pinpoint pupil: Seen in brainstem injury (pontine) 3. Tumors of iris like malignant melanoma.
and also in opium poisoning.
7. Irregularity of the pupil may result following LENS
iridocyclitis or injury to the iris (Fig. 48.18). Lens is examined for transparency, presence of
opacities and pigmented spots. To expose the lens
Heterochromia: Difference in color of iris of 2 eyes
fully, the pupil has to be dilated with homatropine.
usually seen in Horner’s syndrome where the
Cataract is the condition in which the lens becomes
affected eye has hypopigmentated iris (Fig. 48.19).
opaque. This may be partial or total. The location of
• Causes of hypopigmented iris are:
the opacities also differ in different types of cataract
• Horner’s syndrome,
(Figs 48.21 and 48.22). When a lens is dislocated,
• Wardenberg syndrome,
its free margin can be seen. Ophthalmoscopy and
• Fuch’s cyclitis.
slit-lamp examination give further details.
Hyperpigmentation is seen in case of retained
iron foregin body in the eye and in case of melanomas Intraocular Pressure
involving the iris and in generalized melanosis of Normal intraocular tension is 15 to 20 mm Hg. This
the eye-Nevus of Ota (Fig. 48.20). can be estimated by digital tonometry (Fig. 48.23).
Part–II: Specialties
Fig. 48.18: Irregular pupil secondary to iritis Fig. 48.20: Nevus of Ota. Note: Pigmentation of the sclera
Fig. 48.19: Heterochromia iridum—left eye Fig. 48.21: Right eye congenital cataract (arrow).
Note: Opacity of the lens – boy aged 7 years
Chapter 48: Examination in Diseases of the Eyes 633
Part–II: Specialties
Fig. 48.23: Digital tonometry to assess intraocular tension Fig. 48.25: Acute dacryocystitis. Note: Swelling at the medial
end of the lower eyelid due to inflammation of the lacrimal sac
(arrow)
Fig. 48.27: Normal fundus. Note: The optic Fig. 48.29: Postneuritic optic atrophy
disk and macula
Part–II: Specialties
Fig. 48.28: Glaucomatous optic atrophy
Fig. 48.31: Optic disk with inferior notch Fig. 48.32: Optic disk with disk hemorrhage
almost normal, but may be narrower slightly. Rest the retina. The swelling can be measured by
of the retina is normal. focussing on the disk with the positive lenses in the
ophthalmoscope, and expressed in diopters
Consecutive Optic Atrophy (1 mm = 3 diopters). The retinal veins become
This follows widespread degeneration of retina and extremely dilated and tortuous and the disk slowly
is typically seen in retinitis pigmentosa and long mushrooms out with increasing edema. The disk
Part–II: Specialties
standing occlusion of central retinal artery. margin becomes indistinct. Soft exudates and
superficial hemorrhages occur in the posterior pole,
The disk is waxy pale, margins are blurred,
particularly around the disk. Edema throws the
vessels are markedly attenuated, and the physiological
internal limiting membrane into folds and this
cup is obliterated. Sheathing of vessels may or may
gives the appearance of macular fan or macular
not be present.
star. Vision may not be grossly impaired. Even
Glaucomatous Optic Atrophy in fully developed papilledema the vision can be 6/6.
Longstanding papilledema leads to post papilledemic
It is seen in advanced glaucoma. The disk is very optic atrophy and visual loss (Fig. 48.30).
pale. The physiological cup is wide and deep. The
blood vessels are kinked at the edge of the cup. Pseudopapilledema
The choroid around the disk shows atrophy and The appearance of the disk mimics papilledema.
sclerosis-circumpapillary choroidal atrophy (Fig. This may occur in high degrees of hypermetropia,
48.28). astigmatism and opacities in the media which may
make the disc appear hyperemic. Drusen embedded
Postneuritic and Postpapilledemic Optic
in the optic nerve may also mimic papilledma.
Atrophy
Optic Neuritis
These are indistinguishable from one another. The
disk is pale, margins are blurred, physiological cup Fundus picture may be indistinguishable from
is obliterated, the vessels are sheathed on the disk papilledema, but several differences exist.
and beyond (Figs 48.29 and 48.30). 1. Vision: In optic neuritis since the maculopapillary
bundle is affected, sudden and profound fall of
Papilledema vision with a dense central scotoma is the rule. In
papilledema vision is relatively retained till optic
Swelling of the optic disk leads to papilledema. atrophy sets in.
Most frequently this results from conditions that 2. Optic neuritis is usually unilateral whereas
raise intracranial pressure. Earliest evidence of papilledema is often bilateral.
papilledema is hyperemia of the disk and blurring 3. Swelling of the disk seldom exceeds 2 D in optic
of its margins, particularly the nasal. Edema neuritis whereas in papilledema it may reach
gradually fills the physiological cup and spreads to 6 to 8 D.
Chapter 48: Examination in Diseases of the Eyes 637
4. Optic neuritis is associated with fine vitreous proximally and distended distally. This is called
opacities. Untreated cases progress to optic nicking. Sometimes the vein may be pushed aside
atrophy. at crossings. New vessels develop in longstanding
venous occlusion and diabetes. This is called neo-
Blood Vessels
vascularization.
Arteries
Normally arterial blood column is seen through the Hemorrhages
transparent arterial wall and gives the appearance Retinal hemorrhages are always pathological. When
of the normal streak. Thickening of arterial wall the hemorrhage is superficial it occupies the nerve
leads to reflection of light. The streak becomes wider fibre “layer and appears as striate or flame shaped
and appears as burnished copper—copper wire bright red patches. When deeply placed, they appear
arteries. When the arteries are thickened further, as rounded irregular patches which are darker in
they reflect all light and appear brilliantly white- color. When hemorrhage occurs between retina and
silver wire arteries. the vitreous, i.e. preretinal or subhyaloid hemorrhage,
usually the macular area shows it up as a large
Sheathing: When the arteries are seen as white lines
spherical reddish patch. It becomes hemispherical
this is referred to sheathing.
slowly due to settling down of erythrocytes.
Generalized narrowing of arteries occurs in
hypertension arteriosclerosis, vasculitis from various Exudates
causes, central retinal artery occlusion, toxic
Soft exudates are spherical cottonwool-like patches
Part–II: Specialties
amblyopias, migraine and conditions that cause
retinal degeneration. in the retina. These are caused by microinfarcts and
Irregular narrowing appears as irregularity in are seen in vasculitis and hypertension associated
size of the arteries. Constricted segments alternate with renal disease. Hard exudates are irregular
with normal or dilated segments. These changes yellowish white patches or plaques usually seen
occur mainly due to endothelial proliferation of the around the macula. They are due to neuronal
intima. degeneration and lipid infiltration of the retina. They
are seen in diabetes and arteriosclerosis.
Pulsation: Normally pulsations of arteries are not
visible. Arterial pulsation at the disk is always Retinal Degeneration
pathological. This is seen in aortic regurgitation, Degenerative changes involve retina and choroid
aneurysms and thyrotoxicosis. Capillary pulsation so that both the tissues are destroyed leaving the
can occur in aortic regurgitation and this is seen as sclera bare. Pigment cells resist destruction and
alternating hyperemia and pallor of the disk are seen scattered irregularly around degenerative
corresponding to systole and diastole. lesions. Irregular patches of chorioretinal atrophy
are seen in degenerative myopia, and in various
Veins types of choroiditis, retinitis pigmentosa, senile
Congestion of retinal veins occurs in systemic macular degeneration and occlusion of central
diseases such as cardiac failure, polycythemia, retinal artery. In retinal degeneration the pigment
chronic myeloid leukemia, hyperviscosity states, is seen in front of the blood vessels whereas in
waldenstrom’s macroglobulinemia and others. choroidal lesions the blood vessels are seen to run
in front of the pigment.
Arteriovenous Changes New Growths
Normally the veins can be seen through the Tumors may occur in the retina. These include
transparent arteries. In arteriosclerosis, loss of retinoblastoma, angiomatosis, malignant mela-
transparency of the artery obscures the vein. A noma, neurofibromatosis and others. Identifica-
thickened artery may press the vein at crossings and tion of these is by their appearance and further tests
therefore the vein appears to be interrupted like fluorescein angiography.
638 Section 17: Ophthalmology
can reduce ocular complications. lipoproteion deposits. It can also result from
ischaemia due to closure of foveal capillaries.
Clinical Appearance
Clinically significant macular edema (CSME)
Diabetic retinopathy is classified into four groups: includes any of the following feature:
1. Background retinopathy (nonproliferative) 1. Thickening of retina at or within 500 micrometer
(Figs 48.33A and B) of the center of the macula.
2. Preproliferative retinopathy 2. Hard exudates at or within 500 micrometer of
3. Proliferative retinopathy macula.
4. Diabetic maculopathy. 3. Zones of retinal thickening one disk area or larger
Background retinopathy: It is characterised by any part of which is one disk diameter of center
presence of dilated veins, deep retinal hemorrhages of the macula (Fig. 48.34).
A B
Figs 48.33A and B: Diabetic retinopathy—different stages (A) Severe nonproliferative diabetic retinopathy, (B) Moderate
nonproliferative diabetic retinopathy with maculopathy. Note: Cotton wool patches, retinal hemorrhages are prominent. Vascular
proliferation is less prominent in nonproliferative retinopathy. In proliferative neovascularization and abnormal new vessels will
be evident
Chapter 48: Examination in Diseases of the Eyes 639
Part–II: Specialties
not show any fundus abnormality except narrow- In severe anemia, the general fundus is pale, veins
ing and pallor of arterioles caused mainly by spasm. are dilated and hemorrhages with white centers may
Superficial hemorrhages may be seen, but exudates develop.
are absent. When hypertension is associated with Retinopathy in AIDS 50 to 60% of patients
arteriosclerosis the caliber of the arteries is irregular suffering from AIDS show vascular and
with segments of constriction and dilatation. inflammatory lesions. Fluffy white spots or cotton
Sheathing may be present. Hard exudates may be wool spots are frequently seen in the posterior pole.
seen particularly around the macula, but edema is These are caused by ischemia of nerve fiber layer.
absent. Superficial hemorrhages can also develop. Retinitis
In subjects with very high blood pressure levels caused by opportunistic organisms like cytomegal-
as occurring in renal hypertension, proliferative and ovirus is common in the later stages. The retinitis is
fibrous changes occur in the vessels making them characterized by widespread necrosis of retina
narrow and tortuous with arteriovenous nicking. associated with profuse exudation, edema and
Soft exudates, edema, and superficial hemorrhages hemorrhages.
develop. Hard exudates in the macular area Retinopathy of Prematurity
may give the appearance of macular fan or star.
Retinopathy of prematurity (ROP) is essentially a
When hypertension enters the malignant phase,
proliferative retinopathy seen in premature infants.
papilledema also develops. Papilledema, hemorrhage,
Two important risk factors for the development of
soft exudates, edema and vasospasm regress when
ROP are:
the blood pressure is controlled.
1. Earlier gestational age (<32 wks) and
Toxemia of Pregnancy 2. Low birth weight (1500 gm).
3. It also correlates with higher oxygen saturation
The retinopathy of toxemia of pregnancy has caused by excessive oxygen administered to
many features similar to that of hypertension in premature infants. Of late there is increase in the
young subjects. Earliest change is narrowing of incidence of ROP.
the arterioles, particularly the nasal branches. If
hypertension and albuminuria progress, exudates Pathophysiology
and hemorrhages appear in abundance. Exudative Normal retina is gradually vascularized from optic
retinal detachment can occur. disk to the periphery in the second half of gestation.
640 Section 17: Ophthalmology
abnormal the image is blurred—this condition is followed up regularly with suitable visual correction
called ametropia. Ametropia results from alter- and measures to prevent retinal detachment.
ations in the length of the eyeball, changes in corneal
curvature, changes in the lens, and changes in Astigmatism
refractive indices of the media. Of all these, axial Refractive errors caused by abnormalities in corneal
length of the eye is most important. When the and lenticular curvatures are known as astigmatism.
eyeball is shorter the image falls behind the retina Astigmatism is said to be regular when the two
as in hypermetropia and when the eyeball is longer, principal meridians of cornea are at right angles.
the image falls in front of the retina, as in myopia. Only regular astigmatism is amenable to correction
with cylindrical lenses. Irregular astigmatism is
Hypermetropia
caused by corneal scars and keratoconus.
At birth the eyeball is shorter and hypermetropic.
It develops to its normal length by the age of 3 to 4 PROPTOSIS
years. On account of efficient accommodation by Proptosis is protrusion of the eyeball which may
the lens, this defect is compensated and images still be bilateral or unilateral. Apparent proptosis
fall on the retina and produce clear images. If the (pseudoproptosis) may occur in conditions where
eyeball does not grow to its normal length, eyeball is large as in buphthalmos or high myopia.
hypermetropia results. Constant tension of the Congenital bilateral proptosis usually occurs in
muscles of accommodation causes eye strain oxycephaly. Acquired proptosis may be caused by
(asthenopia) and headaches, particularly after orbital tumors or leukemias in childhood. In adults
working with near objects for long periods. In the most common cause is primary thyrotoxicosis.
children with hypermetropia accommodation to
near vision which is associated with excessive Clinical Examination of a
convergence may lead to accommodation type of Patient with Proptosis
convergent squint. Hypermetropia can be correc- Progressive proptosis is a serious disorder which
ted by convex lenses. Full correction is essential may lead to exposure keratitis, ulceration of the
when accommodative squint is detected. cornea and traction and compression of the optic
Chapter 48: Examination in Diseases of the Eyes 641
Part–II: Specialties
f. Periorbital swelling and abnormalities in the distant metastases. Usually such tumors are slow
neighboring structures growing and proptosis is unilateral. Orbital bones
g. Abnormalities in the thyroid are commonly affected in different forms of
h. Enlargement of preauricular and cervical lymph histiocytosis.
nodes In acute leukemias in children uni- or bilateral
i. Diseases of paranasal sinuses and epistaxis. proptosis may develop and progress within weeks.
The term exophthalmic ophthalmoplegia refers In severe cases malignant exophthalmos may
to the condition where the extrinsic muscles are develop.
rendered functionless due to severe exo-phthalmos. Primary thyrotoxicosis (Graves’ disease) is
When proptosis leads to exposure keratitis, ulceration associated with exophthalmos in the vast majority.
of cornea and blindness, it is called malignant Invariably bilateral, it can be unilateral and
exophthalmos. asymmetrical at times. The exophthalmos often
Fig. 48.35: Bilateral proptosis—Leukemia Fig. 48.36: Proptosis right eye due to retinoblastoma
642 Section 17: Ophthalmology
develops along with the thyrotoxic manifestations. may be lost. Steady pressure on the globe reduces
Less commonly, it may precede the systemic the proptosis. Compression of ipsilateral or
manifestations or develop and worsen during, and contralateral common carotid artery tends to reduce
after treatment of the thyroid lesion. the proptosis.
Pulsating exophthalmos is seen in carotico-
cavernous fistula. There is enormous dilatation of Intermittent Proptosis
vessels of lid and conjunctiva. The patient may In conditions like intracerebral arteriovenous
complain of rumbling sounds and auscultation communication and varicosity of orbital veins,
reveals bruit over the orbit. Retinal veins are compression of jugular veins may give rise to
congested, papilledema may be present and vision proptosis or increase an existing proptosis.
Part–II: Specialties
CHAPTER
1
49 Investigations in Diseases of
the Eyes
Fig. 49.1: Fundus fluorescein angiography Fig. 49.3: CT scan showing bilateral proptosis and marked
showing the filling of retinal vessels enlargement of extraocular muscles (arrows)
Part–II: Specialties
Fig. 49.2: Normal CT Scan. Note the normal position of the Fig. 49.4: CT scan showing proptosis left eye
eyeball to extraocular muscle (arrowhead) and optic nerve due to glioma of optic nerve (arrow)
(arrow)
epithelium. Fluorescein angiography is absolutely contrast medium further enhances the orbital
necessary to locate lesions before undertaking shadows of certain orbital tumors. CT scan of the
photocoagulation or laser therapy of retina. It also orbit gives exact site and size of lesion, involvement
helps to study papilledema and to distinguish it from of adjacent structures like bony erosions and
pseudopapilledema. intracranial extensions if any (Figs 49.2 to 49.4).
Part–II: Specialties
Advantages of ultrasonography over CT scan
are:
• It provides similar information as CT.
• It is a dynamic examination allowing several
views on a moving globe.
Forms of USG
• A scan
• B scan
• Ultrasound biomicroscopy (UBM).
A scan: One dimensional of time amplitude
representation of echos received along the beam
path. The distance between echo spikes is recorded Fig. 49.6: Plenty of point like echoes in the vitreous cavity
suggestive of vitreous hemorrhage
along the oscilloscope screen and provides an
indirect measurement of tissue such as globe length
and lens thickness. A scan is mainly used to calculate transducer. This detects anterior segment pathology
the power of IOL to be implanted in the eye. in great detail—cornea, iris, angle, lens and ciliary
body.
B scan: Echos produced are represented as dots
inside of spikes. By the use of scanning techniques Ultrasound Evaluation of the Posterior
the dots are integrated to produce an echo Segment of the Eye
representation of a two dimensional section of the A and B scan biometry: Biometry is the process of
eye. It is very useful to detect the intraocular tumors measuring the power of the cornea (keratometry)
in children like retinoblastoma, vitreous hemorrhage, and the length of the eye, and using this data to
retinal detachment and others. determine the ideal intraocular lens power. If this
calculation is not performed, or if it is inaccurate,
Ultrasound Biomicroscopy
perfect correction of refractive error may not be
Ultrasound biomicroscopy (UBM) is newer and possible. Several other functions can be performed
more sensitive technique using high frequency by these scans.
646 Section 17: Ophthalmology
of vision. Conventional refractive surgery does not Confocal Laser Scanning Ophthalmoscopy
address higher order aberrations or irregular Topographical images of retina and optic nerve are
astigmatism of the optical system. Wave front created by focusing 670 nm laser beam on to these
analysis is currently being used in wave front guided structures. Optic disk parameters like cup area, cup
ablations to enhance vision in refractive surgery volume, CD ratio, rim volume, and nerve fiber layer
patients. thickness at peripapillary region can be calculated
Pachymetry in the computer data system.
Pachymeters measure corneal thickness. Normal Optical Coherence Tomography
corneal thickness is 0.52 to 0.54 mm in the center,
Optical coherence tomography (OCT) is a noncontact
0.65 to 0.67 in periphery. Optical pachymeters are
noninvasive high resolution cross sectional imaging
attached to slit lamp. More sophisticated equipments
technique which can measure tissue thickness with
are now available to measure corneal thickness like
micron scale sensitivity. It uses infrared light waves
orbscan corneal topographer (OCT) and pentacam
40 micrometer coherent light to penetrate the tissue
camera.
and reflected images are caught on a camera. Image
Specular Photomicroscopy shows colors that corresponds to the reflectivity of
This is a slit lamp like instrument which is camera the tissues. Highly reflective tissues like retinal
mounted and gives clear view of endothelial cells pigment epithelium and nerve fiber layer are shown
of cornea. Normal endothelial cell count at birth is as red or white, while photo receptors and choroid
2400 cells/mm². The count decreases with age. are shown blue or black. Linear cross section of
Abnormal shape of the cells and decrease of the tissue is obtained when the scans are put together.
number below normal limit will cause loss of normal Two forms of OCT are available.
endothelial function of keeping the cornea transparent.
Stratus Optical Coherence Tomography
Confocal Microscopy This standard OCT performs 4 to 6 mm long radial
This allows clear high resolution magnified view line scans through retina or optic nerve. This gives
of corneal cells, structure of cornea, organisms information of retinal thickness, nerve fiber layer
infecting cornea like acanthameba, fungi and thickness, glaucoma status, and macular thickness.
Chapter 49: Investigations in Diseases of the Eyes 647
Part–II: Specialties
Fig. 49.10: Normal visual evoked response (VER)
50
1 Ophthalmic Emergencies
Acute congestive glaucoma, Injuries, Burns of the eyes, Causes of sudden loss of vision, Red eye
Several eye diseases require emergency treatment, 5. Instill 2 to 4% pilocarpine drops hourly into
blindening diseases like ophthalmic injuries, corneal the eyes, so as to keep the pupil constricted
ulceration and iridocyclitis have to be treated early maximally—This may help to open up the angle
to prevent visual loss. If infections of the cornea of the anterior chamber.
are not treated promptly, corneal opacities will 6. With the above measures intraocular pressure
develop. Similarly in uveitis, profuse exudation may is usually brought to normal. Curative treatment
block the pupil and lead to posterior synechiae and is essentially surgical. If gonioscopy reveals
further complications. extensive peripheral anterior synechiae, filtration
Among the ophthalmic emergencies acute operation has to be done. If they are minimal,
congestive glaucoma, injuries and the other causes iridectomy will suffice.
of sudden loss of vision are more important.
INJURIES
ACUTE CONGESTIVE GLAUCOMA Both blunt and penetrating injuries require immediate
This affects patients around the age of 50 years, attention.
more commonly women, who have hypermetropia
Blunt Injuries
with smaller eyeballs and shallow anterior chamber.
The condition ushers in with severe headache, Blunt injuries may range in severity from sub-
neuralgic pain and vomiting. Prostration develops conjunctival hemorrhage to rupture of the eyeball.
early. The eyes are red and the lids are edematous. Rupture of blood vessels in the iris or ciliary body
The cornea is hazy due to edema, the anterior may lead to collection of blood in the anterior chamber
chamber is shallow and the pupil is dilated and or the vitreous. Bleeding into anterior chamber leads
vertically oval. The eyeball is stony hard. to secondary glaucoma. Blood staining of the cornea
results in permanent opacification of its posterior
Management surface.
1. Hospitalize the patient.
2. Administer analgesics like morphine 15 mg or Management
pethidine 100 mg by 1M injection. 1. Keep the patient in bed
3. Acetazolamide (Diamox) 500 mg initially and 2. Acetazolamide orally 500 mg to 1 g orally 8
thereafter 250 mg orally to be repeated 6 hrs later. hourly helps to lower intraocular pressure. If the
4. Osmotic agents such as 20% mannitol 200 mL blood fails to be absorbed evacuate it by various
as rapid IV infusion. surgical procedures.
Chapter 50: Ophthalmic Emergencies 649
Traumatic Dislocation of the Lens irrigated with sterile normal saline or 1% sodabicarb
Dislocation of the lens into the anterior chamber solution or at least with tapwater if the sterile
leads to two major complications: solutions are not handy. Ideally weak acids are used
1. It damages the corneal endothelium leading to to irrigate in cases of alkali burns and weak alkalies
permanent opacity. for acid burns. Using retractors the eyeball should
2. The globular lens blocks the angle and produces be examined carefully and any particle like piece
secondary glaucoma. of lime or cement should be removed. If corneal
The eye can be saved only by removing the lens epithelium has been lost, atropine or a weaker
after controlling the intraocular pressure. mydriatic should be instilled along with antibiotic
drops. If conjunctiva has been burnt as evidenced
Management by its dry, pale appearance, attempt should be made
Remove the lens after controlling raised intraocular to prevent adhesion of opposing surfaces of raw
pressure by medical means. conjunctiva and lids. For this, an antibiotic ointment
should be applied in the conjunctival sac in sufficient
Penetrating Injuries quantity and a glass rod passed along the fornix all
These are always serious. There is always the risk around to break adhesions. This maneuver may have
of developing intraocular sepsis and retention of to be repeated. Local application of steroids reduces
foreign bodies inside the eye. scarring and adhesions but this has to be used with
care.
Management
Part–II: Specialties
1. Assess the extent of injury by slit-lamp exa-
CAUSES OF SUDDEN LOSS OF VISION
mination taking particular care to detect retained
foreign bodies. See Flow charts 50.1 and 50.2.
2. USG B scan is useful in detecting the damage to Major causes of sudden loss of vision include:
the posterior segment structures. 1. Acute congestive glaucoma
3. Meticulous repair of the wound is required. 2. Central retinal artery occlusion
4. Administer appropriate antibiotics systemically 3. Optic neuritis and retrobulbar neuritis
and locally in the eye. 4. Retinal detachment
5. Administer appropriate anti-inflammatory drugs 5. Vitreous hemorrhage
such as prednisolone 10 mg qid or an NSAID 6. Miscellaneous conditions, e.g. sudden develop-
(indomethacin) 25 mg qid orally. ment of diabetic cataract, spontaneous dislocation
6. Mydriatics like atropine have to be instilled into of lens into anterior or posterior chamber as
the eye to paralyse the iris. occurring in Marfan’s syndrome, hemorrhage
Most often patient needs further surgical in the macula, occlusion of central retinal vein
procedures to deal with complications. and rapid development of corneal edema in
keratoconus (hydrops cornea).
BURNS OF THE EYES
This may result from fire accidents, as a part of Central Retinal Artery Occlusion
general burns or may be caused by caustic chemicals Most cases of central retinal artery occlusion come
falling into the eye, e.g. lime, acids, alkalies and under observation after a lapse of hours or days. If
other chemicals. the patient reports early, measures to dilate the
Management of Burns of the Eyes retinal vessels are indicated in an attempt to dislodge
the thrombus.
Care should be taken to examine the eyes parti-
cularly when the lids are also affected. It is useful
RED EYE
to instill local anesthetic drops before examination.
Careless or hasty examination may cause not only Some conditions give rise to unilateral or bilateral
pain but also damage to the already injured skin. red eye. These accounts for many cases of eye
Without wasting time, the eyes should be lavishly problems in all general medical services. The
650 Section 17: Ophthalmology
common conditions include simple problems like acute congestive glaucoma. The latter demand
acute conjunctivitis, allergic conjunctivitis, spring specialist cast for management. Flow charts 50.3
catarrh, and subconjunctival hemorrhage and more and 50.4 give details to assess the condition and
serious problems such as iridocyclitis, scleritis and plan management.
Part–II: Specialties
Flow chart 50.3: To diagnose unilateral red eye
652 Section 17: Ophthalmology
18
Ear, Nose and Throat
CHAPTER
51
1 Otorhinolaryngology:
General Considerations
OS Radhakrishna Pillai
General considerations, Anatomy of the ear, Physiology, Anatomy of the nose and paranasal sinuses,
Anatomy of pharynx, Anatomy of larynx
GENERAL CONSIDERATIONS
Diseases of ear, nose and throat are day-to-day
problems in general practice, accounting for
10% or more of the total attendance in any general
hospital out patient service in India. A patient may
present with acute symptoms like severe pain in the
ear, vertigo, sudden deafness, epistaxis, unbearable
pain in the throat and stridor; or chronic symptoms
like ear discharge, progressive deafness, nasal
block, nasal discharge, dysphagia and hoarseness
of voice. The primary care physician has to manage
most of these patients himself and refer only
those who require specialized services to the ENT
surgeon.
A short description of the applied anatomy and
physiology of ear, nose pharynx and larynx is given
below.
Fig. 51.2: Normal tympanic membrane Fig. 51.3: Anatomy of ear—Right side
1. Pars flaccida 1. External auditory meatus
2. Handle of malleus 2. Tympanic membrane
3. Pars tensa 3. Eustachian tube
4. Round window area 4. Ossicles
5. Membranous labyrinth
occipital (C2), auricular branch of vagus, auriculo- The eustachian tube is wider, shorter and more
temporal branch of mandibular division of the horizontal in infants, thus permitting infection to
Part–II: Specialties
trigeminal nerve and a few fibers of the facial nerve. travel from nasophanynx to middle ear readily. Milk
In a patient presenting with pain in the ear, if no may regurgitate into middle ear if the infants are
local cause is detectable, distant sites supplied by not fed in head-up position. This may lead to acute
these nerves should be examined. Referred otalgia otitis media.
is not uncommon. The nerve supply from facial During air travel, a person who has block in the
nerve explains the appearance of herpetic vesicles eustachian tube can develop severe pain in the ear
in the external ear in herpes zoster affecting the while landing. Since the eustachian tube is blocked,
geniculate ganglion of the facial nerve (Ramsay- pressure in the middle ear and atmospheric pressure
Hunt Syndrome) are not equalized as in the normals. Negative
The tympanic membrane which forms the pressure develops in the middle ear and persists
partition between the external auditory meatus while landing leading to serous effusion.
and the middle ear is a pearly white glistening
Persons with block of the eustachian tube should
membrane with a cone of light in the anterior inferior
be advised to inflate the middle ear forcibly by the
quadrant. Functionally, it is a part of middle ear
Valsalva maneuver while landing. Blocking of the
(Fig. 51.2).
eustachian tube is common in persons with coryza
The middle ear is an air filled cavity closely
and naso-respiratory allergy.
related to middle cranial fossa above and jugular
bulb below. It communicates with the nasopharynx The normal appearance of the tympanic
through eustachian tube anteriorly and to mastoid membrane is lost in diseases of middle ear. Tympanic
antrum and air cells posteriorly. membrane will have an oily appearance in serous
Infection from the nasopharynx can spread otitis, and a bluish tinge in hemotympanum
to middle ear through eustachian tube and from (bleeding). In retracted tympanic membrane, the
the middle ear it can spread to the mastoid antrum cone of light is distorted with apparent fore
and air cells leading to mastoiditis, mastoid abscess shortening of handle of the malleus.
and petrositis. Infection from the middle ear can The middle ear contains three ossicles—
spread upwards to the cranial cavity leading to malleus, incus and stapes; two muscles—the tensor
extradural abscess, subdural abscess, brain abscess tympani and stapedius, and the nerves corda
and meningitis which are potentially fatal, if tympani and the tympanic plexus. The tympanic
undiagnosed. plexus is formed by tympanic branch of the
Chapter 51: Otorhinolaryngology: General Considerations 657
glossopharyangeal nerve and sympathetic fibers system. Imbalance can result if there is pathology
from plexus around internal carotid artery. in any of these systems.
The inner ear consists of bony and membranous
labyrinths. The bony labyrinth consists of the three ANATOMY OF NOSE AND PARANASAL
semicircular canals, the vestibule and the cochlea. SINUSES
The membranous labyrinth consists of the three
The external nose is pyramidal in shape and of a
semicircular ducts, utricle, saccule, cochlear duct,
bony part constituted by nasal bones and frontal
endolymphatic duct and sac.
process of the maxilla and a cartilaginous part
The peripheral sense organ of hearing is the
consisting of upper lateral cartilages, alar cartilage
organ of Corti situated in the cochlear duct. The
and sesamoid cartilages. The internal nose is divided
afferent impulses pass through the cochlear division
into right and left nasal cavities by nasal septum.
of the eighth cranial nerve to reach the superior
The nasal septum is formed by the perpendicular
temporal gyrus which is cortical area of hearing.
plate of the ethmoid, the vomer, the septal cartilage,
The peripheral receptors of the vestibular the crest of the nasal bones, nasal spine of the frontal
system are the cristae located in the ampullae of bones, rostrum of the sphenoid, crests of the palatine
semicircular ducts and the maculae of the utricle bones and the maxilla and the anterior nasal spine
and saccule. The cristae of the semicircular canals
of the maxilla. Each nasal cavity has a lateral wall,
respond to angular (rotatory) acceleration while
medial wall, roof and floor. The lateral wall shows
those in the maculae of utricle and saccule respond
three projections, the inferior, middle and superior
to linear acceleration and gravity. Afferents from
Part–II: Specialties
turbinates (conchae) and below and lateral to each
the peripheral receptors pass through the vestibular
turbinate is the corresponding meatus. The nasola-
nerve to reach the vestibular nuclei from where
chrymal duct opens into the anterior part of the
efferents go to the nuclei of 3rd, 4th and 6th cranial
inferior meatus. The frontal sinuses, the maxillary
nerves, the motor part of spinal cord, the autonomic
sinuses and anterior ethmoid cells open into the
nervous system and the temporal cortex.
middle meatus. The posterior ethmoid sinus opens
Physiology of Hearing into the superior meatus (Figs 51.4 and 51.5).
Sound vibrations in the environment are directed to The upper one-third of lateral walls up to
the external auditory canal by the pinna and the superior turbinate, the corresponding part of nasal
tympanic membrane vibrates. The vibrations are septum and roof of the nasal cavity form the
transmitted by the ossicular chain to the labyrinthine olfactory region and the lower 2/3 of nasal cavity
fluid which moves the basilar membrane. forms the respiratory region.
The hair cells of the organ of Corti are stimulated Smell is perceived in the olfactory region where
and electrical impulses are produced which travel the olfactory receptors are situated. The central
along the auditory nerve and pathway to reach the processes of these receptors form the olfactory nerve
auditory cortex of the temporal lobe giving the sense
of hearing. A normal person can hear frequencies
of 20 to 20,000 hertz (Hz). Any defect in the
pathway of sound conduction to inner ear or
conduction of electrical impulses from inner ear to
auditory cortex can result in different types of
hearing loss.
Physiology of the Vestibular System
Body maintains its position and equilibrium by the
use of three systems—the eye, the vestibular system
and the central nervous system. In the central
nervous system, we have the pyramidal system, the
basal ganglia, cerebellum and proprioception Fig. 51.4: Anatomy of nasal septum
658 Section 18: Ear, Nose and Throat
ANATOMY OF PHARYNX
Pharynx is a fibromuscular tube forming the upper
part of air and food passages. It is divided into
nasopharynx, oropharynx and laryngopharynx. The
nasopharynx extends from base of skull to the
horizontal plane passing through the hard palate. A
collection of lymphoid tissue at the junction of the
Fig. 51.5: Anatomy of lateral wall of nose roof and posterior wall of nasopharynx is called
adenoid. Pathological enlargement of the adenoid
in children may produce nasal obstruction, mouth
fibers which pass through the openings of the
breathing and snoring. This may necessitate adenoid
cribriform plate of ethmoid bone and synapse with
curettage. Eustachian tube opening is situated in
cells of olfactory bulb and further fibers pass up to the lateral wall of nasopharynx and just behind the
the pre-pyriform cortex and the amygdaloid nucleus. opening is the fossa of Rosenmuller which is a
Disorders of smell can occur if the odorous common site for malignancy. Examination has been
Part–II: Specialties
substance does not reach the olfactory area or if made easy with the availability of rigid and flexible
there is lesion in the olfactory mucosa or olfactory endoscopes (Fig. 51.6).
pathway. Ansomia (total loss of sense of smell) or The oropharynx extends from the plane of hard
hyposmia (partial loss of smell) can result from palate above to the level of hyoid bone below. The
nasal obstruction from various causes including tonsils are present on the lateral wall. Sometimes
rhinitis. Injury to olfactory nerves or olfactory bulb in children the tonsils are enlarged leading to
in fractures of anterior cranial fossa and intracranial obstruction to breathing. Tonsillectomy used to be
lesions like abscesses, tumors or meningitis which a very common surgical procedure till recent times.
cause pressure on olfactory—tracts lead to ansomia Hypopharynx or laryngopharynx extends from
or other disorders of smell. Parosmia (perversion the level of hyoid bone to the lower border of
of smell) is seen in the recovery phase of post cricoid cartilage. Clinically it is divided into three
influenzal anosmia and intracranial tumors. regions – the pyriform sinus, the post-cricoid region
The blood supply of nose is from several arteries
which are branches of the external carotid artery.
The anterior inferior part of the septum is very
vascular and is called. “Little’s area” where four
arteries anastamose to form the Kiesalbach’s
plexus. This area is a common site for epistaxis.
Cauterization of veins in this region is resorted to
at times, to arrest bleeding.
The paranasal sinuses—the maxillary, frontal,
ethmoid and sphenoid—are air filled cavities which
open into the nose. Probable functions of the
paranasal sinuses are:
1. Air conditioning of inspired air
2. Resonance of voice
3. To act as thermal insulators of eyeballs and brain
4. To reduce the weight of the skull. Fig. 51.6: Anatomy of oropharynx
Chapter 51: Otorhinolaryngology: General Considerations 659
ANATOMY OF LARYNX
Larynx is an integral part of the respiratory tract
and it contains the vocal cords which are the main
organs for voice production. The length of vocal
cords antero-posteriorly is 24 mm in adult males
and 16 mm in adult females. Larynx is made up of
cartilages, muscles, ligaments and joints. It lies in
front of the laryngopharynx opposite the third to Fig. 51.7: Larynx anatomy
sixth cervical vertebrae. Voice is produced by
vibrations of the vocal cords when air under
pressure from the sub-glottic area passes through 14 mm and in deep respiration it can widen up to
the vocal aperture. This voice is converted into 19 mm (Fig. 51.7).
speech by the modulatory actions of lips, tongue, The larynx of an infant differs from that of an
palate, pharynx and teeth. The muscles which act adult in being small, funnel shaped and of a narrower
on the vocal cords are posterior cricoarytenoid lumen. Cartilages are also softer and they collapse
(abductors), lateral cricoarytenoid and inter- easily. In addition, there is more of submucosal tissue
Part–II: Specialties
arytenoids (adductors) and cricothyroid and thyro- which makes it more liable to become edematous in
arytenoid (tensors of vocal cords). All these muscles response to trauma, allergy and inflammation.
except the cricothyroid are supplied by the recurrent At puberty, the larynx of males grow rapidly
laryngeal nerve. The cricothyroid muscles are with increase in length of rima glottidis and
supplied by external laryngeal nerve. Sensory change in character of the voice. The larynx of
supply above the vocal cords is by internal laryngeal females does not undergo such major changes.
nerve and below the vocal cords by recurrent Pubophonia is the term used to denote the
laryngeal nerve. During quiet respiration, the persistence of high pitched voice in males without
distance between the two vocal cords is about undergoing pubertal change.
CHAPTER
52
1 Clinical Examination in
ENT Diseases
OS Radhakrishna Pillai
Symptoms in diseases of the ear, Common symptoms in diseases of nose, paranasal sinuses and
nasopharynx, Symptoms in diseases of oral cavity and oropharynx, Symptoms in diseases of laryx and
laryngopharynx, Physical examination, ENT examination
SYMPTOMS IN DISEASES OF THE EAR a. Via trigeminal nerve: Impacted wisdom tooth,
caries teeth, dental abscess, ulcers and malignant
Pain in the Ear: Otalgia growths of anterior 2/3 of tongue and floor
In furuncles and otitis externa, there is aggravation of mouth, temporomandibular arthritis and
of pain on opening of the mouth and chewing. There malignancy of nose, paranasal sinuses or
is tenderness on pressure over the tragus and on nasopharynx.
pulling the pinna. In acute otitis media and acute b. Via facial nerve: Geniculate ganglion herpes.
exacerbation of chronic otitis media, ear discharge c. Via glossopharyngeal nerve: Acute tonsillitis,
and hearing loss are present. Myringitis bullosa is peritonsillar abscess and malignancies of tonsil,
characterized by vesicles over the surface of the base of tongue and oropharynx.
tympanic membrane which may burst, producing d. Via vagus nerve: Malignancy of larynx and
blood stained discharge. Malignant growths of laryngopharynx.
external and middle ear may present as growths in e. Via greater auricular and lesser occipital
the ear giving rise to blood stained discharge and nerves: Cervical spine lesions, inflammatory and
deafness. traumatic lesions of neck.
Ear lesions may cause referred pain which may It is important to examine these sites in all cases
be felt as headache, even before local pain is manifest. of otalgia when a local cause cannot be detected.
Diseases from distant sites may cause pain
Discharge From the Ear (Table 52.2)
referred to the ear. The pain may be referred along
the trigeminal, facial, glossopharyngeal, vagus, The character of ear discharge, its amount and odor
greater auricular and lesser occipital nerves. Some are to be noted. Watery discharge is usually seen in
important causes of referred otalgia ear are given otitis externa. In chronic suppurative otitis media
in Table 52.1. of tubotympanic type, the discharge is mucoid or
Table 52.1: Common causes of otalgia mucopurulent, not foul smelling and occurring
continuously or intermittently. During attacks of
1. Furuncle ear
2. Diffuse otitis externa Table 52.2: Common causes of discharge from ear
3. Myringitis bullosa
1. Acute and chronic otitis media
4. Herpes Zoster
2. Otitis externa—acute and chronic
5. Keratosis obturans 3. Eczematous dermatitis of external ear
6. Acute otitis media 4. Myringitis bullosa
7. Malignant otitis externa 5. Otomycosis
8. Malignant growths of external and middle ear 6. CSF otorrhea
Chapter 52: Clinical Examination in ENT Diseases 661
Part–II: Specialties
speech frequencies will be considered non- Conductive deafness is due to a defect in the sound
functional. conducing mechanism of the ear. Sensorineural
Hearing impairment may be unilateral or deafness is due to lesion in the cochlea, auditory
nerves and central connections.
bilateral. A detailed history should include the onset,
duration, progress, presence of predisposing factors Psychogenic Deafness
and presence of deafness in family members a. Malingering where there is a conscious effort on
(Tables 52.3 to 52.6). the part of the person to deceive
b. Hysterical, where there is a subconscious wish
Table 52.3: Common causes of conductive hearing loss to raise the hearing threshold and hence, outside
1. Congenital Atresia of external auditory canal, stenosis of the patient’s control.
external auditory canal, anomalies of middle ear Deafness of sudden outset may follow head
ossicles
2. Traumatic Perforation of tympanic membrane ossicular, dis-
injury, blast injury, viral infections or vascular
continuity, hemotympanum accidents of the brain. A detailed history, full clinical
3. Inflammatory Acute and chronic otitis media, serous effusion examination and various hearing tests are required
into middle ear to diagnose the type and degree of hearing loss and
4. Neoplastic Benign and malignant growths of external auditory
canal and middle ear
plan treatment.
5. Miscellaneous Wax and foreign bodies in ear, otosclerosis,
tympanosclerosis, adhesive otitis
Tinnitus
Tinnitus indicates hearing of adventitious sounds.
It is said to be subjective when audible only to the
Common causes of sensorineural hearing loss
Table 52.4:
in neonates
patient and objective when audible to others also.
Objective tinnitus may be due to myoclonus
1. Genetic factors
2. Maternal infections—toxoplasmosis, rubella, cytomegalovirus involving the palatal muscles, tensor tympani or
infection, herpes, syphilis stapedius muscle, arteriovenous shunts, glomus
3. Drugs during pregnancy jugulare tumors, and aneurysms of occipital artery,
4. Diseases of mother—diabetes, hypothyroidism, toxemia of
pregnancy
superficial temporal artery and aortic arch.
5. Prematurity—birth injury Subjective tinnitus may be due to various causes
6. Neonatal jaundice like wax in the ear, sensorineural deafness of
7. Neonatal meningitis
different etiology, otosclerosis, acoustic trauma,
662 Section 18: Ear, Nose and Throat
anemia, leukemia, hypertension and renal diseases. may be seen in chronic suppurative otitis media and
Emotional factors may also cause tinnitus and in in head injury. Patients taking ototoxic drugs may
turn, tinnitus itself may lead to anxiety. There is also get vertigo. Vertigo with discharging ear may
still another group in whom no cause is detectable be due to labyrinthitis.
(idiopathic tinnitus).
COMMON SYMPTOMS IN DISEASES OF NOSE,
Vertigo PARANASAL SINUSES AND NASOPHARYNX
Vertigo is defined as a sensation of rotation or
Nasal Obstruction
unsteadiness which the patient may experience.
The history goes a long way in the diagnosis of This may be unilateral or bilateral, continuous or
its etiology. It is important to ascertain whether intermittent. In infants nasal obstruction may be due
the patient’s complaint is a true sensation of rotation to congenital atresia, adenoids, allergic rhinitis,
or a syncopal attack in which patient gets a secretions, or obstructing foreign bodies. In children
blackout, falls momentarily, and quickly regains nasal obstruction may be due to adenoids, foreign
conciousness (Table 52.7). bodies in the nose, rhinoliths, nasopharyngeal
Other symptoms of neurosis like palpitation, fibroma, antrochoanal polyp and injury to nose
breathlessness, fatigue, insomnia, sweating and leading to fracture of nasal bones.
tremors may be present. In these patients there will In adults nasal obstruction may be due to deviated
no nystagmus or hearing loss. nasal septum, nasal allergy, polyps, rhinosporidiosis
Episodic vertigo with fluctuating deafness and and benign or malignant growths in the nose and
paranasal sinuses.
Part–II: Specialties
headache is usually felt over the vertex, occiput or SYMPTOMS IN DISEASES OF ORAL CAVITY
behind the eyes. AND OROPHARYNX
Epistaxis Pain in the throat: This is a very common symp-
Bleeding from nose is called epistaxis. It may be tom which occurs in acute infections of oral cavity
and oropharynx. Ulcers of mouth or oropharynx,
due to local or general causes. Infection of nose
tonsillitis and malignancy are the other common
and paranasal sinuses, congenital telangiectasis
causes.
involving nasal septum, trauma to nasal mucosa,
growths in the nose, paranasal sinuses and naso- Dysphagia: Difficulty in swallowing is called
pharynx, presence of foreign bodies and rhino- dysphagia. This may be due to a variety of lesions
sporidiosis are common local causes of epistaxis. in the oral cavity, pharynx or esophagus. The lesion
In children, repeated bleeding may occur from may be inflammatory, paralytic or neo-plastic.
the prominent retrocolumellar vein. Recurrent, Odynophagia: Pain on deglutition may be due to
profuse, painless bleeding from nose in children is inflammatory lesions in the oropharynx, laryngo-
characteristic of nasopharyngeal angiofibroma. pharynx or esophagus. Malignancy of the oro-
pharynx or laryngopharynx can also cause
In adults atherosclerotic changes in the vessels
odynophagia Impaction of fish bone in the throat is
of nose and hypertension are common causes of
a notuncommon cause of odynophagia in India.
nasal bleeding. Epistaxis is a common prodromal
symptom in several infections such as rheumatic Irritant cough: Diseases which produce irritation
fever and influenza. Purpuric disorders may cause of throat due to inflammation, allergy or presence
Part–II: Specialties
of secretions can lead to irritant cough. Regurgitation
epistaxis as one of the hemorrhagic manifestations.
of acid gastric contents into the esophagus is a
Anosmia common cause of irritant cough (gastroesophageal
reflux disease—GERD)
Loss of sense of smell may occur as a result of
destructive lesions of nose, lesions affecting the SYMPTOMS IN DISEASES OF LARYNX
olfactory nerves, fracture of the anterior cranial AND LARYNGOPHARYNX
fossa and central lesions of brain involving uncus
and hippocampus. Anosmia may be uni- or bilateral. Hoarseness of voice: Even though the term
Bilateral anosmia is a frequent symptom in hysteria. hoarseness literally means a rough and harsh sound,
it is generally used to denote a change in the
Sneezing character of voice, as the patient may just complain
This is a reflex reaction initiated by abnormal of an altered voice and may not be able to describe
accurately the type of change in the voice. Any
stimulation of nasal mucosa. This is a common
disease which interferes with the movement and
symptom of nasal allergy, foreign bodies in the
vibration of vocal cords can produce hoarseness of
nose, and rhinitis. The reflex is similar to cough
voice. Acute and chronic laryngitis, laryngeal
reflex with the following differences. The area of
paralysis, congenital lesions, chronic granulomatous
stimulation is the nasal mucosa. The air is ejected
lesions and benign and malignant tumors are the
forcibly through the nose so as to blowout discharges
common causes of hoarseness of voice.
or other irritants from the nostrils.
Complete loss of voice is called aphonia.
Nasal Voice Functional aphonia may occur in hysterical patients
Diseases of nose and nasopharynx produce change and can be diagnosed by the fact that the patient
in tone of voice. Enlarged adenoids and naso- can cough effectively and the vocal cords will be
pharyngeal tumors cause closed nasal voice called seen to move on laryngoscopic examination.
rhinolalia clausa. Palatal paralysis, cleft palate and Dysphonia: It is abnormal alteration of vocal sounds.
short palate lead to hypernasality of voice called Phonaesthenia: Weakness of the voice due to
rhinolalia aperta. weakness of muscles of phonation is called
664 Section 18: Ear, Nose and Throat
phonaesthenia. This is sometimes seen in pro- The examination is preferably performed in:
fessionals who use their voice continuously and for 1. Detailed history
prolonged periods irregularly. 2. General examination
Pubophonia: It is the change in voice that starts 3. Local examination
around puberty in males and is characterized by 4. Systemic examination when required
cracking or break in voice. 5. Investigations.
Pain: Pain lower down in throat is usually seen in With this routine, the diagnosis can be obtai-
perichondritis, tuberculosis or carcinoma of larynx. ned in almost all cases.
The pain may be referred to the ear also.
Irritant cough: Dry cough may be due to irritation PHYSICAL EXAMINATION
in the vocal cords by secretions or due to foreign
General appearance of the patient may give
bodies, polyps, granulations, and benign and
diagnostic clues in many cases. A child with
malignant growths of the larynx.
adenoids may have the typical “adenoid facies”,
Dyspnea: Any disease which produces laryngeal
consisting of open mouth, vacant expression,
obstruction may result in dyspnea. Edema of the
underslung jaw, protuberent anterior teeth, malar
larynx, foreign bodies in the larynx, juvenile
prominence and pinched nose. Nasopharyngeal
multiple papillomatosis and carcinoma are some of
fibroma may lead to “frog faced deformity” with
the laryngeal causes of dyspnea. These lead
widening of the root of nose, proptosis and lateral
to stridor which is harsh sound heard during
shift of eyes. In peritonsillar abscess the head is
respiration.
Part–II: Specialties
Special Points to be Taken Care rynx, oropharynx and larynx are inter-related,
are Given Below examination is complete only when all these regions
are totally examined. The method of examination
History
of each region is described separately.
Some diseases may have direct relationship with
occupation of the patient and this has to be enquired Minimum Instruments Required
into. For example, deafness may develop in persons
1. One set of ear speculum, preferably black finish
working in nosiy surroundings and hoarseness of
2. One set of Thudichurn’ s nasal speculum with
voice is a common symptom in professionals who
different sizes of nasal blades
strain their voice. After recording the presenting
3. Lack’s tongue depressor
complaints, their evolution and past treatment if any,
4. Laryngeal mirror of different sizes (sizes 3 are
have to be noted.
more commonly used)
Positive interrogation may be required to bring
5. Postnasal mirror of different sizes (sizes 0,1 and
out associated symptoms which the patient may not
2 are used more frequently
volunteer. For example, in a case with vertigo as
the major complaint, the occurrence of deafness or 6. Siegle’s pneumatic speculum
discharge from the ear may not be forthcoming, 7. Tuning forks of frequencies 256, 512 and 1024
unless leading questions are asked. Hz
8. Jobson-Hom probe.
Care should be taken to elicit past illnesses such
as syphilis, typhoid, mumps, and tuberculosis
EQUIPMENT REQUIRED FOR PERFORMING
Part–II: Specialties
which may produce sensorineural deafness or
recurrent tonsillitis which may be the source for PROPER PHYSICAL EXAMINATION
infection of the middle ear and mastoids. The
These include an ENT examination chair and
family history may give clues to diagnose diseases
such as otosclerosis, Pendred’s syndrome, hemo- illumination by a Bull’s eye lamp and head mirror
philia, multiple telangiectasis, acoustic neuromas or the Clar head light (Figs 52.1 to 52.3). Fiberoptic
and several others which run in families. head lights and the revolving head light source
provided with ENT treatment units are more modern
Heavy smoking, alcoholism and the habit of
sophisticated equipments.
chewing tobacco with betel, areca nut and lime are
factors which predispose to malignancies in the The examination is preferably performed in a
mouth, pharynx, and larynx. semidark room. The patient should be seated in front
of the examiner on an ENT examination chair,
Local Examination of ENT Organs leaning forward slightly with his back kept straight
The organ to be examined first will depend upon and feet on the floor. The examiner sits in front of
the main complaint. But since ear, nose, nasopha- the patient on a revolving chair. If the Bull’s eye
Fig. 52.1: Set up for ENT examination Fig. 52.2: Correct method of using the head mirror
666 Section 18: Ear, Nose and Throat
Fig. 52.3: Clar headlight in use Fig. 52.4: Method of holding a child for ENT examination
lamp and head mirror are used, the light source is ulcerating lesions. Congenital pre-auricular sinus
kept above and behind the left shoulder of the patient is seen as a discharging opening at the root of the
at the level of his left ear. The head mirror which is helix.
a concave mirror 10 cm in diameter with a focal
Preauricular Region
length of about 20 cm is worn by the examiner and
manipulated to focus the light on the part to be This should be inspected. Swelling in this region is
Part–II: Specialties
examined (Fig. 52.2). The right eye of the examiner usually caused by preauricular lymphadenitis or
sees through the hole of the mirror while the left ulceration of infected preauricular sinus.
eye sees directly.
Postauricular Area
The examination of children requires special
mention. The child is seated on the lap of the This should also be inspected carefully for swelling,
parent with his legs held firmly between her legs scar, sinus or fistula. Swelling in the postaural area
(Fig. 52.4). Left hand of the parent holds the child’s may suggest sub-periosteal abscess, postauricular
hands in front of his chest while his right hand holds lymphadenitis,cellulitis spreading from furuncle of
the child’s forehead to fix the head. If possible, external ear canal, allergic dermatitis or benign
children are examined without using instruments. tumors. Postauricular edema at site of emergence
of mastoid emissary vein suggests thrombosis of
EXAMINATION OF THE EAR the sigmoid sinus. This sign is called Greisinger’s
Inspection sign. Inspection of postaural sulcus gives clue to the
cause of the swelling. The sulcus is not obliterated in
Pinna mastoid abscess whereas in postauricular edema due
Patient’s head is turned to one side so that the ear to furuncle in the ear the sulcus is obliterated.
to be examined is towards the examiner and the light
External Auditory Canal
is reflected on to that ear (Figs 52.5 to 52.8). Any
obvious pathology in the pinna is noted. Congenital In adults the external auditory canal of the right ear
anomalies like microtia, macrotia, anotia and bat is brought into view by pulling the pinna upwards
ear are easy to diagnose. Swelling of the pinna and backwards with the thumb and index finger of
occurs in hematomas, perichondritis or abscess. the left hand (Fig. 52.5). For the left ear the right
Allergic oedema of pinna is usually due to hand is used.
medicaments like chloramphenicol ear drops or due The method brings the outer cartilagenous part
to wearing of new ornaments. Erysipelas of face in line with the inner bony part and allows full
may extend to pinna. Ulcers of pinna may be benign view of the external auditory canal and tympanic
or malignant. Rodent ulcer, squamous cell membrane. While pulling on the pinna, the facial
carcinoma, ulcerated molluscum sebaceum and expression of the patient should be watched. In acute
eczematous dermatitis are some of the common inflammatory diseases of the cartilaginous part of
Chapter 52: Clinical Examination in ENT Diseases 667
Fig. 52.5: Inspection of right auditory canal Fig. 52.7: Method of using ear speculum for right ear
Part–II: Specialties
Fig. 52.6: Method of syringing the ear for Fig. 52.8: Method of using ear speculum for left ear
removal of wax and foreign body
This brings the tympanic membrane clearly into through the perforation and other lesions in the
view. middle ear as seen through the perforation are to be
Normal tympanic membrane is a thin lustrous noted.
pearly grey translucent membrane set obliquely
between the external auditory canal and middle ear. Types of Tympanic Membrane Perforation
(Figs 52.10A to E)
It is oval in shape, concave, and measures approxi-
mately 10 mm vertically and 8 mm horizontally. 1. Central perforation: Perforation is in pars tensa
Maximum concavity is in the center and it is called with a rim of tympanic membrane all around it.
umbo. An ivory colored ridge is seen running 2. Marginal perforation: The perforation is in pars
upwards and forwards from the umbo. It is produced tensa and part of the circumference of the
by the handle of the malleus which ends above in a perforation is formed by the bony wall.
tiny knob of pin head size the short process of the 3. Attic perforation: The perforation is situated in
malleus. The anterior and posterior malleolar folds pars flaccida.
run anteriorly and posteriorly from the handle of 4. Subtotal perforation: It is very large central
malleus dividing the lympanic membrane into two perforation.
parts. The upper part is pars flaccida (Shrapnell’s 5. Total perforation: It is one when the whole of
membrane) and the lower part is pars tensa. The the pars tensa with the tympanic annulus is
cone of light is a conical reflection of light which involved.
extends in the anteroinferior quadrant of the ear Attic and marginal perforations are usually seen
drum. The pars tensa is divided into four quadrants with atticoantral type of chronic suppurative otitis
Part–II: Specialties
Part–II: Specialties
Fig. 52.10D: Subtotal perforation Fig. 52.10E: Total perforation
seen as white flakes with a characteristic foul smell. that the eustachian tube is patent and tympanic
Retraction of the tympanic membrane may be membrane is mobile.
evidenced by the following features:
1. Distortion of cone of light Examination Using Siegle’s Pneumatic
2. Apparent shortening of the handle of malleus Speculum (Figs 52.11 and 52.12)
3. Prominence of lateral process of malleus and Siegle’s pneumatic speculum is an aural speculum
anterior and posterior malleolar folds. When the which gives a magnification of 2.5 and which is
tympanic membrane is retracted, the patency of provided with a rubber bulb for increasing or
the eustachian tube and mobility of the tympanic decreasing the pressures in the external auditory
membrane are to be tested by Valsalva’s maneuver canal. Using a speculum of the proper size tympanic
and with the use of Siegle’s pneumatic speculum. membrane is visualized and the patient is asked
Valsalva maneuver is performed by asking the to do the Valsalva’s maneuver. The tympanic
patient to blow his cheeks and inflate the ears membrane is observed to bulge. The pressure in
with the nose and mouth closed, while the surgeon the external auditory canal can be altered by
views the tympanic membrane. A definite outward compression or release of the rubber bulb and the
movement of posterior half of pars tensa indicates mobility of the membrane is also studied. The use
670 Section 18: Ear, Nose and Throat
Fig. 52.11: Examination using Siegle’s pneumatic Fig. 52.12: Examination using Siegle’s pneumatic
speculum right ear speculum left ear
of Siegle’s pneumatic speculum helps to detect sation and whispered speech. A normal person will
mobility of the tympanic membrane, patency of be able to hear speech at conversational level at
eustachian tube, pin hole perforation of the 12 meters and whispered voice at 6 meters in a
membrane, to differentiate an open perforation from very quiet room. Since most of the rooms in which
a thin healed perforation and to elicit the fistula sign. hearing tests are carried out do not allow a distance
In case where the tympanic membrane looks greater than 6 meters, it has become customary to
Part–II: Specialties
absolutely normal, further examinations like hearing consider 6 meters as the distance for normal
tests and vestibulbar function tests are carried out standard. The patient is first instructed to repeat
depending on the patient’s complaints. what the examiner says without watching the
examiner’s lips. Normal conversational voice is
Palpation
used first and then whisper voice. Both ears are
Preauricular and postauricular regions should be tested separately. The ear not being tested is masked
palpated. by a finger inserted into the external auditory canal
Mastoiditis is characterized by tenderness over or by producing some sound in that ear (e.g.
mastoid antrum, which can be elicited by gentle repeatedly pressing the tragus over the external
pressure over the cymba concha. canal or rubbing a piece of paper over the pinna or
by using a Barany’s noise box).
Auditory Function Tests
The distance at which the patient repeats the
1. Conversational and whispering voice test conversation and whispered voice is noted, the test
2. Tuning fork tests
is repeated on the other side also. This test helps to
3. Audiometry.
compare the hearing in both ears and also to get a
I. Subjective audiometry—Pure tone audio- preliminary idea about gross hearing defects.
metry, Speech tone audiometry, Bekesy self
recording audiometry. Tuning Fork Tests
II. Objective audiometry—Impedance audio-
metry, psychogalvanic skin resistance These tests help to assess the type of hearing loss
audiometry, evoked responses audiometry, and also to compare both ears. Clinically, deafness
electrocochleography. may be classified as sensorineural and conductive.
Voice test and tuning fork tests are performed Deafness caused by impairment of conduction along
along with the clinical examination. The others are the neural path is termed sensorineural deafness.
done as special investigations. Conductive deafness is caused by defective con-
duction of vibration to the internal ear often by
Conversational and Whispering Voice Test diseases of the middle ear and ossicles. Tuning fork
In these tests, the examiner measures the distance of frequency 512 Hz is preferable since the notes
at which the patient can hear and repeat conver- of higher frequency forks tend to decay quickly not
Chapter 52: Clinical Examination in ENT Diseases 671
A B
Figs 52.13A and B: Rinne’s test (A) Air conduction, (B) Bone conduction
Part–II: Specialties
process while the patient’s head is steadied with
the left hand. The patient is asked to indicate when
the sound disappears and the fork is immediately
held erect and in line with the external auditory
meatus about 2 cm away. If the patient still hears
the note, the test is over and Rinne is termed positive. Fig. 52.14: Weber’s test
onto his own mastoid process and occludes the Fracture of nasal bones is detected by palpa-
external auditory canal. If the examiner still hears tion of the dorsum of the nose. Lateral movement
the note, the absolute bone conduction of the patient of the nasal bones brings out crepitus.
is reduced (provided the examiner’s hearing is
normal). Anterior Rhinoscopy
Interpretation This is done with a nasal speculum. Thudichum’s
Absolute bone conduction (ABC) of the patient is (Fig. 52.16), Duplay’s (Fig. 52.17), or St Clair
equal to that of the examiner. Thomson’s nasal speculum can be used. The
speculum is introduced into the nostril and the light
Conductive deafness: ABC of patient is the same
is directed into the nasal cavity.
as that of the examiner.
The septum, nose, floor of the nose, inferior
Sensorineural Deafness meatus and turbinate and middle meatus and
ABC of the patient is less than that of the examiner. turbinate are carefully examined. The degree of
There are several other tuning fork tests like Bing patency of each side, the color of the mucous
test, Gelle test, Escat test and Bonnier test, which membrane, presence of mucus, pus or crusts in the
are not routinely performed. nose, and any other lesion are noted. If any mass is
seen in the nose, it is gently palpated with a cotton
Psychogenic Deafness
bud, to know its attachment, consistency, sensitivity
To detect psychogenic deafness various tests like to touch and tendency to bleed. In children with
Chimanimoos test, Doorfler Stewart test, Stenger history of unilateral foul smelling discharge, foreign
test, Lombard’s test, Erhard’s test and others can body or a rhinolith may be detected. Nasal polyp is
be performed. seen as a bluish grey, smooth, shining mass which
EXAMINATION OF NOSE is mobile and insensitive to touch. Rhinosporidiosis
is seen as reddish irregular mass with white dots
Inspection over the surface, which are sensitive and bleed on
Look for deformities of the nose. The tip of the touch. Carcinoma of the nose and paranasal sinuses
nose is elevated with the thumb and the vestibule appear as firm, fleshy masses. Hematoma and
is inspected with the light focussed on to it abscess present as bilateral fluctuant swellings in
(Fig. 52.15). the anterior part of the nasal septum.
Chapter 52: Clinical Examination in ENT Diseases 673
Fig. 52.16: Anterior rhinoscopy using Thudichum’s speculum Fig. 52.17: Anterior rhinoscopy using Dupley’s speculum
Part–II: Specialties
into the nose by a syringe. The volumetric quantity
depressor below the nostrils and noting the areas of of air required to produce sensation of smell is
fogging on the tongue depressor while the patient recorded for each substance.
gently exhales through the nose. This test helps to compare one nostril with the
Tests for Smell Sensation other and one patient with another, and also to assess
Bottles containing clove oil, peppermint oil and the progress of the disease (Fig. 52.18).
tincture asafoetida are used as test substances.
Any other familiar substance can be used
depending on the circumstances. Each nostril is
tested separately. One nostril is closed by finger
and the bottles are brought to the open nostril one
by one and the patient is asked to recognize the smell
of each substance separately. After this, the other
nostril is tested. It is preferable to instruct the patient
to close his eyes, to avoid visual identification.
Irritants such as ammonia and substances with
strong pungent odor tend to mask the sensation of
smell for variable periods. Hence, these have to be
avoided.
Rhinomanometry
The study of nasal pressure and flow is called Fig. 52.18: Olfactory spectrogram normal and with anosmic
rhinomanometry. Active rhinomanometry is the zones:
recording of nasal air flow and pressure with normal 1. (Eth)-Ethereal
2. (ca)-camphoraceous
breathing. Passive rhinomanometry is generation of 3. (mk)-musky
nasal air flow and pressure from an external source 4. (flr)-floral
such as a fan or a pump to drive in air into the nose. 5. (mt)-minty
6. (pt)-pungent
Nasal resistance motors are now available and some 7. (pd)-putrid
of the more modem equipments incorprate a micro- Note: The anosmic zone for the particular smell is represented
computer to process and store the information. by the shaded area.
674 Section 18: Ear, Nose and Throat
Loss of sense of smell is called anosmia. Any cheek, with forefinger on one side and the middle
disorder of perception of the sense of smell is called finger on the other, and then noting the facial
parosmia. It may be a false sense of odors or expression of the patient and comparing the pain
perception of those which do not exist. Anosmia experienced on either side (Fig. 52.19).
may be due to local abnormalities in the nose or The infraorbital rim can then be palpated for
abnormalities of the neurological mechanism of any step deformity (as in fractures) or for blunting
olfaction (olfactory nerves and its connections). as occurs in malignancy of the maxillary sinus.
Neurological causes are further, described in Palpate the anterolateral wall of the maxillary
Chapter 32. Local conditions include rhinitis, antrum for irregularity or bulge.
blocking of nose, fracture of base of skull and
similar causes. While attributing anosmia to Frontal Sinuses
neurological cause, all such local conditions should In case of frontal sinusitis, tenderness is elicited
be ruled out. by pressing over the floor of the frontal sinus, with
forefinger on one side and middle finger on the
Examination of Paranasal Sinuses opposite. Palpation of the supraorbital rim should
also be done for any irregularity (Fig. 52.20).
Inspection
Empyema, mucocele and tumors of frontal sinus Ethmoid Sinuses
may reveal obvious swelling over the forehead In ethmoid inflammation, tenderness is elicited by
which can be easily made out. Inflammation or pressing on the sides of the nose midway between
Part–II: Specialties
tumors of the maxillary sinus may produce swelling the inner canthi of the eyes and the nasion.
of the face lateral to the nose. Swelling medial to
the medial canthus of the eye may be caused by Transillumination Test
pathology of the ethmoid. This is performed in a dark room. A lighted bulb is
placed in the oral cavity and the patient is asked to
Palpation
close the lips. Normally, an infraorbital crescent
Inflammation of the paranasal sinuses can be appears as a glow below the orbit on either side. In
detected by eliciting tenderness on palpation. maxillary sinusitis, the sinus becomes opaque and
the glow is abolished. For detecting frontal sinusitis,
Maxillary Sinuses the test is performed by keeping the lighted bulb
Tenderness over the maxillary sinuses can be against the floor of the frontal sinus and noting the
elicited by pressing over the canine fossa on the glow over the forehead. Both sides are compared.
Fig. 52.19: Eliciting tenderness over the maxillary sinuses Fig. 52.20: Eliciting tenderness over frontal sinuses
Chapter 52: Clinical Examination in ENT Diseases 675
EXAMINATION OF NASOPHARYNX
The procedure is first explained to the patient. A
post-nasal mirror is warmed by showing the mirror
surface over the flame of a spirit lamp or dipping it
in hot water and the metal surface of the mirror is
tested against the dorsum of the examiner’s hand,
to ascertain that it is not too hot. Warming the mirror
avoids fogging by moisture in the patient’s breath.
The patient is asked to breathe quietly through the Fig. 52.22: Diagram of structures seen in posterior rhinoscopy
nose and relax with the mouth kept open. Using a
is the fossa of Rossenmuller which is a frequent
Lack’s tongue depressor the anterior 2/3 of the
site of malignancy (Fig. 52.22).
tongue is depressed with the left hand. The light is
The roof and posterior wall of nasopharynx
focussed on the posterior pharyngeal wall just below
are visualized next. Adenoid tissue is seen as a
the uvula. The warmed postnasal mirror is held in
pinkish mass with vertical grooves over the surface
the right hand and passed into the oropharynx
at the junction of the roof and posterior wall of
between the posterior pharyngeal wall and soft
nasopharynx. Nasopharyngeal fibroma appears
palate without touching either (Fig. 52.21).
as a red, lobulated mass with prominent vessels.
The posterior end of the septum is seen as a
Nasopharyngeal cancer appears as a proliferative
vertical edge. On either side of the posterior end of
or ulcerative lesion. In some hypersensitive patients,
Part–II: Specialties
septum, the choanae are seen. The posterior edges
pharynx may have to be anesthetised by spraying
of the inferior and middle turbinates are seen on
or painting 4% xylocaine, to avoid retching.
the lateral side of the nasal cavity. Posterior end of
Further examination of nasopharynx is done by
superior turbinate is rather difficult to visualize.
fiber optic nasopharyngoscopy or by Yanker’s
Hypertrophied posterior end of inferior
nasopharyngeal speculum.
turbinate appears as rounded, mulberry-like
swellings on each side in the choanae. Discharge EXAMINATION OF ORAL CAVITY AND
may be seen trickling from the meati over the ends OROPHARYNX
of the turbinates. Abnormalities such as antero-
choanal polyp will be seen as a greyish smooth The patient is asked to open the mouth and the light
swellings coming out of the choanna into the is reflected into the oral cavity (Fig. 52.23)
nasopharynx. A lateral tilt of the mirror brings the Lips, cheek, teeth, gums, tongue, floor of mouth
lateral wall of the nasopharynx into view. The and palate are carefully examined for any lesions.
eustachian tube opening and tubal elevation can Pigmentation of the mucosa, ulcers or growths are
be visualized. Above and behind the tubal elevation all looked for. Patient is asked to put out the tongue
as far as possible. Note, if there is any restriction tumors. A bulge of the posterior pharyngeal
of movement and whether the tongue is deviated to wall on one side of the midline in a child with
any side. The dorsum and the lateral borders of the dysphagia and dyspnea is characteristic of an acute
tongue are inspected. The patient is asked to rotate retropharyngeal abscess. Cold abscess arising from
the tongue up towards the roof of the mouth. This tuberculosis of cervical vertebrae may be seen as a
facilitates the examination of its undersurface and chronic retropharyngeal abscess in adults.
the floor of mouth. White horny outgrowths arising from the
mucosa of the tonsils and pharynx without any
Method of Examination of the Oropharynx
evidence of inflammation are characteristic of
The tongue is depressed with a Lack’s tongue keratosis pharyngis.
depressor to bring into view the oropharynx. The Carcinoma of the tonsil presents as an ulcer
tongue depressor should not go beyond the anterior which hard, everted edges, whereas a gumma
2/3 of tongue since it will cause the gag reflex. The manifests in the form of a punched out ulcer.
palatoglossal and palatopharyngeal folds, the
tonsils, the tonsillolingual sulcus, posterior EXAMINATION OF LARYNX AND
pharyngeal wall and palate should be carefully LARYNGOPHARYNX
inspected for any lesion. The patient is asked to say”
Ah” and the movement of soft palate is noted The examination of larynx using a laryngeal mirror
(Fig. 52.24). is called indirect laryngoscopy. The procedure is
Acute tonsillitis is characterized by congestion explained to the patient who is seated directly facing
Part–II: Specialties
of tonsils with white spots over the crypts. Mem- the examiner.
brane formation over the tonsil may be noticed in The patient protrudes the tongue as far as
diphtheria, streptococcal tonsillitis, and moniliasis. possible after removing dentures if any. The light
In diphtheria, the membrane is greyish white and is focused into the patient’s mouth. The examiner
firmly adherent to the surface. In streptococcal holds the protruded tongue firmly with a gauze
tonsillitis, the membrane is whitish and can be strip between the thumb and middle finger of the
removed easily. In Vincent’s angina, the tonsil suffers left hand, while the index finger of the same hand
much destruction and the membrane extends deeply. is kept resting against the upper teeth for steady-
A milky white, curd like patch which is easily ing the face and for retracting the upper lip. The
removable is seen in monilial infection. patient is asked to breathe gently and a warmed
Unilateral enlargement of tonsil may suggest laryngeal mirror of appropriate size, held in the
tonsillar abscess, tonsillolith or tumor. Tonsil may right hand like a pen with the mirror facing
be pushed medially by parapharyngeal abscess or downwards, is introduced into the oral cavity. The
mirror is rested against the soft palate without
touching the posterior pharyngeal wall.
Posterior part of tongue, vallecula, lingual aspect
of epiglottis and its margins are the structures seen
first (Fig. 52.25).
By tilting the mirror, the laryngeal aspect of
epiglottis, arytenoids, ary-epiglottic folds, the
vestibule of larynx, vestibular folds and vocal cords
come into view. The vestibular folds appear as dull
red bands above the vocal cords. Vocal cords appear
as whitish, flat, ribbon-like bands below the
vestibular folds. The patient is asked to say “ee” or
“eh” when the movement of vocal cords can be seen.
Below the vocal cords, the walls of subglottis are
Fig. 52.24: Examination of oropharynx hidden from view but a few rings of trachea may be
Chapter 52: Clinical Examination in ENT Diseases 677
seen anteriorly. By tilting the mirror suitably the Palpation of the Larynx
adjacent pharyngeal walls can be inspected. If the The larynx should be palpated to detect widening
patient gags or retches, the posterior pharyngeal wall of the thyroid cartilage. Growths in pyriform fossa
is anesthetized by spraying 4% xylocaine. In obese or laryngeal growths extending beyond the larynx
Part–II: Specialties
patients with short neck indirect laryngoscopy is lead to widening. Mobility of the larynx over
difficult to perform. prevertebral fasica is detected by grasping the
In unilateral recurrent laryngeal nerve paralysis thyroid cartilage between thumb and index finger
the ipsilateral vocal cord assumes a median or and moving it from side to side. The gritty sensation
paramedian position and does not move laterally created by this maneuver (crepitus) is abolished in
on deep inspiration. Some of these patients may be lesions which push the larynx forwards away from
asymptomatic whereas others may have dysphonia. the prevertebral fascia, e.g. retropharyngeal abscess
In many cases, the voice usually improves due to and postcricoid malignancy.
CHAPTER
53
1 Special Investigations
in ENT Diseases
OS Radhakrishna Pillai
Aim of investigations is to confirm the diagnosis, Symbols used in audiogram are given in
quantitate the loss of function, establish the etiology Table 53.1
of the diseases and plan the treatment modalities. Table 53.1: Symbols used in audiograms
Modality Ear
ASSESSMENT OF AUDITORY FUNCTION
Right Left
Air conduction unmasked O X
Audiometry
Air conduction masked
Audiometer is an electrical instrument used to Bone conduction unmasked < >
measure hearing threshold at various frequencies. Bone conduction masked [ ]
Subjective and objective audiometry help to diagnose
No response
the type and degree of deafness and locate the site
of lesion.
Subjective Audiometry
Pure Tone Audiometry
The threshold of hearing by air conduction and
bone conduction for frequencies—125, 250, 500,
1000, 2000, 3000, 4000, 6000, and 8000 Hz is
determined. The examiner applies a sound stimulus
and gradually increases its intensity till it is heard
by the subject. An alternative method is to apply to
the ear a sound that is readily heard and gradually
decreasing it till it disappears. The test is performed
with sounds of different frequencies. The lowest
intensity at which the subject hears the sound is
marked as the threshold at that frequency. Both air
conduction and bone conduction are studied. The
audiogram is a graphic record of the hearing
threshold at different frequencies (Figs 53.1 to Fig. 53.1: Pure tone audiogram—normal
53.3). X-air conduction, (]-bone conduction)
Chapter 53: Special Investigations in ENT Diseases 679
Fig. 53.2: Conductive deafness right ear Fig. 53.3: Sensorineural deafness of left ear
Part–II: Specialties
superimpose on the graph. The range of 0–20 dB pathway. Speech discrimination is good in conductive
is considered as normal threshold for hearing. deafness. It is poor in retrocochlear lesions but better
In conductive deafness, the audiogram will show in cochlear lesions.
impairment of air conduction while bone conduction In addition, the response to hearing aids can be
will be normal. In sensorineural type of deafness both predicted and the improvement with auditory
air and bone conduction curves show equal loss of training can be assessed.
hearing.
Alternate Binaural Loudness Balance Test
Speech Audiometry
Clinical speech audiometry records word-identi- This test is used to detect recruitment in unilateral
fication scores for a set of prerecorded words, given deafness. Recruitment is a phenomenon in which the
at different intensity levels. Reception threshold and ear which does not hear low intensity sounds, will
discrimination of speech are measured. hear higher intensity sounds as loud or even louder
than the normally hearing ear. A tone is presented
Speech Reception Threshold alternately to the normal and affected ear and the
Spondee words which are words with two syllables, intensity in the affected ear is adjusted to match the
both pronounced with equal stress are used, e.g. loudness in the normal ear. In conductive deafness
sunset, seashore, horse-shoe, tooth brush, farewell, and retrocochlear deafness the initial difference is
etc. The intensity at which the patient identifies and maintained throughout while in cochlear deafness
correctly repeats 50% of the words, is called speech recruitment is seen.
reception threshold. Patients with cochlear deafness distinguish
Speech Discrimination smaller changes in intensity of pure tones better than
those with conductive or retrocochlear deafness.
This is tested by using phonetically balanced words
which are mono syllables, e.g. cat and bat, sit and
Speech Audiometry—Alternate Method
hit. These words are presented at an intensity about
25 dB greater than the individual’s speech reception Here the percentage of phonetically balanced words
threshold. The percentage of words that the patient correctly heard by the patient at different intensity
can repeat correctly is his discrimination score or levels are charted on a graph and two parameters
phonetically balanced score. are assessed.
680 Section 18: Ear, Nose and Throat
Fig. 53.4A: Calculation of half peak level. A–normal, Fig. 53.4B: C-sensorineural hearing loss
B–conductive hearing loss D-retrocochlear lesion
Part–II: Specialties
Fig. 53.6: Bekesy audiogram–Type 2 Fig. 53.9: Bekesy audiogram–Type 5
Part–II: Specialties
• Wave VII - Auditory radiations no evidence of middle ear disease, it is named
Measurement of latency from the stimulus Hennobert’s sign. It is seen most commonly in
to the appearance of waveforms and the charac- congenital or late tertiary syphilis, rarely it may
teristic wave-form patterns are compared with occur in Meniere’s disease also.
normal patterns. Variations in the patterns help to
Spontaneous Nystagmus
identify and localize the lesions. Brainstem evoked
audiometry has its greatest use in the diagnosis of Nystagmus is involuntary rhythmic eye move-
retrocochlear lesions and nonorganic hearing loss. ments. Spontaneous nystagmus is seen in vesti-
This test can be done on infants and this is a great bular lesions. It is fine and rotatory with two
advantage. BERA is now an established method of components—a slow component of vestibular origin
hearing assessment in neonates and infants. and a fast component due to central correcting
mechanism. The direction of fast component is taken
Cortical Evoked Response Audiometry for assigning the direction of nystagmus. Nystagmus
This records the electrical activity occurring in the can be graded as follows:
cortex caused by sound stimuli. The active electrode First Degree
is placed on the vertex of the head and reference
Nystagmus is present only when the patient looks
electrode on the mastoid process. This test can be
towards the side of fast component.
performed only in adults and older children.
Second Degree
Evoked Otoacoustic Emission Test
Nystagmus is present when the patient looks straight
This is a test intended to detect hearing loss even in and towards the direction of fast component as well.
neonates and infants. Otoacoustic emissions are low Generally vestibular nystagmus does not last for
level sounds produced by the internal ear even if it more than 6 weeks.
is not stimulated. When the ear is stimulated by
external sound stimuli these otoacoustic emissions How to Look for Nystagmus?
become more apparent. These are called transient Always look for nystagmus under good illumination.
evoked otoacoustic emissions. Recording of these First observe the eyes in their primary position. In
echo sounds and their interpretation enable the this position, congenital pendular nystagmus and
detection of cochlear lesions even in neonates. second degree jerk nystagmus can be detected. The
684 Section 18: Ear, Nose and Throat
Note: While testing for nystagmus, the finger should with warm water first. Then the contralateral ear is
not be held too close to the patient’s eyes so as to tested first with warm water and later with cold
avoid the accommodation reflex. Similarly, water. The test is concluded by cold water
extremes of gaze should be avoided because even stimulation of the affected ear. Between each
normal individuals may show nystagmus in these irrigation, rest periods of 7 minutes are allowed.
positions due to muscle fatigue, especially if the Normally nystagmus occurs for 90 to 140 seconds
gaze is maintained for more than 30 seconds. after the onset of irrigation and it is prolonged by
Anxious individuals may show nystagmus within further 40 seconds when visual fixation is abolished.
1 to 2 mm of extreme abduction and adduction of
the eyes. In both these situations, the oscillatory Interpretation
movements of the eyes will be irregular and ill a. Normal response: Equal response in both ears
sustained and they are not pathological, they are to all four tests.
more correctly termed as ‘nystagmoid’ movements. b. Canal paresis: Duration of nystagmus for hot
Generally nystagmus due to peripheral lesions and cold is reduced.
enhances when visual fixation is abolished, and
nystagmus due to central lesions reduces. If the
labyrinth is irritable or hyperfunctioning on one side,
direction of nystagmus is towards the same side.
When the labyrinth is hypo-or nonfunctioning the
direction of nystagmus is to the opposite side.
(Also refer to chapter 32 Neurology)
Induced Nystagmus
The function of vestibular system may be evalu-
ated by stimulating the labyrinth and noting the
responses.
Videonystagmography also known as video–
oculography has recently become the preferred
method for recording eye movements during
vestibular testing. Fig. 53.15: Caloric test-procedure
Chapter 53: Special Investigations in ENT Diseases 685
Part–II: Specialties
Dundas-Grant Test
Fig. 53.16: Calorigram—normal caloric response
If the patient has perforation of the tympanic
membrane, cold air or oxygen is used instead of
ice-cold water to stimulate the labyrinth.
Hypoactive vestibular response occurs in
toxicity due to streptomycin, serous labyrinthitis,
Meniere’s disease, labyrinthine concussion, acoustic
neuroma and sometimes after mumps.
Positional Test
Positional nystagmus can be induced by placing
the patient’s head in different positions. Patient is
seated on a couch in such a way that when he lies
Fig. 53.17: Calorigram—right canal paresis
supine his head will extend beyond its edge. The
procedure is explained to the patient. His head is
turned 90° to the right or left, and he is asked to
lie down quickly, the examiner holds his head
turned to right or left, 30° below the horizontal.
This position is maintained for 30 seconds.
If nystagmus occurs, its latency, direction, duration
and fatigability are all noted. Then the patient is
asked to sit up quickly while the examiner who
holds the head brings it straight so that the patient
can look straight. Again nystagmus is looked for.
Fine, horizontal, fatigable nystagmus occurs in
vestibular lesions and benign positional vertigo.
Rotatory or horizonto-rotatory nystagmus is seen
Fig. 53.18: Calorigram—directional preponderance to left in central lesions (Figs 53.19A and B).
686 Section 18: Ear, Nose and Throat
BACTERIOLOGICAL EXAMINATION
Swabs collected from the ear, nose, throat can be
Part–II: Specialties
subjected to microbiological tests to identify the
infecting agent and determine the sensitivity to
antimicrobial drugs.
RADIOLOGY
Ear Diseases
Plain radiographs of the temporal bone reveal the
extent of mastoid disease, the condition of the ossicles
Fig. 53.21: Normal electronystagmogram (ENG) and extent of pneumatization. Several special views
are available to demonstrate different portions of
test the subject is rotated about an “earth vertical the temporal bone and middle ear. Towne’s view
axis” at a velocity of 300° to 400°/sec. During the and transorbital view of the petrous temporal bone
ongoing rotation the subject is gradually translated are commonly taken in suspected cases of acoustic
(shifted) 3.5 to 4 cm first to the right and then to the neuroma to demonstrate enlargement of the internal
left along an interaural axis, to a position at which auditory meatus (Fig. 53.22).
one utricle becomes aligned with the axis of rotation
Nose and Paranasal Sinuses
and at this point it is subjected only to gravitational
forces. This stimulus induces ocular counter-rolling For the nasal bones a lateral view is taken by placing
which reflects the otolithocular reflex. The ocular a dental film in direct contact with the side of the
counter-rolling is measured using videooculography. nose and centering the incident beam horizontally
Signs of dominance of one or the other utricle can be through the nose. This can be supplemented by a
detected from high speed rotation. craniocaudal projection obtained by inserting an
occlusal film between the teeth.
Assessment of the Saccule—Vestibular For paranasal sinuses occipitomental view
Evoked Myogenic Potentials (Water’s view) is usually preferred. Occipito-
The myogenic potentials from the tonically frontal, submentovertical, lateral and oblique views
contracted sternocleidomastoid muscle in response may be taken if needed, depending on the site of
to loud sound delivered to the ear are measured. pathology. Sinusitis gives rise to haziness of the
688 Section 18: Ear, Nose and Throat
Fig. 53.22: X-rays lateral view of skull for normal mastoid air- Fig. 53.24: X-ray Bilateral maxillary sinusitis. Note: Bilateral
cells—arrow points to normal on the left L. X-rays lateral view opacity of the sinuses (arrows)
of skull mastoiditis—arrow point to sclerosed mastoid air cells
Tomogram
Conventional tomography can demonstrate lesions
in the paranasal sinuses, vocal cords, vestibular
Fig. 53.23: X-ray maxillary sinusitis left Note: Opacity caused bands and laryngeal masses. Conventional tomo-
by exudate filled maxillary sinus (arrow). Right side is normal
graphy has been replaced by computed tomography
sinus without bone erosion. Frontal mucocele reveals at present.
loss of scalloping of frontal sinus. Malignancy of
sinuses is associated with bone erosion (Figs 53.23 Laryngogram
and 53.24). After anaesthetizing the larynx, 10 cc of an oil based
Nasopharyngeal lesions show up as soft tissue iodine contrast medium is dropped slowly over the
masses obstructing the airway or eroding the base tongue into the larynx and frontal and lateral view
of skull, in the submentovertical views of the skull. skiagrams of larynx are taken during phonation,
inspiration and valsalva’s maneuver. Laryngogram
Pharynx and Larynx will give information as to the site, size and extent
Plain radiograph of the lateral view of the neck of laryngeal pathology.
brings out the cervical spine as well as the pharynx.
Caries spine and other lesions of cervical vertebrae Computed Tomography
can be easily detected. Retropharyngeal abscess is
usually seen as widening of the prevertebral space, CT Scan
with air fluid level at times and with straightening Computed tomography helps to pinpoint ear lesions
of the anterior border of the vertebral column. For such as tumors and abscesses and also to note
demonstration of elongated styloid process an intracranial complications.
Chapter 53: Special Investigations in ENT Diseases 689
Part–II: Specialties
vessels. Arteries and veins can also be differentiated.
photography.
Magnetic resonance imaging (MRI) can
differentiate tumor tissue from retained fluid within Nasal Endoscopy
the sinus. The extension of sinus neoplasia into
Examination of the nasal cavities using an
cranial cavity is clearly brought out. Nasopharyngeal
endoscope has become an integral part of
lesions can also be delineated clearly.
investigation of diseases of nose and paranasal
MRI of the larynx can give correct information sinuses (Figs 53.25 to 53.28).
regarding extent of tumor spread.
Indications
Angiography
1. Chronic and recurrent sinusitis
It is a useful procedure in nasopharyngeal angio
2. Headache and facial neuralgia
fibroma and glomus jugulare tumors. It also
3. Permanent coryza
facilitates preoperative embolization of the feeding
4. Epistaxis, epiphora, chronic pharyngitis and
vessel.
laryngitis, and chronic otitis media
BIOPSY 5. Disease of epipharynx
6. Hyposmia/anosmia
This will be required when patient presents with 7. CSF rhinorrhea
granulomas, polyps or growth in the ear, nose or 8. For biopsy from nose and paranasal sinuses.
throat.
Procedure
STROBOSCOPY AND CINEPHOTOGRAPHY
The examination is carried out with the patient
The vibration of vocal cords can be visualized seated or recumbent. The nasal cavity is anesthe-
and analyzed by means of a stroboscope which tized by administering local anesthetic spray or
provides an interrupted source of light and adjusts inserting swabs soaked with local anesthetic. The
the frequency of light interruption to the note instruments used are 0°, 30° and 70° scopes, which
produced by the larynx. Cinephotography has also are 4 mm in diameter for adults and 2.7 mm in
been used for assessing vocal cord function. diameter for infants.
690 Section 18: Ear, Nose and Throat
Fig. 53.26: Endoscopic view of nasal cavity. U–uncinate Fig. 53.28: Flexible nasopharyngoscope
process, B–bulla ethmoidalis, M–middle turbinate, S–septum
nose
Part–II: Specialties
4. View into the tympanomeatal angle
5. Assessment of radical mastoid cavity
6. Postoperative examination
7. Photographic and video documentation.
0° and 30° endoscopes with 3 mm and 6 mm
diameter are available.
POLYSOMNOGRAPHY
Fig. 53.30: Normal tympanic membrane
seen through otoscope This study is performed in a sleep laboratory in order
to confirm the diagnosis of sleep apnea syndrome
from the antrum for microbiological tests and and to assess its severity. It involves the continuous
exfoliative cytology for malignant cells. Contrast
recording of EEG, ECG electrooculogram, chin
radiography of the sinuses can be done after antral
electromyogram and respiratory movements of
puncture.
the chest and abdominal wall throughout sleep.
Otoendoscopy (Figs 53.29 to 53.31) Oronasal air flow and oxygen saturation are
Advantages of otoendoscopy are: monitored. In addition to the detection of oxygen
1. Assessment of the entire tympanic membrane, the desaturation and cardiac arrhythmias, these
annulus and the wall of the auditory meatus. recordings also allow sleep to be staged, REM sleep
2. Helps in the differential diagnosis of fixed and to be recognized and obstructive central and mixed
mobile retraction of the tympanic membrane, apneas to be distinguished.
SECTION
19
Examination of Oral Mucosa
and Teeth (Dental Examination)
CHAPTER
54
1 Oral Mucosa, Teeth and Gums
Angel Jacob
Examination of oral mucosa, Teeth and gums, Salivary glands, Ulcers of oral mucosa, Lumps or swelling
in the mouth, Xerostomia, Halitosis, Examination of the teeth, Mandibular fracture and dislocation,
Malocclusion of teeth, Examination of gingival and periodontium, Bleeding from the gums gingival
enlargement
Fig. 54.1: Mouth mirror, graduated probe, Fig. 54.2: Examination of lower labial sulci
explorer and tweezers
696 Section 19: Examination of Oral Mucosa and Teeth (Dental Examination)
Fig. 54.3: Examination of the upper and lower buccal sulci Fig. 54.5: Examination of the lateral border of the tongue
Part–II: Specialties
Fig. 54.4: Examination of the dorsum of the tongue Fig. 54.6: Examination of the floor of the mouth
Part–II: Specialties
to one side. Bimanual palpation is done by pressing
over the lateral aspect of the joint. Intra-auricular erythematosus, gastrointestinal disorders like
palpation is done by placing the little finger into Chron’s disease, ulcerative colitis.
the external auditory meatus and gently pressing
Miscellaneous
forward can reveal tenderness. Clicking sounds can
also be heard on opening due to the sudden movement Recurrent aphthous stomatitis, ulcers due to allergic
of the disk relative to the condyle. TMJ locking reaction, necrotizing sialometaplasia, Behcet’s
and dislocation can also be present. syndrome and lichenoid reactions.
An ulcer should be examined using a systematic
Lining Mucosa
approach.
Normal buccal mucosa has the following features:
• Linea alba buccalis Site
• Fordyces granules Adjacent to a sharp tooth, edges of denture—
• Wharton’s duct. traumatic.
Inspection reveals the site, size and shape and Interdental papilla: Acute necrotizing ulcerative
palpation reveals whether the lesion is soft, firm or stomatitis.
hard. Note whether the edges are well defined or
Posterior part of the mouth: Coxsackievirus, e.g.
diffuse and if the lesion is mobile or fixed.
herpangina.
The following changes can be observed in the
oral mucosa: Number of ulcers: Multiple sites suggest viral
Ulcers, white patches, red, vesicular and bullous infection or recurrent aphthae.
lesions, enlargements and swellings. Oral changes Shape
in systemic diseases, and miscellaneous conditions.
Round, oval, crescentic—traumatic ulcer, irregular
ULCERS OF ORAL MUCOSA —cytomegalovirus, coalescing—herpetic ulcers.
Angular or stellate—TB, punched out—tertiary
Traumatic
syphilis.
Over extended denture, sharp tooth, sharp edge of
a fractured tooth, thermal burns, chemical burns, Floor
iatrogenic. Should be examined for color.
698 Section 19: Examination of Oral Mucosa and Teeth (Dental Examination)
Part–II: Specialties
Acute Necrotizing Ulcerative Gingivitis Differential Diagnosis
Inspection shows punched out crater like depressions Traumatic ulcer.
on the interdental papilla and marginal gingiva.
There is a pseudomembranous slough covering the Pemphigus
ulcer and its removal reveals a raw surface. Inspection reveals bullae which rapidly form
This is associated with sudden onset of pain, shallow ulcers. The epithelium can be peeled off
tenderness, profuse salivation, metallic taste, fetid easily leaving behind a denuded base. This is known
odor and usually appears in immunocompromised as Nicolsky’s sign. The margins are ragged, the
patients, debilitated patients, starvation, smokers and surface covered with white or blood tinged exudates
people with protracted work without adequate rest. (Fig. 54.9). The gingiva is diffuse and erythematous.
On palpation the lesion bleeds easily and there is Erosive Lichen Planus
severe pain. Seventy percent of patients with skin involvement
Differential Diagnosis has oral lesions but only 10% of patients having
oral lesions have skin lesions. It is seen in women
Recurrent aphthous stomatitis, erythema multiforme,
over 30 years of age. On inspection, they are painful
bullous drug induced exanthematous lesions, bullous
ulcers that are shallow, irregular erosions. They are
mucous membrane pemphigoid. About 90% of
bilateral and affects the buccal mucosa, tongue,
pemphigus also appears in the oral mucosa and 60%
labial mucosa and gingiva. The palate and lingual
of it appears first in the oral mucosa.
mucosa are usually spared. The size ranges from a
Investigations few millimeters to several centimeters in diameter.
The floor is yellow with a layer of fibrin covering
Nikolsky’s sign, biopsy, immunofluorescent
the base and the edges may have sunken margins
antibody test.
due to fibrosis and the borders are usually
Erythema Multiforme erythematous.
Inspection: Usually appears on the lips followed Differential Diagnosis
by buccal mucosa, palate, tongue and face.
Gingival atropic lesions resemble mucous membrane
It appears as vesicles that rapidly turn into ulcers.
pemphigoid.
The base is erythematous. Patients cannot swallow
and saliva drools out and is blood tinged. The lips Investigation
are extensively involved and oral mucosa is denuded
Part–II: Specialties
Mucosal biopsy.
of epithelium in large areas. Sloughing of mucosa
reveals bright red raw surface (Figs 54.10 and Bullous Pemphigoid
54.11). The initial defect is subepthelial in the lamina lucida
portion of the basement membrane.
Differential Diagnosis
Primary herpetic gingivostomatitis, pemphigus Inspection
vulgaris, mucous membrane pemphigoid, allergic There are presence of bullous lesions initially which
reactions, and erosive lichen planus. rupture to form ulcerations and erosions. The
gingiva presents with inflammation, generalized
Investigation edema, desquamation and localized areas of vesicle
Mucosal biopsy. formation. The vesicles may also be present on the
Fig. 54.10: Erythema multiforme on palate (arrow) Fig. 54.11: Erythema multiforme on lips (arrow)
Chapter 54: Oral Mucosa, Teeth and Gums 701
Part–II: Specialties
Direct immunofluorescent study will show fluor- Blood examination.
escent immunoglobins and complements in the
basement membrane zone. MALIGNANT ULCERS
Pemphigus vulgaris, erythema multiforme, bullous The oral mucosa is a very common site for
pemphigoid, Behcet’s syndrome. malignancy in India. The habits of “Pan” chewing
and tobacco smoking predispose to the development
Behcet’s Syndrome of oral cancer. On inspection the lesion appears as
circular, crescentic or irregular ulcers with raised,
Multisystem disorder with common triad of features
everted or rolled edge. The floor may be granular
that include ulcers of the aphthous type, genital
and ragged and bleed easily with the base indurated
ulceration and eye lesions.
and fixed to the deeper tissues. The site is often the
Necrotizing Sialometaplasia tongue, floor of the mouth, buccal mucosa and
alveolar ridge (Figs 54.12 to 54.14). The lesion may
A painful ulcer on the palate found midway between
be painless in the early stages but may become
the palatal raphe and the gingival margin usually in
painful when the tumor invades the neural tissue.
the molar region. On inspection they are single and There are swollen nontender glands in the neck.
large up to two centimeters in diameter. The margins There is loosening of the teeth in carcinoma of the
are irregular in shape with the base often being the gingiva.
palatal bone and the floor is yellow with necrotic
debris. The edges are inverted or heaped-up and on Investigations
palpation the ulcer is indurated. This resembles Biopsy and histopathological examination, plain
squamous cell carcinoma clinically and histo- radiology, CT, MRI and bone scintigraphy.
pathologically also resembles squamous cell
carcinoma and mucoepidermoid carcinoma but the Non-Hodgkin’s Lymphoma
condition is self-limiting and heals spontaneously Inspection reveals a circular or irregular ulcer on
in 2 to 3 months. the gingiva, palate, buccal mucosa or pharynx. The
702 Section 19: Examination of Oral Mucosa and Teeth (Dental Examination)
Kaposi’s Sarcoma
On examination, they appear as typically single or
multiple blue, red or purple, macules, papules,
nodules or ulcers. It begins as flat, blue, red or purple
Part–II: Specialties
Part–II: Specialties
Necrotizing sialometaplasia Systemic lupus erythematosus
Recurrent aphthous stomatitis
Discoid lupus erythematosus.
Aphthous ulcers
Neoplasia and Premalignant Conditions
KERATOTIC AND NON-KERATOTIC Leukoplakia (Fig. 54.17)
WHITE LESIONS Speckled leukoplakia
Normal variation: Erythroplakia
• Leukoedema Squamous cell carcinoma
• Fordyce granule Oral submucous fibrosis.
• Linea alba. Miscellaneous
Fordyce Granules Vitamin A deficiency
Skin graft.
Inspection shows small, yellowish spots either
discretely separated or forming relatively large
plaques projecting above the surface. On the tongue
they appear as dome shaped nodules varying from
a few mm to 2 cm in diameter on the midline dorsum
of the tongue. They are sharply delineated with a
smooth surface. They do not ulcerate. On palpation
the lesions have a slightly cheesy consistency.
Linea alba is a white line on the buccal mucosa
seen at the line of occlusion.
Removable White Patch
Leukoedema (variant of oral mucosa that disappears
on stretching).
• Epithelial or food debris
• Milk curd (babies) Fig. 54.15: Smoker’s keratosis
704 Section 19: Examination of Oral Mucosa and Teeth (Dental Examination)
saliva not expressible from the parotid gland, It can be detected on inspection by using a mouth
characteristic lobulated tongue, red with partial or mirror and a probe. If there is a catch on pulling the
complete depapillation. There may be complications explorer over the tooth surface, then dental caries
of xerostomia like dental caries and candidiasis. is suspected (Fig. 54.18).
There can also be ascending suppurative sialadenitis. Teeth are opaque white in color if the enamel,
dentine and the pulp are intact. Attrition of the teeth
HALITOSIS (OFFENSIVE BREATH) and decrease in the amount of enamel present
Diagnosis of halitosis is made from full history, on the teeth will expose the underlying dentine
examination or assessment of halitosis simply by giving it a yellow discoloration. There is increase
in sensitivity. Caries can present with varied
smelling the exhaled air (organoleptic method),
symptoms like no symptoms in initial lesion,
halimeter which give the amount of volatile amines,
sensitivity, sharp shooting, intermittent pain and
sulphur compounds, methylmercaptans and others
continuous pain that interferes with sleep in case of
in the breath.
infection of the pulp and periodontal tissues. There
If there is no genuine halitosis it is due to will also be referred pain to the shoulder and neck
psychogenic causes. Halitosis can be caused in case of mandibular molar teeth, orbital region in
due to recently ingested food like garlic, onion, case of canines, maxillary sinus region and temporal
drugs like alcohol, chloral nitrites/nitrates, dimethyl region in case of maxillary molars. Presence of a
sulphoxide, cytotoxics, phenothiazines, amphet- periapical abscess as a result of caries can also be
amines or smoking. It is also caused by oral, sinus detected by percussion of the tooth with a handle of
Part–II: Specialties
or pharyngeal infections like abscess, dry socket, an instrument (Fig. 54.19). Presence of pain indicates
pericoronitis, acute ulcerative gingivitis, tonsillitis, periapical lesion which can even be excruciating.
sinusitis nasal discharge or foreign body and due to Sharp stabbing pain is associated with exposed
dry mouth or respiratory disease, hepatic disease, dentine associated with caries, fractured restoration,
renal disease, gastrointestinal disease, diabetes fractured tooth, cracked tooth, early pulpitis,
mellitus or other conditions. trigeminal neuralgia and glossopharyngeal neuralgia.
EXAMINATION OF THE TEETH Dull Throbbing Pain
Examination of the tooth is done by using a mouth • Late pulpitis
mirror and an explorer. Dental caries may be present • Apical and lateral periodontitis
in the pits on fissures on the biting surface of the • Periodontal-endodontal lesion
teeth, on the smooth surface below the contact point • Acute necrotising ulcerative gingivitis
between the teeth and also present on root surface. • Dry socket
Part–II: Specialties
dental origin from maxillary sinusitis. Proper of teeth when the jaws are closed. Occlusion is a
history has to be taken. In case of maxillary complex phenomenon involving the teeth, periodontal
sinusitis, pain cannot be localized to a single ligament, temporomandibular joint, muscles, jaws
tooth, pain on bending the head and a history of and the masticatory system. Malocclusion may be
rhinitis. Vitality tests will show that the tooth is due to dental, skeletal or a combination of causes.
vital. In pain is of dental origin, pain can be Dental irregularities are due to crowing, spacing,
localized to the particular tooth and the vitality crossbite, open bite and deep bite (Fig. 54.21).
tests will show if the pulp is hyperemic or Malocclusion due to irregularities of the teeth can
necrotic. be corrected by orthodontic therapy (Fig. 54.22),
Investigations: Intraoral periapical radiograph, Skeletal malocclusion if noticed during the growth
radiograph of the maxillary sinus and CT scan. period can be corrected by growth modification
Fig. 54.21: Before orthodontic treatment Fig. 54.22: After orthodontic treatment
708 Section 19: Examination of Oral Mucosa and Teeth (Dental Examination)
procedures like functional and orthopedic appliances. The gingiva should be probed with a graduated
After the growth is completed, skeletal maloc- probe (William’s graduated probe) to detect the
clusions are corrected by means of orthognathic presence of pockets (Fig. 54.25). The presence of
surgery. periodontal pocket is a sign of periodontitis.
Periodontitis can be diagnosed by the presence
EXAMINATION OF GINGIVA AND of periodontal pockets, pus discharge, mobility,
PERIODONTIUM pathological migration of teeth, periodontal abscess,
pain and bleeding. Since periodontitis is a chronic
The healthy gingiva is pale pink or coral pink in infection releasing large amounts of cytokines into
color with the marginal gingiva scalloped at the level the blood stream, it is considered to be risk factor
of cementoenamel junction. The interdental papilla for coronary heart disease, preterm low birth weight
fills the embrasures between the teeth. There is infants, cerebrovascular accidents, poor glycemic
presence of stippling in the attached gingiva region control in diabetics and risk of pneumonia.
of the interdental papilla (Fig. 54.23). In some situations gingiva, buccal mucosa and
tongue may be the only sites at which systemic
Changes in the Gingiva due to Disease diseases are manifested.
In the gingiva, there may be changes in the color, Acute periodontal abscess on inspection is
contour, consistency, texture, tendency to bleed, edematous and red with a smooth shiny surface and
suppuration and pain. There can be the presence of the area is dome like and relatively firm or pointed
vesicular, bullous and ulcerative lesions, red and and soft (Figs 54.26 and 54.27). In most cases there
Part–II: Specialties
white lesions, pigmented lesions, benign and is pus discharge from the gingival margin with gentle
malignant lesions. There can also be presence of digital pressure. There is presence of periodontal
plaques, papules, macules, pustules, sinuses and pocket on probing. This is accompanied by
fistulas. The gingiva should be inspected for its symptoms like throbbing, radiating pain, exquisite
color, contour, consistency, surface texture, size,
position, tendency to bleed and pain. Palpate
the lateral and apical areas of the tooth. This may
help to locate the origin of any radiating pain
that the patient cannot localize. Infection deep in
the periodontal tissues and the early stages of
periodontal disease can also be located by palpation.
Presence of pus in the periodontal tissues as it occurs
in periodontal infection can be determined by
placing the ball of the index finger along the lateral
aspect of the marginal gingiva and applying pressure Fig. 54.24: Periodontitis—pus discharge visualized by
in a rolling motion towards the crown (Fig. 54.24). using the ball of the index finger
Fig. 54.23: Healthy gingiva Fig. 54.25: Deep periodontal pocket with
inflammatory gingival enlargement
Chapter 54: Oral Mucosa, Teeth and Gums 709
Part–II: Specialties
inflammation in individual patients or among
Fig. 54.26: Acute periodontal abscess (arrow) subjects in large population groups.
Score 0: Normal gingiva
Score 1: Mild inflammation—slight change in
color and slight edema; no bleeding on
probing.
Score 2: Moderate inflammation—redness,
edema and glazing; bleeding on probing.
Score 3: Severe inflammation—marked redness
and edema; ulceration; tendency for
spontaneous bleeding.
The most common cause of chronic and recurrent
bleeding is chronic inflammation as a result of
plaque and calculus accumulation.
Acute episodes of bleeding occurs as a result of
Fig. 54.27: Periodontal abscess (arrow) injury.
Spontaneous bleeding or bleeding on slight
provocation occurs in acute necrotizing ulcerative
tenderness of the gingiva to palpation, tooth gingivitis. Hemorrhagic disorders in which
mobility, lymphadenitis and less frequently systemic abnormal gingival bleeding is encountered include
effects such as fever, leukocytosis and malaise. scurvy, platelet disorders (thrombocytopenia and
Periapical abscess is present more towards the thrombocytopathy), hypoprothrombinemia (vitamin
apex of the root but in children it can also appear K deficiency) and other coagulation defects
on the lateral aspect. There is presence of a deep (hemophilia, leukemia, Christmas disease), deficient
carious lesion or a nonvital tooth (the tooth is platelet thromboplastic factor (PF3) resulting from
discolored—brownish, vitality test is negative). uremia, multiple myeloma and post-rubella purpura.
Gingival abscess is found on the marginal Other rare causes of bleeding includes anticon-
gingiva and occurs in previously disease free areas. vulsant drug medication, calcium channel blocking
710 Section 19: Examination of Oral Mucosa and Teeth (Dental Examination)
drugs, immunosuppressants, antiplatelet drugs and systemically from therapeutic use or household
thermal and chemical burns of the gums. environments can discolor the gingiva. Typically
metals produce a bluish or bluish black line in the
Changes in Color of the Gingiva
gingiva that follows the contour of the margin.
The normal coral pink color of the gingiva is red
in inflammation with a bluish hue in chronic Changes in Consistency of the Gingiva
inflammation. The redness is limited to the marginal Acute and chronic inflammations produce changes
gingiva in acute necrotizing ulcerative gingivitis in the normal resilient consistency of the gingiva.
with punched out crater like depressions of the The gingiva is edematous in acute inflammation.
interdental papilla and covered with a pseudomem- In chronic inflammation there can be fibrotic areas
branous slough and demarcated from the normal as well. Firm leathery consistency is found in
mucosa by a linear erythema. Sometimes the gingival fibromatosis. The gingiva can even cover
lesions are denuded of the surface pseudomem- the teeth and interfere with the normal eruption
brane, exposing the gingival margin which is red, patterns.
shiny and hemorrhagic.
Changes in Texture
When there is diffuse, erythematous, shiny
involvement of the gingiva and the adjacent oral Smooth surface texture is found in atropic gingivitis
mucosa the differential diagnosis may be erthythema as in desquamative gingivitis (Fig. 54.28). Hyper-
multiforme, Stevens Johnson’s syndrome, bullous keratosis results in a leathery texture, and drug
lichen planus, desquamative gingivitis and recurrent induced gingival overgrowth produces a nodular
Part–II: Specialties
Fig. 54.30: Drug induced gingival hyperplasia Fig. 54.32: Mucocele of gums
Part–II: Specialties
Hemorrhage occurs spontaneously or on slight
trauma. Gingiva that is red, friable, granular and
bleeds easily may be a feature of plasma cell
gingivitis.
Bluish red enlargement of the gingiva with a
shiny surface moderately firm in consistency and a
Fig. 54.31: Idiopathic gingival enlargement tendency towards friability and hemorrhage
spontaneously or on slight provocation may be
secondarily infected. The enlargement is fibrotic leukemic gingival enlargement.
with a coarse texture. When secondarily infected Leukoplakia can also take the form of raised
there is bleeding and the surface is smooth and the irregularly shaped keratinous masses. Exophytic,
consistency is soft and edematous (Fig. 54.30). irregular outgrowth or ulcerative lesions on the
When the enlargement involves the interdental gingiva may be squamous cell carcimona—
papilla and the marginal gingiva and it can cover investigation; biopsy.
the teeth, the enlarged gingiva is firm and leathery Darkly pigmented flat or nodular lesion
and characteristically with a minute pebbled characterized by rapid growth and early metastasis
surface. Massive enlargement of the gingiva which is a feature of malignant melanoma. In addition to
can cover the surfaces of the teeth and even interfere this gingival enlargement can also be a presenting
with tooth eruption is seen in idiopathic gingival feature of cysts, benign and malignant tumors and
enlargement (Fig. 54.31). malignant metastasis from distant sites.
Pregnancy tumor is a discrete, mushroom like, Cysts of the soft tissues of the mouth include
flattened spherical mass that protrudes from the developmental cyst like dermoid and epidermoid
gingival margin or from the interproximal space cysts, lymphoepithelial (branchial cyst), thyrogl-
attached by a sessile or a pedunculated base. It is ossal duct cyst, anterior median lingual cyst,
dusky red or magenta has a smooth glistening mucoceles, ranula and parasitic cysts. These can
surface that exhibits numerous deep pin point be confirmed by biopsy (Fig. 54.32).
CHAPTER
55
1 Investigations in Dentistry
Angel Jacob
Diagnostic tests in dentistry, Radiograpy, CT scan, Investigative procedures in oral mucosal disease
denotes inflammation and accumulation of fluid. Intraoral periapical radiograph: This helps to
Greater tenderness to percussion in an apical direction assess the root and surrounding bone.
suggests apical periodontitis. Greater tenderness to
Orthopantomograph
percussion in a lateral direction suggests acute
periodontitis. Like vitality testing a number of teeth This helps to have a general survey and shows the
should be tested in addition to the suspected tooth antrum and the temporomandibular joints and the
and testing should begin on the healthy tooth. radiation dose is considerably lower than a full
mouth survey using periapical radiography.
Mobility of Teeth
Tooth mobility is assessed by use of two instrument Radiovisiography
handles one placed on the buccal and other on the Radiovisiography (RVG) is used particularly when
lingual aspect of the tooth. Alternatively, a finger there is need for repeated films. It is useful in
may be substituted for one of the instruments. reducing radiation exposure.
Increased mobility is caused by reduced bone
support like periodontitis, neoplasms, cysts, abscess Sialography
or inflammation of the periodontal ligament like Sialography involves injection of a radiopaque
apical periodontitis, periodontal disease, trauma or contrast media into the salivary duct followed by
traumatic occlusion, crown or root fracture or oblique lateral, posteroanterior or rotated postero-
fracture of the supporting bone. anterior radiographs. Silalography helps to assess
patients with xerostomia, salivary swelling, ductal
Transillumination
Part–II: Specialties
obstruction and salivary aplasia.
It is useful in the diagnosis of interproximal caries
of anterior and posterior teeth. Intraoral transillum- Arthroscopy
ination in a darkened room has been employed in Arthroscopy involves injection of a radiopaque
the diagnosis of maxillary sinussitis. contrast media into the lower space of temporo-
Biting on a rubber, wood point, rubber dam mandibular joint. The main indication is in suspected
material helps in the diagnosis of a cracked tooth. internal joint derangements.
Auscultation with a stethoscope placed over a
temperomandibular joint may assist in the diagnosis Stereoscopic Radiography
of joint clicks or crepitus. This is used in detailed examination of fractures.
Diagnostic Local Anesthesia CT Scan
Dental pain particularly due to pulpitis is difficult It is useful in the detection of oral cancers, fractures,
to localize. The patient may not even be aware from maxillary sinusitis of dental origin. In order to distin-
which jaw the pain arises. Elimination of pain by guish maxillary sinusitis and sinusitis secondary to
nerve blocks helps to localize the correct jaws. dental infection, a properly angled periapical
Infiltration can be used to localize the particular radiographs along with panoramic view will give
causative tooth. definite idea regarding any sinus lesions like mucosal
Temperature of an accessible facial swelling can hyperplasia, mucosal build up in the sinus floor or
be gauged by placing the back of the operator’s complete opacification. This can be confirmed by a
ungloved fingers on the swelling. corresponding CT scan. The resolution should be
confirmed with a follow-up radiograph or a CT scan.
RADIOGRAPHY The increased use of digital CT imaging is of great
value in the diagnosis and follow-up of maxillary
Bite Wing Radiograph
sinusitis of dental origin.
This helps to assess the crowns of teeth, inter-
proximal caries, restorations, alveolar bone height, Soft Probes
over hanging margins of restorations and height of These are endodontic silver points or gutta percha
pulp chambers. that may be inserted along sinuses and viewed
714 Section 19: Examination of Oral Mucosa and Teeth (Dental Examination)
radiographically. In a similar way, needles can be Fine needle aspiration cytology: Lymph node
inserted into tissue to localize a foreign body. FNAC and FNAB can be done if malignancy is
suspected and if it cannot be subjected to open
INVESTIGATIVE PROCEDURES IN ORAL biopsy.
MUCOSAL DISEASE
Main Indications of Biopsy
Procedures Lesions that have neoplastic or premalignant
potential. Lesions not responding to treatment or
Biopsy
progressing despite treatment like leukoplakia and
If a vesiculobullous disorder is suspected, mucosal erythroplakia. Persistent lesions failing to respond
biopsies should be submitted for histopathological to treatment like ulcers or radiolucent and radio-
and direct immunofluorescence examinations. opaque bone lesions. Persistent lesions of uncertain
Excisional biopsy: Biopsies can be excisional if etiology of soft or hard tissue. Persistent focal
the lesions are smaller than 1 cm in diameter and lesions involving the gingiva or periodontium and
used when the clinician is fairly certain that the nonhealing extraction sites.
lesion is benign. Biopsy can be done to confirm clinical diagnosis.
Incisional biopsy: This is applicable if the lesion Hematological screening, hemoglobin, red cell
is large and there is suspicion of malignancy. This and white cell indices: Essential to exclude
is contraindicated in pigmented and vascular lesions. systemic causes of oral diseases especially in case
of ulcers, glossitis or angular stomatitis.
Part–II: Specialties
Tissue breakdown products like hydroxyproline, necrosis factor or oxidative stress markers can be
pyridinoline, collagen telopeptides, osteocalcin, and assessed.
osteonectin. Cytogenetic aberrations can be used as markers
This is especially important because recent for assessing the risk of development of oral
studies have shown that periodontal disease is a risk cancer.
factor for many systemic diseases like coronary Recently, in addition to visual and tactile
artery disease, atherosclerosis, myocardial infarction, examination, bitewing radiographs, and fiberoptic
preterm low birth weight infants, pneumonia and transillumination, other technologies have been
poor glycemic control of diabetes. introduced to diagnose early stages of carious
Biochemical markers for dental caries such as lesions. These include electrical conductance
nitric oxide and its metabolites, IgA and micro- measurements, multiphoton imaging, ultrasound and
biological analysis for the presence of Strepto- quantitative fluorescence analysis.
coccus mutans, lactobacilli and actinomycetes Thermovision technique is an efficient tool for
species can be performed for assessing the risk and the diagnosis of physiological state and acute and
presence of dental caries. chronic pathology of mucus membrane of the oral
Biochemical markers for oral mucus membrane cavity. Both, physiological and pathological states
diseases like lichen planus, specific antigens in are characterized by significant differences in
stratum granulosum and stratum spinosum, tumor temperature distribution.
Part–II: Specialties
SECTION
20
Statistics and Clinical
Epidemiology, Research
Methodology for the Beginner
and Community Medicine
CHAPTER
56
1 Introduction to Statistics and
Clinical Epidemiology–I
V Raman Kutty
Basic epidemiology for the clinician, Elements of statistics, Approaches to statistical inference, Testing of
hypothesis, Interpretation of screening tests, Evidence based medicine
0-1 (0%–100%). In the previous example of stroke, both groups are the same, we would expect the ratio
the cumulative incidence will be 0.0005 or 0.05% of risks to be unity (or 1). Any ratio where the group
in one year, in whatever way it is measured. with the characteristic— often called the ‘exposed’
group—has a higher risk in comparison to the group
Prevalence Proportion without the characteristic—the ‘unexposed’ group—
Prevalence proportion indicates the proportion of will be higher than one. This ratio is called the
people who are sick at one point of time, compared ‘relative risk’, or ‘risk ratio’, and is often shortened
to the whole population. This can also vary from none to RR. This ratio can be lower than one if the
to all, or in other words, from 0 to 1. In estimating ‘exposed’ group has a lower risk, as when the
prevalence, we do not take the time element into exposure is protective, like a vaccine.
consideration—it is like a still photograph of a Among the measures of disease frequency,
sportsman which freezes the action. From the incidence measures give an indication of the force
photograph, we are not able to gauge the strength of attack of a disease—how fast it is spreading in
or speed of the action. A disease can spread so fast the population. Hence, studies reporting incidence
as to kill almost every body in a community, and rates are important in prioritizing intervention
thus, leave a low prevalence. Diseases which neither programs. Prevalence measures give us an idea
get cured nor lead to fatalities can have a high about the burden of disease at any moment of time,
prevalence. Low back pain and chronic headache and are important in planning services. Relative
would be examples. Thus, prevalence is dependant risk measures associated with an exposure indicate
on the rate of occurrence as well as the duration. how important the exposure could be as a causative
Part–II: Specialties
Risk and Its Assessment factor in the disease. This is especially important in
chronic diseases which have many potential risk
Much of medical research is concerned with ‘risk’ factors.
and its assessment. Risk simply means the chance—
or the probability—of an event happening to a Odds Ratio
person. In medical research, this event can be
‘Odds’ is a concept related to probability, and
occurrence of disease, occurrence of complications,
therefore to risk. If ‘p’ is the probability of an event
death, recovery or hospitalization. Risk is usually
occurring, then it follows that the probability of the
estimated by the incidence proportion—the incidence
event not occurring must be 1-p. The ratio p/ (1-p) is
proportion of disease in a group of people is a
called the ‘odds’ of the event. The probability of a
measure of the group’s average risk for the disease
fair coin turning up heads is ½, so the odds of the
for the relevant time interval. Note that risk is
event is (0.5/0.5) = 1.
always expressed with reference to a group, and a
period of time. Thus, when we talk about the annual We have learnt earlier that the relative risk, or
risk of tuberculosis among smokers, the lifetime risk the ratio of risks, can be expressed as:
of lung cancer in men, or the five year risk of breast Probability of the event in exposed
cancer in women over the age of thirty, it would be
Probability of the event in unexposed
equivalent to what the incidence proportion of
the disease would be in a group with similar Similarly, the odds ratio can be calculated as:
characteristics observed for the relevant period of
time. Prob (event) in exposed/1-Prob (event)
Often we are interested in how much higher the in exposed
risk of disease is in a group with a certain Prob (event) in unexposed/1-Prob (event)
characteristic, when compared to one without the
in unexposed
characteristic. Thus, when we ask the question, ‘Is
the risk of breast cancer higher in obese as compared Odds ratios are often reported in medical
to nonobese women?’ we are making a comparison literature. This is mainly because the odds ratio is
of risk in two groups, i.e. obese and nonobese practically the same as the risk ratio when the event
women. If the risks—or incidence proportions—in under scrutiny has a small probability, as most
Chapter 56: Introduction to Statistics and Clinical Epidemiology–I 721
medical events have. So whenever the literature a 10% chance of being selected in the sample, or,
discusses odds ratios, we can take them to be the in other words, the probability of selection of each
equivalent of risk ratios. Thus, when an odds ratio, of the elements of the universe in the sample is 0.1.
shortened as OR, for an event is higher than 1 in a Other methods of probability sampling are
group with a certain characteristic, it means that the systematic sampling, stratified random sampling,
group has a higher risk of getting the event when and cluster sampling. The advantage of probability
compared to a group without the characteristic. sampling is that it helps us to make a reliable and
valid inference about the population from the
ELEMENTS OF STATISTICS sample.
Measurements can be made with varying
Measures of Expectation or Averages degrees of precision. The characteristics which we
Most investigations measure or estimate some quantity measure are sometimes called ‘variables’ since they
or other. This may be subjects’ height or weight, or it vary in value from one subject to the next.
may be some biochemical value such as fasting blood In some instances, the attribute or the characteristic
sugar, serum low density lipoprotein cholesterol which we want to measure can only be put in
(LDLC), or uric acid. Often the measurement made categories. Patients can be either male or female.
is of an event such as the incidence rate of cataract Subjects may have a disease or do not have it. Such
in people over the age of fifty years. The investigator types of variables are called ‘categorical’. Often
wants to know about this measure in a large group we can rank subjects on the basis of the presence of
of people. This group is generally called the the attribute—pregnant women can be in the
Part–II: Specialties
‘population’ or the ‘universe’. The population or the I, II, or III trimester of pregnancy. Complications from
universe consists of all the individuals or units about a disease can be ranked as life threatening, serious,
whom we want to make an inference. In a study and minor. Such variables, where there is an implicit
about malnutrition in women in a particular village, ranking, are called ‘ordinal’. There are some
the universe or the population for the study consists attributes where the measurement can be made with
of all the women in the village. In a study about the any degree of accuracy. Height can be measured in
efficacy of streptokinase in coronary heart disease centimeters, millimeters, or in fraction of these.
among patients admitted to a particular hospital, Glucose level in blood can be measured in
the universe consists of all such patients. But in most milligrams or even in finer units. These are called
cases, the investigator is not able to study all the ‘continuous’ variables.
individuals in the universe. He or she has to select When the investigator makes measurements or
a ‘sample’ or a small group from among the universe estimations on a number of subjects in a group or
or population. The study is limited to this sample, sample, he or she often has to summarize the
but the inferences are made about the whole observations for communication, because it is
population. cumbersome to represent each and every measurement
The process of selecting a sample is called in a concise article or paper. Summarization of
sampling. In most scientific studies, some form of categorical variables is easy because they can be
probability sampling is employed. Probability represented as a table of categories with counts of
sampling is a method where we can compute the subjects in each category, with each attribute
exact probability of each individual in the population properly labeled. Ordinal variables can also be so
being selected in the sample. The most common represented. In the case of continuous variables, we
technique of probability sampling is simple random often employ some summary value which represents
sampling. This means that the sample is drawn using the group which is measured. This summary value
some method which generates random numbers, such is dependent on the frequencies of occurrence of
as using a random number table or using a computer various values in the group. Since the value should
program. This does not mean that the sample is represent the group, this is often some sort of an
drawn haphazardly. Suppose from a population of average value which is the ‘expectation’ for that
one hundred, a ten percent sample is drawn attribute in that group. Often the most commonly
randomly. Here each element in the population has occurring value is used—this is the ‘mode’.
722 Section 20: Statistics and Clinical Epidemiology, Research Methodology
Sometimes the central value of the one which divides of 1000 men in a factory, estimated from a sample
the group into two equal halves if they are ranked of 100, can be 165 centimeters (95% confidence
from the lowest to highest—is used. This is called interval, 160–170). In another example, the
the ‘median’. The most commonly used measure of estimated prevalence of coronary heart disease in a
summarization is the arithmetical average—adding district, computed from a random sample of 1500
up all the values and dividing by the total number adults, is 35/1000 (90% confidence limits 32, 38).
of subjects. The measure we employ in this case is The first statement implies that we can say with
called the ‘mean’. 95% confidence that the true mean height of the
The mean, mode or median gives us one value 1000 men in the factory, the parameter that we set
which represents the group. But this alone does not out to estimate, lies within the interval 160–170.
summarize the measurements in the group. Groups There is a 5% chance that the true mean height is
may be very different with respect to the variation not within these numbers. Similarly we are 90%
within them. An estimate of the variability within sure that the true mean prevalence of coronary
the group is given by a measure called ‘variance’. disease in the district is within 32 to 38 per thousand.
We get the variance by taking the difference of each Confidence estimates may be generated around
individual value from the mean, squaring it, adding incidence rates, prevalence values, odds ratios or
the squared values together, and taking their any estimate of a population parameter from a
average—the average of the squared differences. randomly drawn sample.
Often, a measure called ‘standard deviation’ is
employed instead of the variance. This is simply Testing of Hypothesis
Part–II: Specialties
the square root of the variance. Confidence intervals constitute one type of statistical
Why do we want measures such as the mean statements. There is a tendency for more and more
and the standard deviation? journals to insist on reporting of confidence limits
One major reason is to describe the group with in papers submitted to them. There is another format
respect to the characteristic (descriptive statistics). for statistical inference which used to be much more
Men and women, as well as people of different widely used, and is still quite popular. This is called
nationalities, vary with respect to their height; this ‘hypothesis testing’. A hypothesis is a statement
can be represented as the mean heights and standard about a characteristic or relationship in the
deviations in each group. This makes the comparison population of interest which the researcher wants
of groups easy. Another important reason arises to explore.
when we take a small sample from a large population Research hypotheses are stated as ‘null
in order to study the characteristics of the population hypotheses’. The researcher puts it in a negative
—since we are not able to study every individual in way, though it may not actually be so stated in the
the population, we have to make inferences about article. A physician wants to see if routine use of a
the population from the sample (statistical inference). new anti-inflammatory agent X, reduces pain in
The mean and standard deviation help us to do that. the joints. He has a research question, “Does the
Depending upon certain assumptions about the use of drug X in a dose of 500 milligrams three
distribution of values in the universe or population, times daily for five days relieve joint pain in 50%
(which we will not go into here), and using the mean of sufferers of severe rheumatoid arthritis?” This
and the standard deviation of the sample, the process question is reformulated by the researcher as a null
of statistical inference helps us to make some hypothesis: “Use of drug X in a dose of 500
statements about the population characteristics. milligrams 3 times daily for 5 days, does not reduce
joint pain in 50% of sufferers of severe rheumatoid
APPROACHES TO STATISTICAL INFERENCE arthritis”. Note that research questions, as well as
null hypotheses, are precisely stated and very
Confidence Intervals specific as to the population (sufferers of severe
Very often in the literature, we come across an rheumatoid arthritis), intervention (drug X in a
estimate, with a 95% or 90% confidence interval or dose of 500 mg 3 times daily for 5 days), and the
confidence limits given alongside. The mean height estimate of the effect (50% reduction in pain).
Chapter 56: Introduction to Statistics and Clinical Epidemiology–I 723
Part–II: Specialties
2. Set up the null hypothesis
Why is the prisoner presumed innocent/null 3. Decide the alpha error rate
hypothesis presumed to be true? 4. Look at the data
There are two types of mistakes the judge can 5. Use appropriate statistical tests
make: 6. Conclude whether Ho is to be rejected or not.
1. Concluding that the prisoner is guilty when in Statistical “significance” though we have fixed
fact he is innocent an alpha error rate before we embark on statistical
2. Concluding that the prisoner is innocent when testing, the procedure gives us a ‘p’ value or probability
he is in fact, guilty. of having committed an alpha error. This tells us
“Even if a thousand guilty persons go free, not whether the data support the null hypothesis or not.
even a single innocent person should be punished”. P<0.05 (or any other predetermined level) means:
Type 1 mistake is the more serious one. We want 1. We reject Ho, but there is a 0.05 chance that we
to avoid it at all costs. Similarly, in research, are making a mistake (alpha error).
rejecting a true null hypothesis is considered a more 2. If the null hypothesis (that there is no difference)
serious error than not rejecting a false null were true, the probability of observing these data
hypothesis. would be as low as this—hence the null hypothesis
is unlikely to be true.
Conclusion from Trial The term “statistical significance” is to be
treated strictly as a technical term, meaning that
Actual situation
the data showed a “p” value below the predetermined
Guilty Not guilty alpha error rate. This is to be distinguished from
Guilty Punishment to the Innocent person actual or clinical significance, which is a measure
accused—correct convicted more
decision serious error of the importance of a finding in practice or real life.
Not guilty Guilty person let Accused person In fact, it is advisable to avoid the term “significance”
free—less serious set free—correct except in the technical, statistical sense. Often
error decision
statistically significant results are of the least
724 Section 20: Statistics and Clinical Epidemiology, Research Methodology
importance in life (except if you are looking for a Test c = false d = true c + d = all who
publication!), and sometimes findings of great negative negative, negative tested
(test negative
clinical portent may turn out to be statistically not negative
significant (we should not say ‘statistically but having
insignificant’, by the way) because there were not disease)
enough number of subjects in the study. a + c = all b + d= all a+b+c+d=
with without all who were
Beta error rate is the chance of not rejecting a disease disease tested
Ho which is actually not true (which means you are
unable to detect a true difference using this test, Prevalence of disease = a + c/(a + b + c + d)
which in some way relates to the capability of the ‘sensitivity’ of a test refers to the ability of the test
test procedure). If this chance is very high, that to identify true disease—out of 100 persons with
means the capability of the test is very low. Hence disease, how many would be correctly classified
(1-Beta) is called the Power of the Test. by the test as having disease? It can be seen that it
is estimated by (a/a+c). Similarly, specificity is the
INTERPRETATION OF SCREENING TESTS ability of the test to identify truly those without
In the course of clinical practice, we are called upon disease—out of 100 persons without disease, how
to do and interpret a number of laboratory and other many would be correctly classified as not having
tests. Sometimes tests are used to ‘screen’ for a rare disease? This is estimated by (d/b+d). A test has
disease, i.e. to find out how many of the screened two additional characteristics—the positive
people are highly likely to have the disease. This is predictive value and negative predictive value.
Part–II: Specialties
especially true of cancer, cardiovascular disease Positive predictive value (a/a+b) indicates what
such as coronary disease, hypertension, HIV status, proportion of those testing positive will be truly
and many other chronic conditions. Screening helps positive; negative predictive value (d/c+d), in a
clinicians to identify early cases and institute similar vein, indicates the proportion of truly
treatment, thereby avoiding serious consequences negative subjects out of those testing negative.
later. Usually, a screening test is a less costly test Sensitivity and specificity are attributes of the test;
which indicates which subjects are likely to have positive and negative predictive values depend
the disease, so that they can be investigated in full. also on the prevalence of disease. In other words,
However, when we apply a screening test, or positive predictive value of a test is a characteristic
any laboratory test to a person, there is the likelihood of the test as applied to a population; it changes if
of one of two types of mistakes happening: the same test is applied to another population. For
a. A person without the disease may be labeled by example, if we apply a test with 99% sensitivity
the test as having disease—this is called ‘false and 99% specificity to a population where the
positive’ prevalence of disease is 1per thousand (0.1%), then
b. A person with the disease may be missed by the the positive predictive value is only around 9%; or
test—this is called ‘false negative’. in other words, around 91 people out of every 100
who tested positive will be false positives. When
This is demonstrated by the following diagram:
the same test is applied to a population where the
Test status Disease status
prevalence is as high as 10%, the positive predictive
(inference (true state of affairs) value shoots up to 91% (This can be checked by
from the test) putting in some hypothetical numbers in the table).
Having Not having
disease disease Likelihood Ratios
Test a = true b = false a + b = all who Before we do a laboratory or screening test on a
positive positive positive tested positive
(test positive patient, we have an idea of the probability of disease
without in the person, which is formed from history taking
having and our previous knowledge about the occurrence
disease)
of disease in similar patients. For example, when a
Contd... forty-five year old male comes to the casualty with
Chapter 56: Introduction to Statistics and Clinical Epidemiology–I 725
complaint of chest pain, the index of suspicion for EVIDENCE BASED MEDICINE
myocardial infarction will be high. When we do a
laboratory test, this is to confirm or reject our Medicine is an ever changing science. What was
provisional diagnosis. This can be formally captured accepted practice yesterday is often questioned
using epidemiological principles. Our notion about today, and what is the gospel truth today, would be
the chance of disease in the person before doing the subject to scrutiny tomorrow. Hence, the practitioner
test can be represented by the ‘prior odds of disease’, is often at a loss to understand, evaluate and digest
which is (Probability of having disease/1- the trends at the pace at which they occur. Ideally, a
probability of having disease) in the person. The doctor should undertake only such diagnostic and
probability of disease in any person can, for therapeutic procedures as have been shown to be
convenience, be equated to the prevalence of the efficacious. This is because administering an
condition in the population from which he comes. unproven drug or intervention would put the patient
Thus in India, where roughly around 10% of adults to unnecessary risk. However, many drugs are
may be expected to be diabetics, the ‘prior odds of introduced in the market with claims to high levels
diabetes’ in a random adult patient will be = (0.1/ of efficacy. Doctors sometimes find it difficult to
0.9) = 0.11. When we do a screening or lab test on evaluate the weight of evidence in favor, or against
a patient, we can apply a value called the ‘likelihood such claims. In modern times, the volume of
ratio of a positive test’ to these prior odds to get information that is available to the practicing
what is known as the ‘posterior odds of disease’. physician has increased exponentially, so much so
The likelihood ratio of a positive test is given by that one finds it difficult to deal with it. It then
Part–II: Specialties
the formula, (sensitivity/1- specificity). Thus, if an becomes imperative to have yardsticks for deciding
Indian community is screened for diabetes with a which articles should be trusted more with respect
test (finger prick test) with a sensitivity of 95% and to their findings. In this quest, knowledge of research
specificity of 80%, and a subject turns out positive, design and epidemiology plays an important part.
then the posterior odds of diabetes = prior odds × The concept of ‘evidence based medicine’ has
likelihood ratio = 0.11 × (0.95/0.20) = 0.52. From gained popularity in recent years. It is an approach
this, we can calculate the posterior probability that tries to instill in clinicians a healthy skepticism
as (posterior probability = [posterior odds/1+ about clinical practice, and arm them with tools to
posterior odds]) = 0.34, or 34%. Thus before testing, examine the evidence in favor of new, as well as
we thought the individual had a 10% chance of old, therapeutic and diagnostic interventions.
having the disease; if the test turns positive, we
A doctor learns the elements of her practice from
revise our estimate of his chance of having diabetes
her teachers, textbooks, and from her seniors and
as more than three times our original estimate. The
same thing applies if the test turns negative also; colleagues in the wards. As she graduates and starts
but in this case, we use the ‘likelihood ratio for a to practice, she depends on her own experience. She
negative test’ as a multiplier. This ratio is given by adds to this what she learns from continuing
the formula (1-sensitivity)/specificity. In this education programs, and articles in medical
particular case, if the test turns out negative, journals. It is important to develop a critical faculty
multiplying the prior odds of having diabetes, 0.11, for ranking these inputs in the order of their
by the likelihood ratio of a negative test, ((1–0.95)/ credibility.
0.80), we get 0.062 as the posterior odds of not Even though what we learn as students remain
having diabetes, which translates into a probability important, it is crucial to subject them to scrutiny
of less than 1%. In the beginning, our estimate of very often. A mode of examination, a diagnostic test,
the chance of the patient having the disease was a therapeutic intervention may go out of vogue,
around one in ten; after we get the test as negative, because newer methods have been discovered.
we revise our estimate to less than one in a hundred. Should we continue to hold on to the old method, or
The sensitivity and specificity of a test as well as should we abandon those and whole heartedly
the prior probability of disease (prior odds) play a accept what is new? As extreme cases, we all know
large part in determining the interpretation of both of people who never give up the ways they learnt as
positive and negative tests. students, and continue to practice medicine exactly
726 Section 20: Statistics and Clinical Epidemiology, Research Methodology
the same way for fifty years; and those who jump from pain. The greatest weight of evidence is
on to any new bandwagon without critically given to experimental studies, where the
examining whether it benefits the patient. Both are investigator manipulates the conditions so that
bad role models. How shall we sift the evidence? one group receives the intervention of interest
Most new therapeutic and diagnostic approaches and the other doesn’t, and the outcomes are
and drugs claim to be supported by ‘scientific’ compared.
studies. We should examine how scientific are 3. What is the size of the effect reported? Statistical
the studies that support these claims. Anything significance alone should not be taken as the
which has not been published in a medical journal criterion to judge any finding. Sometimes a tiny
does not merit a second look at all. Even among effect can attain statistical significance, but it may
published articles, make sure that these have come not be important clinically. Size of the effect can
out in peer reviewed and indexed journals. How be the proportion of people cured, the degree of
does one know if a journal is peer reviewed and pain relief, or any measurable outcome.
indexed? Fortunately, it has become rather easy, 4. Who were the subjects in the study? Was
since most peer-reviewed and indexed journals are there enough numbers, or was it a small study
abstracted by services such as Medline and Embase. involving only a few subjects? Did the subjects
So any journal which does not find its place in include men, women and children? Are the
Medline (the online medical literature data base subjects comparable in their ethnicity, habits and
available free of cost on the internet, courtesy the social and economic situation to the patients you
National Library of Medicine, USA) should be want to treat, or should they be treated as a special
Part–II: Specialties
intervention is decided randomly. This controls for 2. Search the literature for all studies fulfilling the
the effect of other variables in influencing the criteria. This is usually done by computer,
interpretation, by balancing the distribution of these augmented by other methods.
attributes in the two groups equally. The RCT 3. Use statistical norms to give weight to findings
further reduces error by masking (earlier term= from each study. These may be sample size
‘blinding’) the subjects as well as the investigator, (number of subjects studied), the rigour of
so that comparisons are not influenced by personal exclusion and inclusion of subjects, comparability
beliefs. Thus, the RCT becomes the ‘gold standard’ of techniques used for measurement, and effect
for the ideal study. However, it is not practical size reported.
to do RCTs for every research question, because 4. Combine results from all the studies statistically,
most of these involve harmful exposures, and it is so that the reviewer can report one main
unethical to expose human subjects to such conclusion which incorporates evidence from all
exposures. So we have to resort to ‘observational the studies.
designs’, where either an unexposed group is
Though the technique appears neat and
compared to one or more exposed groups with
appealing it has its own pit falls. For one, the search
respect to the outcomes (cohort design), or a group
for reported studies may not yield comprehensive
with outcome is compared to group without outcome
results, due to many reasons. Many a time, yield of
with respect to levels of exposure (case-control
a computer search depends on the search engine,
design).
the terms used and the skill of the person doing the
When we look for evidence of association
search. Moreover, ‘publication bias’ may bedevil
Part–II: Specialties
between an outcome and an exposure (is physical
many searches. Most medical journals favor papers
exercise associated with protection from heart
reporting positive results, i.e. those reporting that
disease?), we may find many articles which may
any new drug or procedure is efficacious, and they
give inconsistent, or even conflicting answers.
tend not to publish articles saying that these are not
There is a hierarchy of evidence which helps us to
efficacious. Hence, a search of the published
decide how much importance we should give to each
literature tends to yield many more papers reporting
of these studies. Based on design considerations,
positive results than negative results.
we give the place of honour to RCTs—so if we can
find a study where subjects have been randomized Though we want the meta-analysis to be very
into two groups, one of whom has been intensively objective, we can hardly avoid an element of
pursued to take up physical exercise and have done subjectivity. This is because the analyst sets the
so, and compared heart disease among these two criteria for selection of studies into the analysis,
groups, this study will get the highest consideration. and these can often be very subjective. One great
Other observational studies—cohort and case advantage of meta-analysis, however, is that it is
control— may get less importance. There may also able often to report an effect size which combines
be several RCTs reporting on the same association, those from smaller studies, and this would be
with varying results—in this case, we have a way equivalent to doing one study with subjects from
of combining information from all the studies to all the studies participating in it.
come up with one final answer. This statistical The Cochrane collaboration is a foundation
technique is called ‘meta-analysis’; it is given the setup exclusively to promote evidence based
highest position in the ‘evidence pyramid’. A meta- medicine. It is based in the UK, with sister
analysis usually goes through the following steps: foundations in many other countries. It was founded
1. Set down the criteria for accepting a reported by Archie Cochrane, who supported the cause of
study as part of the meta-analysis. Here, the randomized control trials to answer questions of
journal of publication, the methodology, the therapeutic efficacy. They have compiled a database
techniques of measurement, and the subjects of of all available RCTs to answer various therapeutic
study may all be criteria for acceptability. questions.
CHAPTER
57
1 Research Methodology
for the Beginner
V Raman Kutty
has been demonstrated in some other population Apart from journals another important source
may need to be done in the local population for of information about current state of knowledge in
confirmation. Thus, reading the medical literature any field is the textbook. Textbooks contain
enables you to build up the background for your authentic information, though they could be
research and answer the question ‘why is this outdated, compared to journals. Some textbooks are
research important?’ also available through the worldwide web.
Medical literature is available in many forms. Dissertations and unpublished student work is
Most commonly, there are textbooks and journals. another source of information on any topic, but they
Journals are now a days divided into categories are more difficult to access because they are not
depending on their importance. Each scientific journal listed systematically and available to everyone.
carries an ‘impact factor’—a number which indicates
the impact that any article in that journal will have Preparing for Your Research—Writing
up a Proposal
among the medical readers. This reflects the
credibility of the journal and is calculated taking into Having decided your research question and scanned
account many attributes such as the nature of the the literature, you need to prepare a research
journal, the number of articles submitted to it, the proposal. This is needed if you want to apply to any
review process, the areas of coverage and many other external funding agency for support, as well as for
factors. The higher the impact factor, the greater the most internal review committees. The research
weight to be attached to any article published in the proposal or ‘protocol’ as it is sometimes called—
journal. Among medical journals, there are journals usually has several parts. It is easily remembered
Part–II: Specialties
for the general medical reader, such as the Lancet by thinking ‘why-what-how-in what time-at what
and the New England Journal of Medicine which cost’.
publish articles that are of interest to most medical
readers. They generally have a higher impact Introduction
compared to the specialty journals, which cater to a This covers the background for your study and
narrower breed of readers within each specialty. justifies the need for it, based on current medical
Currently many journals are accessible on the literature on the subject. In other words, it covers
worldwide web; however, many of them are freely ‘why’ you want to do an ‘what’ you want to do.
available only to those who are subscribers. Some
institutional libraries provide access to members of Objectives
the institution to journal websites. However, This section sets out the research question, and the
abstracts (short summaries) of all articles published specific objectives coming out of it, in measurable
in journals are collected and published by indexing terms; ‘what’ you are trying to achieve.
databases such as the Index Medicus, whose
electronic, online version is called ‘Medline’. Methods
Medline is made available to the public through This section covers ‘how’ you are going to do
Pubmed, a service of the National Library of your research. It should have information on the
Medicine in the US. If we search Pubmed, we will number of subjects, details of the design of the study,
know what articles have been published in any how the information will be collected (through
indexed and peer reviewed journal in the subject in questionnaire, laboratory tests, other methods), and
recent years. We can collect the abstracts which are how you would later analyze your data.
of interest to us, and read them to know what
research by other people have come up with. Index Time Frame and Budget
Medicus is not the only medical indexing database; Each proposal should be accompanied by a plan
there are many, some of which specialize in certain detailing the expected time for each of the activities
types of journals, including Excerpta Medica. Most under it and the total time for the project to be
of these, with the exception of Pubmed, however, completed. The budget should include all the
do not come free of charge. expected costs, including salaries, consumables,
730 Section 20: Statistics and Clinical Epidemiology, Research Methodology
travel costs, equipment costs, including costs for or prevent the outcome under study. Exposures are
data analysis and writing up of the report. also called risk factors.
Apart from the above, each proposal should also Before starting the research and as you develop
mention the ethical considerations of the particular the proposal, consult a statistician or epidemiologist
research. There is an increasing awareness of the for advice on issues such as design, sample size,
need to promote ethical research and to protect the and use of computer programs. Going to them after
rights of the subjects at all times. All proposals collection of data may not be of much use.
usually go before an institutional ethical committee
or review board (IRB); it scrutinizes the proposal Data Analysis and Report Writing
to see whether there is any potential harm to the Information which helps you to arrive at an answer
subjects and whether they have been protected from to your research question is called data. This is
it, what are the benefits accruing to them from the collected through questionnaires, or from laboratory
research, and whether their confidentiality would investigation results, or observations. Usually this
be maintained. It is the onus of the researcher to is collected in a structured format, with all important
convince the review board on all these points. details collected from each individual subject in the
study using a ‘proforma’ or protocol. This protocol
RESEARCH METHODS FOR PHYSICIANS should be discussed with your co-workers and
Research in medicine and health usually employs one submitted along with the research proposal; after
of the three broad general approaches—the clinical, approval by the funding agency and review board,
laboratory, and field research. The general principles it is tested (pilot testing) on a small sample of
Part–II: Specialties
of research design, defining the universe of the subjects before finalizing. This helps to bring out
research (the group of people your research findings any obvious mistakes or omissions. Data collected
would apply to), picking the sample, analysis and in protocols, from all subjects, needs to be entered
communication of the results would be broadly into the computer before analysis.
similar; the setting for the research, however, would Many computer programs help in entering,
vary in the three different types of approaches. storing, correcting and analyzing data. It is very
Clinical research is done on patients or potential helpful to pick the program even as you start the
patients in a hospital setting. Field research involves research; in this way, data can be entered as it is
going to the community to identify your subjects; very collected. A simple spreadsheet such as Excel would
often the subjects may also be healthy individuals suffice to enter data for most studies. Epi-Info is a
rather than patients. Laboratory research is done with free program which can be obtained from CDC
either material collected from patients (such as blood Atlanta website which also helps in epidemiological
or tissue- in vitro studies), or involves experiments data entry and analysis. If you plan to do very
done on animals (in vivo studies). Both clinical sophisticated analysis, perhaps data should be
research and field research can be experimental— entered in advanced software; the catch here is that
when an intervention is introduced in one group of such programs are usually extremely expensive,
subjects deliberately by the researcher and compared precluding individuals from buying and using them.
with another group which does not receive the There are, however, freely available programs of
intervention, or observational—when the researcher comparable power and sophistication, such as “R”;
only collects information and follows up both groups this program needs a lot of familiarization before one
to compare them. It can be descriptive when the can easily use it.
objective of the research is only to describe a The advantage of many programs is that you
phenomenon in detail—as in case studies or can reproduce the proforma or protocol on the
surveys—or analytical when we try to find computer, so that as you open the data base, the
associations between outcomes and ‘exposures’. An computer prompts you with the same questions in
exposure can be any attribute such as a behavior like the same order as in the questionnaire; you only
smoking or drinking, an ethnic identity or nationality, have to type in the answers from the completed
gender, age group, environmental exposures, or any forms. It is useful to decide on numerical codes for
characteristic which the researcher thinks might cause most answers before you enter them, as it facilitates
Chapter 57: Research Methodology for the Beginner 731
analysis. Analysis software also helps you to put in important rows such as the header row, but never
checks on data entry, which reduces the number of use vertical grid lines.
errors. Ideally, after data entry, it should be checked The writing of the research report should follow
randomly for wrong entry by another person. The the pattern set in the research proposal: introduction,
investigator herself can do logical checks, such as objectives, methods, results, discussion, conclusions,
looking for unlikely or illogical entries in age or acknowledgments, appendices. Introduction
sex or other characteristics. In case such entries contains the brief review of literature and presents
surface, the original protocol should be verified for the case for doing the study. Next come the specific
mistakes in data entry. objectives for the current study, followed by the
methods section. The methods should cover the
Data Presentation and Reporting population in which the study is undertaken, the
After data entry and cleaning of data, they should method of selecting the sample, the number of
be examined for their distribution and patterns. subjects in the sample, inclusion and exclusion
This is called data description, and suggests clues criteria for selection, design of the study, instruments
about what further analysis to do. It may point to used for extracting information, including study
questionnaire or laboratory methods and how they
possible associations between variables and the
were developed and validated. All tables and charts,
outcome—these are to be further confirmed by
and any other relevant findings from the study, are
analysis. It may bring up unusual values for some
included in the results section. Discussion of the
characteristics in some individuals—‘outliers’ or
results should be done in the light of the earlier
strange data. These should then be checked to see
Part–II: Specialties
studies, and any limitation of the study that the
whether these are genuine values, or have come
author is aware of should be mentioned here. The
about as a result of mistaken data entry. Sometimes
last section should set out the salient conclusions
outliers are discarded from further analysis.
from the study.
We generally use various types of charts to
References should be given in the correct format.
describe data distribution—the commonest are
Generally, medical articles follow the Vancouver
histograms, bar charts, line diagrams and pie
style, otherwise known as the ‘uniform pattern for
diagrams. In reporting findings of a study, we biomedical journals’. Here whenever a previously
should neither underplay nor exaggerate; use plain, published work is quoted or referred to in the text
2 dimensional charts with clear labeling. of the research report, it is acknowledged by a
Relationships between two attributes in subjects number. This number is generally given as a
are usually brought out by cross tabulation—these superscript and follows the order in which the
are presented as tables. Tables should always have references appear, the first reference given the
a header which indicates the table number in Arabic number 1, the next number 2 and so on. Each article
(never in Roman) numerals, and explains what is is numbered the first time it is referred to, and any
presented in the table. Both rows and columns further reference to it indicated by the same number.
should be clearly labeled, and if the source of At the end of the text, after the main body of the
information in the table is not from the data report, in the reference section, all the referred
collected by the researcher, the external source articles and books are listed in the order in which
should be clearly mentioned at the bottom of the they are referred to, indicated by their corresponding
table. All tables and charts in a research report number, with the name of the journal, year of
should be self-explanatory, which means that the publication, volume, and page numbers. Books, and
reader should not be forced to refer back to the chapters in books, also have a distinct citation style
text to find out what the table or chart is showing. (details are given on the website: Citing Medicine:
Tables should generally be devoid of all grid-lines; the NLM style guide for authors, editors and
you may use a few horizontal lines to set off publishers (www.ncbi.nlm.nih.gov)).
732 Section 20: Statistics and Clinical Epidemiology, Research Methodology
Fig. 57.1: Bar chart showing birth weight proportions, Fig. 57.3: Birth weight categories in Jhagadia district,
Jhagadia district, Gujarat, 2004–2008 Gujarat, 2004-2008
(Source: SEWA-Rural Hospital, Gujarat) (Source: SEWA-Rural Hospital, Gujarat)
CHAPTER
58
1 Community Medicine
V Raman Kutty
Community health, Health status of community, Millennium development goals, National Health Policy
(2002), Role of doctor in health care delivery, Primary health care, Role of a PHC doctor, Health information
system, Organization of clinical practice by a young doctor, Health Education
children below 5 years. 3 out of 4 people in the least Goal 3: Promote gender equality and empower
developed countries of the world die before the women.
age of fifty. Two million children die every year Goal 4: Reduce child mortality.
from diseases for which there are effective vaccines. Goal 5: Improve maternal health.
Most of these deaths occur in developing countries. Goal 6: Combat HIV/AIDS, malaria and other
Though there has been a great improvement diseases.
in health all over the world, the fruits of this Goal 7: Ensure environmental sustainability.
achievement are not equally distributed. The rich
Goal 8: Develop a global partnership for
countries have the greatest advantage. Technological development.
progress and economic development in those
We can see that the MDG’s are directly
countries have played a role in this. Food supply
has doubled in the past 40 years, and per capita concerned with health; while goals 4, 5 and 6 are
income globally has risen by 2.5 times in 50 years. specific health targets, others are contributory
Adult literacy has improved by 50% since 1970. factors. The maternal mortality, infant mortality and
underfive mortality targets to be achieved by India
There has been progress in most fronts including
by 2015 are: 109/100,000, 27/1000, and 41/1000
malnutrition and infectious diseases. The world has
live births respectively. Though considerable
succeeded in reducing or eradicating some of the
progress has been made, India has not achieved the
communicable diseases. Smallpox, dracunculosis
goals set for the country in the MDGs.
and poliomyelitis are among these. Malnutrition
has been controlled in large parts of the world. NATIONAL HEALTH POLICY (2002)
Part–II: Specialties
Part–II: Specialties
levels of health care. However, it sees the need for ROLE OF DOCTORS IN HEALTH
setting standards of infrastructure, equipment and CARE DELIVERY
training in the private sector and for monitoring
its performance through a system of accreditation. Any doctor working in a community should assess
The need for social health insurance to cover the its health status and health needs as an essential
poorest sections of the society, so that their spending prerequisite. The health problems may vary from
in the private sector can be subsidized, is also place to place and in different communities
envisaged. depending on the lifestyle and other characteristics.
Other areas of concern in the NHP are the cost Major contributing factors to the health problems
of drugs and their availability, including the impact in India are:
of globalization and the need for combating its 1. Communicable diseases.
adverse effects on the population, ethics and health 2. Malnutrition.
research, environmental and occupational health. 3. Inadequate sanitation.
Two of the most important policy initiatives to 4. Inadequate medical care.
follow from the NHP are the National Rural Health 5. Population explosion.
Mission, and the Health Insurance Scheme for the The Government of India has launched various
poor. The NRHM proposes to strengthen the rural national programs from time to time to tackle these
health care infrastructure in the country through problems.
providing enough resources in the public sector in The main national programs having a bearing
health. It provides funds for appointing doctors on the health are:
and other personnel, as well as for developing 1. Malaria eradication.
infrastructure and for consumables. It is envisaged 2. Filariasis control.
as a participatory program, with the local self- 3. Tuberculosis control.
governments (LSGs) playing an active part. Every 4. Leprosy eradication.
village is expected to form a village sanitation 5. Diarrheal disease control.
committee consisting of both health workers and 6. Sexually transmitted diseases (STDs) control.
representatives of the people, who will look after 7. Prevention of blindness and visual impairment.
public health issues in the village. The uniqueness 8. Control of iodine deficiency disorders.
of the NRHM is that it functions through female 9. Universal immunization.
736 Section 20: Statistics and Clinical Epidemiology, Research Methodology
10. Family welfare. and where service is available for the patient. The
11. Water supply and sanitation. doctor should also carefully keep the records of
12. Guinea worm eradication. the patient for further references.
13. Diabetes control. In India, primary health centers, or PHCs and
14. Control of acquired immuno-deficiency their subcenters form the first accessible health
syndrome (AIDS). care institution for the rural population. Only those
Most of these national programs are imple- needing higher level care are to be referred to
mented through the primary health centers (PHCs) larger hospitals. The orderly delivery of health care
whose medical officers are the key persons through this network of primary, secondary and
responsible for implementation. tertiary care centers along with preventive and
promotive activities is what is conceived as primary
PRIMARY HEALTH CARE health care. Primary health care, however, is not
The concept of primary health care (PHC) was limited to PHCs; it is delivered through a much
originally conceived at an international conference wider network including private general practitioners
at Alma Ata in the former Soviet Union in 1978. and private hospitals. Much of the work of the
Elements of the same idea was contained in the outpatient departments of major hospitals also
recommendations of the Bhore committee report involves elements of primary health care. Ideally,
which was published in 1946. Primary health care primary health care should incorporate the
was conceived as a strategy for achieving health principles of:
for all by 2000. The components incorporated in i. Continuity of care (the same physician sees the
Part–II: Specialties
defined geographical area. Subsequently several or doing research. Thus the quality of medical care
modifications have occurred. At present mini PHCs depends to a large extent on the quality of health
have also been established and therefore one PHC information. Information should be current,
serves a population of 30,000 only. The PHCs reliable, explicit, relevant, readily available, and
undertake comprehensive health care including in a form which could be used easily. Depending on
preventive, promotive and curative services. There the type of information needed, the sources vary.
is a subcenter for a population of 5000. For information on the health status of
communities, physicians can make use of the
ROLE OF A PHC DOCTOR following sources:
The medical officer is the leader of the health team. Mortality and Fertility Statistics
In addition to his clinical responsibilities he These include the crude death rate, the crude birth
has to perform other duties. He should have rate, the infant mortality rate, maternal mortality
communication skills to educate and motivate his rate, and the fertility indices. These are available
staff to do their jobs effectively. The medical officer from sources such as the census reports, the sample
of the PHC is responsible for all health related registration system of the Government of India,
events occurring in his area. This includes epidemi- and other publications of the ministry of health.
ological investigation and preventive action when
outbreaks of diseases occur. His skills should Morbidity and Utilization Statistics
include management of the six M’s viz. men, Morbidity refers to the level of sickness. Among
materials, machines, money, methods, and moments statistics relating to morbidity will be prevalence
Part–II: Specialties
(time). He could be conversant with the basic and incidence rates of various diseases, number
principle various health data available to him, and of work days lost due to disease. Utilization
for onward transmission. statistics refers to information on the use of the
The PHC doctor should have clinical skills health system by the people. Rates of hospitalization,
to impart curative services in a situation where people’s preference for various systems, and public
many laboratory tests and other sophisticated versus private hospitals estimates of money spent
investigations may not be available. He should refer on treating sickness, proportion of births in
patients in the right time to higher centers for hospitals, immunization coverage, all belong to this
further management. The doctor should realize the class of statistics. These are not routinely collected
limitations in imparting curative services in the rural in India. They may be available from various
set up. The vast majority of the health problems surveys. The National Sample Survey Organization
encountered in a primary health center can be and the National Council for Applied Economic
managed there itself if the doctor applies his skill Research (NCAER) are two organizations which
occassionally do such surveys.
and judgment effectively. He should establish
Practicing physicians may have much more
proper liason with hospitals where specialist care
need for information regarding current development
is available. Once the patient comes back from
in the understanding and management of diseases
these centers, the PHC doctor should continue further
in their speciality. For this they traditionally have
management and follow-up.
depended on a variety of sources such as journals
HEALTH INFORMATION SYSTEM and textbooks. Now they have a wider choice of
sources including the Internet. However, all sources
For the effective practice of medicine, a physician may not guarantee the same degree of authenticity
needs a continuous flow of information. The in the information they provide. The major such
organization and storage of health records should sources are:
begin with the primary care physician. He or she a. Continuing medical education programs: These
needs to be up to date on the latest developments have become very popular. The reliability of the
in the research front, especially the current information provided is dependent to a large
management of common diseases. For this the degree on the speaker. Hence it is worthwhile
physician has to depend on a variety of sources. checking the credentials of the person providing
Information is essential also for managing a hospital the information before accepting it.
738 Section 20: Statistics and Clinical Epidemiology, Research Methodology
b. Textbooks: Textbooks are generally a reliable Medline is available at several sites on the
source of information, as a fair amount of worldwide web including the sites of leading
planning and editing go into their preparation. journals such as the Lancet, BMJ, NEJM, etc.
The one drawback with text books as a source of special interest groups related to various
knew knowledge is that they tend to be slightly practicing specialities which are present on the
outdated. This is because the preparation or web provide another quick way of being abreast
revision of large volumes take time. Recently, of current developments in the field.
developments in printing technology using the ORGANIZATION OF CLINICAL PRACTICE
computer have made the process much faster,
BY A YOUNG DOCTOR
hence this may no longer pose a serious problem.
c. Journal articles: Journal articles continue to Knowledge of a few principles of management will
provide very current information for the clinician. enable a doctor to develop his on clinical practices
Among journal articles, review articles are the at various levels. A general outline is given below:
most authentic since they collate a lot of facts In a clinic the doctor is the manager. He should
from multiple sources. Original research articles be able to organize and implement his practice
report findings of a single research group. The effectively applying managerial skills.
information they provide can be incorporated into Man Power
practice only with some caution. It may always
Managing men is the most important aspect.
be better to wait till a new finding is corroborated
Different type of people with different attitudes,
by other independent researchers.
ways of living and different educational back-
Part–II: Specialties
Part–II: Specialties
to spent a great amount of time mastering varied consultation, encourage this.
technical skills. This leaves them little time for 6. Be deliberate: Above all, spend time with the
consciously developing their ability to interact with patient. Discuss his or her problems, even if they
patients. The explosive growth of specialization has do not relate immediately to the sickness.
contributed to this. Formerly the personal element HEALTH EDUCATION
in the doctor’s manners, the ability to soothe the
patient’s feelings and inspire confidence by his or This aims at inducing changes in personal and groups
her behavior was a large component in what the attitudes and behavior so as to promote healthier
physician gave to each patient. The purely technical living.
content was much less important partly because The main objectives are:
therapeutic science had not advanced so much. Now a. Informing people
there seems to be a reversal of the situation. With b. Motivating people
the advance of treatment of modalities and their c. Guiding them into action.
variety, the personal element in doctor’s behavior Practice of Health Education
has assumed a less important role, especially in the 1. Individual and family health education: A doctor
doctor’s minds. Modern medical training also has a major role in health education in his clinic
contributes to this by laying less emphasis in or consultation room. Educate the person on
developing interpersonal skills. In many medical matters of health such as diet, causation and
schools, these may never be assessed at any point nature of his illness, methods for prevention,
and a student who has high degree of competence in personal hygiene, and others. By this, the
this area may go unrewarded. individual and family will be equipped to tackle
Doctors interact with patients in many situations: their health problems more effectively.
in the clinic, in the ward, prior to surgery, and post- 2. Group health education: Matters of health directly
operatively. There are also many different occasions important to the group have to be introduced and
which demand different approaches to handling. discussed in camps or seminars, e.g. feeding
The doctor may be called upon to convey the practices to the mothers, immunization to children.
diagnosis of a fatal disease to the patient or relatives. 3. Educating of the general public through mass
He may have to gently guide the patient and family media like television, radio, newspapers, and
in a difficult decision. The patient any seek his magazines. Health education message can be
guidance in coping with a chronic disease. In any disseminated widely.
SECTION
21
Information Systems
in Medicine
CHAPTER
Practical Applications of
59
1 Information Technology
for Patient Care
KK Krishna Kumar
Information technology, Computer hardware, Software organization, System architecture, Internet and
world-wide web, Selection of IT systems, Biomedical equipment and electronic accessories, Practical
applications of IT in health care, Office automation and hospital, Digital library and information on the web,
Decision support and expert systems, CME and collaboration, Glossary
making. Processing electronic medical records will improve performance when handling big file
includes: size, multitasking, online information sharing and
i. Collection and systematic storage of data. sending and receiving video, audio and high
ii. Compilation and update of data recorded at resolution images through broadband connections.
different time intervals (date). The display monitor, hard disk drive, CD/DVD
iii. Conditional or selective retrieval of data and drives keyboard and mouse forms part of the basic
creating need based reports. equipment. Software requiring high performance
iv. Comparison of observed data to normal computing like Holter signal analysis, pacemaker
parameters. activity monitor and digital image processing
v. Numerical analysis and reviewing evidence (DICOM standard) calls for hardware upgrade like
before decision making. extra RAM, additional external cache memory,
vi. Data mining and developing expert systems. graphics accelerator cards and high performance
Hospital management systems are enterprise hard drives instead of standard ones. Personal
wide solutions that integrate patient information, computers should also have additional ports/
record of clinical and paramedical services, workflow expansion slots to connect add-on devices when
administration, resource management and financial necessary, like external speakers, MP3 players, pen
accounting. There are cost effective solutions to drive, portable hard disk, webcam, projector, video
manage operations of any scale from consulting recorder, digital camera, mobile phones and to
chamber practice to multispeciality hospitals. directly plug in flash memory cards. Therefore
IT can collate, correlate and combine data serious users should look for expansion slots like
Part–II: Specialties
obtained from different sources, both qualitative audio and microphone jack, USB ports, VGA output,
(like radiologist’s opinion) as well as quantitative PS/2 connectors, PCMCIA ports or card reader,
(like lab report) and assist doctors in decision ethernet port (RJ45), phone jack (RJ11), Firewire/
making. Automation of diagnostic services improves IEEE 1394 port and HDMI (high definition
reliability, staff productivity and patient satisfaction. multimedia interface). Sometimes if you have to
Computer controlled instruments and equipment connect the computer to old type of analog projectors
relieve health care professionals of routine tasks and or television and printers or scanners the S-Video
repetitive procedures which are prone to human connector and Parallel ports should also be included.
errors. Lab quality control measures can be Most laptops are equipped with built-in wireless
implemented through computerized records audit. LAN adapter for accessing Wi-Fi hot spots, 3G/
Web and mobile phone enabled applications help WiMax for mobile phone services, Bluetooth for
patients schedule appointments, check follow-up close range device to device data transfer and IR
visits, send lab reports and seek medical advice remote control (Figs 59.1 and 59.2).
without contacting the administrative personnel in Nowadays, a standard desktop or laptop having
a clinic or hospital. Doctors offer professional Inter Core 2 Duo 2.1 GHz processor, 15" TFT-LCD
assistance to remote clinics and individuals through monitor of XGA resolution, 2 GB RAM, 200 GB
telemedicine. hard disk capacity and other standard specifications
COMPUTER HARDWARE
Practically every application in medicine can be run
on desktop or laptop computers. The data processing
speed of the central processing unit (CPU) is
determined by the specifications of the chip
manufacturer (Intel, AMD, Motorola or Cyrix),
quality of the motherboard and the clock speed in
mega /giga hertz. It is important to install adequate
random access memory (RAM) according to the
minimum RAM recommended for installed software
applications. Providing additional RAM capacity Fig. 59.1: Laptop computer
Chapter 59: Practical Applications of Information Technology for Patient Care 745
Part–II: Specialties
Desktops are best suited for routine professional computer can respond to user commands. After
and office work and Laptops are only for people booting the system is ready to receive external inputs
on the move. and commands and the OS layer co-ordinates the
Personal computers have evolved from two job scheduling on each component (module),
popular design standards—IBM compatibles or manages memory access, maintains internal
PCs and Apple macs. Though IBM brand personal communication pathways, synchronizes data flow
computers business was sold off to another and diagnose and rectify errors to complete the
company, their innovations continue to influence given task.
new generation machines. Personal computers with earlier OS like CP/M,
DOS are rarely found these days. The popular OS
SOFTWARE ORGANIZATION for personal computers are Microsoft WINDOWS,
Computer users only know English like or similar LINUX and Apple Mac OS. A network OS allows
spoken language commands to make systems work. sharing of files and resources like printer, scanner
However these commands have to be translated into across a local area network or intranet. Many
equivalent set of electronic instructions (machine institutions still maintain client/server and peer-
language) for the hardware to process. Step by step to-peer type of networks running Microsoft
instructions that translate a user’s command into WINDOWS NT or some version of UNIX, Sun
machine language to process a set of input and Solaris or Novell Netware on their user terminals
display the output in a readable form is called a for accessing storage area networks (an array of
computer program. Several programs that function hard disks) and high speed and secure connections,
together to execute useful real life tasks is called with much less likelihood of crash when compared
software. Hardware is not functional without the to PC OS. Increasingly with more and more Web
instructional logic, i.e. software. Software is applications being developed that uses the
classified according to its control hierarchy and ubiquitous TCP/IP communication protocol, all
scope of operation. personal computer OS will be able to access
any type of network servers (high performance
Operating System computers) and shared devices in a network without
The hardware is assembled using components or network OS. OS does not come with any ready
modules that are dedicated to perform one or at to use medical applications. It features only
746 Section 21: Information Systems in Medicine
housekeeping tasks like configuring the look and using English like commands into machine
feel of user interfaces, configuring devices, data language. COBOL, FORTRAN, C, C ++, HTML,
security and access control, hard disk access, file SQL and Java are popular programming languages.
and folder organization and error diagnostics, A computer program is only part of software. A
fault fixing and data recovery. Before buying a program is first created without syntax errors, in
computer with preinstalled OS or when upgrading an easily understandable format after inserting
to a new version or when changing to a new OS, suitable comments with a text editor. It is run in a
users have to make sure that the utilities and controlled manner, tested for errors (bugs) in
application software they wish to run subsequently response to different data input conditions, and then
is compatible with it. the bugs have to be traced to the particular line of
code in the program and fixed. After a piece of
Utility Tools program code is error free, it is compiled together
Software that provides short cuts to make routine with other programs to generate the software.
tasks easier, enhances system performance, Whenever there are changes in the software code
improves security and guarantees virus protection, the development team has to keep track of the all
and helps recover from data loss, software corruption previous versions so that an earlier version can be
or system crash is known as utility. Utility software restored, in case the latest release has major bugs.
sold by third party vendors are more user friendly In order to speed up the software development
and technically superior to similar features available project many library functions or sub-programs of
in the OS itself. Popular utilities include system frequently used instruction set are maintained and
Part–II: Specialties
recovery manager, disk storage and clean up, file reused by simply linking it to any new program
sharing, data compression and encryption, Antivirus which is under development. Thus, software
and performance enhancing tools. professionals make use of an integrated development
environment that comprises of source code text
Programming Language and editor, run time simulation, testing and debugging
Software Development Kit platform, compiler or interpreter, version control and
Programs written in English like vocabulary follow build automation tools to deliver application
a set of rules—program syntax. But the hardware software packages. Microsoft visual studio, Java
can only process digital signals that represent development kit and Microsoft. Net Framework
instructions in binary codes (combination of 1s and (pronounced dot net) are popular application
0s). Language processors convert programs written software development tools (Figs 59.3 and 59.4).
Fig. 59.3: Different software layers Fig. 59.4: Standard view of word processor
Chapter 59: Practical Applications of Information Technology for Patient Care 747
Part–II: Specialties
Software protected by copyrights has to be licensed come with detailed instructions for installation and
for use. The license fee for personal and home use configuration and system administration guide, user
editions of popular branded software is reasonable manuals and demo or self-learning CD. Independent
and ensures technical support and regular upgrades software vendors also provide 24 × 7 help desk,
from the company. bug fix and technical support. In case of three tier
Free and open source software (FOSS) that can architecture web applications, on receiving customer
be used without such copyright restrictions are also complaint, the software company can directly access
available in lieu of proprietary software. It can be the remote site where the application is hosted and
downloaded from official websites and installed fix any bugs without traveling onsite.
either free or for a nominal fee. OpenOffice.org is
an office suite which is the most widely used FOSS SYSTEM ARCHITECTURE
application. It originated as StarOffice and today
mega corporations like oracle are offering their The design of software and communication protocols
versions of FOSS. However, users may have to to meet the computing demands, network traffic and
depend upon independent software professionals user load on a system is called architecture. During
and third parties for technical support and training. the early period in mid 80s application software was
Before a particular version of an OS is installed or built around the database whereby the user could
upgraded make sure that the existing application directly access the data, lock the files, perform
software is compatible with it. useful tasks and then unlock. This one tier model
Buying or custom made business application became a big bottleneck when different users wanted
software or enterprise solution is a joint effort by a to share the same data and system was busy
team of system analysts, software developers processing too many user requests to respond
and end users. System analysts are consultants quickly. Even today a system designed to run on a
who have the domain knowledge about clinical PC with one user having all privileges is called a
practice, health care delivery processes and hospital stand alone application. Later the database was
administration and are familiar about the technology, delinked from the front end (presentation for user
software project management and cost. A hospital interaction) in a client/server two tier model. In
information system integrates administrative, this type of multiuser system the database was
financial and clinical aspects of the hospital. Key maintained in the central server and only the front
functional areas it can support are: end ran in the client machine. Therefore the software
748 Section 21: Information Systems in Medicine
Medical professionals are familiar with new age of information published as text, graphic and
phrases like ‘cyber space’, ‘e-mail’, ‘web surfing’, multimedia content in public domain (free to use)
‘information super highway’ and ‘broadband made available through internet is www. A service
services’. Even if these terms are unfamiliar, one that relies solely on its own secure network without
sitting before a computer connected to internet can alternate internet access is an online service. There
bring up a search engine like Google, Yahoo or are online services that provide value added content
Altavista and type in the keywords and quickly get on payment. Users should note that:
a list of hyperlinks to dictionary, article or web page • Online services are usually billed ‘pay as you
that explains the term, in a matter of minutes. The use’ while internet services are fixed fee
terms internet and Worldwide web (www) are often subscriptions.
used in everyday speech without much distinction. • Online services exert more control on the
However, the internet and the worldwide web are content published and undertake editorial and
not one and the same. The internet is a global data peer review while internet content or www may
communications system. It is a hardware and not meet the strict academic and research
software infrastructure that provides connectivity standards.
between computers. In contrast, the web is one of • Internet can at best be a quick reference for
the services communicated via the Internet. It is a popular topics and personal reports but good
collection of interconnected documents and other online services and e-journals should be referred
resources, linked by hyperlinks and URLs (uniform for any serious professional or research work.
resource locator) (Figs 59.5 and 59.6). Before the arrival of internet, each organization
The connection that allows computers to could set up its own wide area network by installing
communicate, share files and access common routers, link directly to communication satellites
devices is called a network. A network should have through VSAT or subscribe to proprietary online
high bandwidth to carry all signals (traffic), must services and complete the last mile through leased
be secure and support industry standard connectors telephone lines. Until the internet infrastructure
and ports. When the network cables are installed of servers and routers communicating across TCP/
within a building or premises it is a local area network. IP protocol became reliable and affordable to
A private network across different premises, states everyone, there were proprietary online services like
or countries using telecommunication link AOL and CompuServ.
Chapter 59: Practical Applications of Information Technology for Patient Care 749
Part–II: Specialties
Fig. 59.6: A telemedicine network
A web browser is an application that can search staff play an important role in the success or failure
and present information identified by URL from of IT. The initial project should always aim to
the web. Internet Explorer, Mozilla FireFox and demonstrate the advantages of well designed and
Opera are common web browsers. An application uniform data entry forms and quick response of the
that is hosted in a browser controlled environment database. Gradually the manual data entry should
and programmed in browser supported language give way to automatic data reading and display
is called web application. Web applications require devices like attendance recording (magnetic strip),
very little disk space in the client, upgrade automatically bar code readers (optical readers) and radiofrequency
with new features and is compatible with all popular identification tags. Thus the system will evolve into
OS like Windows, Mac and Linux. semiautomated or fully automated solution as the
organization grows.
SELECTION OF IT SYSTEMS
Before investing in IT the doctor or end user
IT has a number of applications that automate the and systems analyst have to evaluate the technology
workflow processes in an institution. Introducing and features best suited for the system, cost, ease
new systems in an environment with well established of implementation and return on investment. They
manual operations is a difficult first step. Corporate have to look for compatibility between hardware
policy, peer pressure and computer literacy among and software, scalability without huge additional
750 Section 21: Information Systems in Medicine
investment, portability (common interface) across developed using. NET or J2EE framework with
other electronic and biomedical equipment and open robust middleware products and high end databases
standards instead of proprietary technology. Since like Microsoft SQL server, Oracle, Sybase, DB2
there are different CPUs, hardware architecture and and Informix.
OSs, application software packages have to be While evaluating different solutions it is standard
written to run across different platforms. For practice to compute the total cost of ownership over
example among PCs running Microsoft Windows, three years. The budget for initial implementation
Linux or Mac OS, each requires different set of should include cost of hardware, communication
compatible software. Sometimes two software devices and licensed software for both COTS and
cannot run simultaneously. It is a recommended application software, customization of features,
practice to install a demo version of the software providing network connectivity, site installation,
that the user intends to buy, run and evaluate its training and technical support. The recurring
suitability before buying licensed installation. expenditure covers annual maintenance contract,
The hardware specifications should have enough upgrading licence for more number of users and
capacity to scale up (operate without loss of consulting fees for providing technical help when
performance) when more number of users are added, new features have to be added, or new office
more software is run concurrently and new automation equipment or hospital equipment has to
electronic and biomedical devices are added and be installed. Today many high end systems are
large volume of data has to be stored. The network available for use as software as a service model,
bandwidth should be able to carry large sized whereby the customer is charged on a subscription
Part–II: Specialties
images, video and multimedia files. The software plus transaction fee basis instead of one time
should be designed on industry standard platform. investment. In order to compute the return on
investment the project team has to take into
Some of the rapid application development
consideration the need to modernize hospital
tools or graphical user interface (GUI) for IBM
administration and financial transactions, value
compatible PC software are Microsoft Visual Basic,
addition due to improved quality of medical services,
Java, C# (pronounced C sharp) and Embarcadero
increased revenues by increasing the productivity
Delphi and makes use of MS-Access or MySQL
of different profit centers and hospital staff, cost
database. Applications can be developed using
savings due to reduced administrative work and
FireWire SDK, XCode or Eclipse for Apple Mac
opportunities for collaboration with other doctors,
OS. Such a system will serve the needs of a doctor
outsourced service providers and hospitals.
or polyclinic handling about 200 outpatients a day.
It is less important to select systems on the basis
Besides the simple GUIs, the popular HTML/
of ease of implementation because leading
XML standard (compatible with popular web computerized systems offer similar technology
browsers) front end tools for the rich look and feel compatible with health care industry standards,
of client/server software are PowerBuilder, Adobe guarantee enterprise wide integration and offer
Dreamweaver, Microsoft Front Page and Expression many user friendly features. It may be helpful to
Web, PHP and similar packages. The popular take a look of the feature list, installation guide,
databases recommended for installations with 10 and user manuals and help files to make sure that
concurrent users (between 50 to 200 connected customer documentation is of good quality before
users) are MySQL and lite (scaled down) versions choosing appropriate software. It is more important
of Microsoft SQL Server, Oracle and Sybase. Two- to review the readiness of the Doctor or institution
tier systems are adequate for a 100 bedded hospital to adapt to a new system. Once the hardware and
with limited clinical and nonclinical services and network infrastructure are in place, then the end user
offline internet access with other centers. readiness can be understood from their awareness
A large multispecialty hospital with online about the work flow process changes and benefits
collaboration with other centers must have three- of new IT system, computer literacy and willingness
tier architecture systems. Many applications are to undergo training.
Chapter 59: Practical Applications of Information Technology for Patient Care 751
Part–II: Specialties
another repeat scan procedure. Software can also equipment, mobile phones and mobile internet
change view angle (aperture), obtain a calibrated connectivity will be very convenient and enhance
measure of artefacts or shadows and color code the user experience of PCs.
according to predefined parameters. Wherever Small clinics and hospitals can use COTS
communication has to be established between the solutions for registration, patient records, lab,
equipment and office computer without staff pharmacy, purchasing and stores, payroll and
intervention, sophisticated accessories are interfaced. financial accounting. Web applications makes it
Direct on-line EKG and EEG recording consists easy to send and receive information that should be
of leads connected to analog-to-digital converter shared with collaborating centers like test request
which converts the electrical activity into digital forms or reference letter, lab and radiology reports,
video files which can be directly viewed on VDU prescriptions and treatment notes and discharge
or replayed later on media player software. These summary. Complete hospital information system for
have done away with paper strip recordings. Remote bigger hospitals will need some customization
monitoring of vital parameters of ambulatory before it is ready for roll out. New generation ERP
patients through radio transmitters, wireless infrared (enterprise resource planning) software aims to
transceivers or mobile SMS/MMS enabled gadgets enable a ‘paperless office’ where all internal and
are more reliable and convenient. In modern clinics external information flow is managed by the system.
and hospitals wireless hot spots are installed in This facilitates easy processing of bill (receivables
several locations so that ambulatory patients are and payables) settlements, corporate reimbursements,
never out of range. insurance claims and other key business transactions.
Ultrasonography is aided by acoustic transducers
and associated circuits that can be controlled by Medical Records and Lab Automation
PCs to focus, scan and reproduce echograms. Patient records and case sheets are vital information
Another useful accessory is the touch sensitive that doctors have to maintain in a systematic and
graphic display screen with or without stylus. It is easily retrievable manner. The responsibility of the
frequently used for web conferencing and Continuing doctor and hospital administration as the custodian
medical education (CME) workshops for discussing of correct, relevant, updated, and medicolegally
anatomic details, obtaining expert opinion and sustainable information about patients under their
planning surgical procedures. care has to be emphasized while using IT for medical
752 Section 21: Information Systems in Medicine
record keeping. Different institutions follow Digital Library and Information on the Web
different formats of medical records. The HIPAA Documentation of advances in medical knowledge
legislation (Health Insurance Portability and is necessary to update skill and be aware of latest
Accountability Act) enacted by US Congress in practices. A wide array of textbooks, journals,
1996 laid down standards for disclosure of health CME tutorials, monographs and other medical
care transactions, privacy of health data and literature is available in CD-ROM and DVD
administrative simplification for health maintenance formats. The advantages of digital documents over
organizations. Today the Problem Oriented Medical printed books are less price, convenient size, better
Records (POMR) template which came about as a quality content, pick and choose kind of presentation,
result of the evidence based medicine principle have quick search, automatic indexing and cross-
been incorporated in several versions of EMR. The referencing (hyperlinks) and personalized utilities
flow of information in case of inpatients will for dictionary look up, annotation and book
systematically corelate history, clinical findings and marking. The embedded audio and video clips makes
general investigations to validate the provisional for interesting and realistic look and feel while
diagnosis. After reviewing the results of additional reading the text. MEDLINE and MEDLARS are
tests for confirming the diagnosis the best course online medical information search services that
of treatment is decided. The outcome of treatment collect information from a wide variety of national
is monitored at every stage during the period and international medical journals and service
of hospital stay and if the patient’s condition is subscriber requests. Medical Subject Heading
contrary to expected prognosis, other causes and (MeSH) is a database of subject index which makes
Part–II: Specialties
exacerbating factors are investigated. this search easier. Untrained users are sometimes
Outpatient records are single page forms to frustrated by the large lists produced by simple
capture brief clinical notes, routine test results and searches. Using MeSH terms in conjunction
prescriptions in a simplified manner, designed to with Boolean text—words, limits for search and
describe conditions not requiring hospitalization. qualifiers for sorting refines the search process.
When a patient is treated as outpatient and inpatient, Except for regular medical practice or using
both sets of records should be seamlessly integrated familiar software, any other serious minded pursuit
datewise. represents considerable time for learning new
Even though IT obviates the need for paper software and investment in new gadgets. The world
records certain documents like referral notes or wide web provides and opportunity to make best
consent letter should be preserved for medical audit use of this training and investment. The backbone
and medicolegal purposes. or the permanently dedicated resources of the
internet consists of very powerful servers open for
Clinical diagnostics and lab investigations yield
global access and maintained by US Department of
numeric results which can be easily computerized.
Defence, European Academic Research Network,
Many equipment have provision to directly transfer
few educational and commercial networks like
data on to PCs and printout formatted reports.
Telenet, JANET and CompuServ. Since the
Software used for lab automation can receive ownership of internet transcends boundaries the
online request for test, prepare priority queue for issues related to governance are managed by a
equipment and task list for staff, schedule specimen multilateral body—Internet Governance Forum. The
collection, assign unique identification number and www is a vast repository of information, updated
print labels or tags, prepare checklist for each with new information every second, which in
test, capture data, store it in EMR or send by principle is accessible to anyone in the world
e-mail/SMS, compare with normal range, detect through a telephone line. Websites are hosted by
trends in a patient over a period, identify equipment commercial network (.net) governments (.gov),
variability for recalibration and determine specimen commercial business (.com), not for profit
sampling size for research. Some software also organizations (.org) and educational institutions
feature animated demonstrations and instruction (.edu). There are also content providers with less
about laboratory procedures for the benefit of well known website suffixes like .biz, .ac and
inexperienced staff. country based ones. Internet browsing refers to
Chapter 59: Practical Applications of Information Technology for Patient Care 753
searching for information containing key words, interview and physical examination may fall short
then viewing the list of headings and titles tagged of the optimum scientific standards. Using computer
to the key word and finally clicking the links to see displayed standard questionnaire, patients can
the web page, abstract or find the homepage of the answer questions regarding family history,
appropriate website. If the content is useful then symptoms, lifestyle and habits and past medications
we can download to our computer. There are both in the privacy and comfort, without being probed
free downloadable sites and ‘pay to use’ sites. The by the doctor. From this a flow chart approach to
simplest way to pay online is to use credit cards evaluate the patient’s response can lead to a fairly
through payment gateway services. Payment good differential diagnosis. More advanced
gateways are secure websites that ensure fraud free software can combine this data with demographic
and confidential cash transaction between buyer and profile, susceptibility factors, predisposing risks
seller. Users should be very careful about providing and latest research findings to narrow down the list
credit card numbers and other personal identity and suggest further investigation.
information to websites without security certificate Most of the expert systems developed for
(e.g. VeriSign SSL) and privacy policy. If one diagnosis and monitoring therapy have demonstrated
doesn’t have valid credit card, they can also notify the concept of clinical decision making based on
their bank to electronically fund transfer (EFT) to quantitative and qualitative data, without being
the bank account of the seller. For this one should available commercially. One of the earliest projects
know the EFT code of receiving bank. Once fund is carried out in 1977 at University of Southern
transferred the bank sends e-mail with digital California was the Digitalis Therapy Adviser. This
Part–II: Specialties
signature to both parties confirming the transaction. expert system monitored the cardiac functions, renal
Many banks offer direct online banking facility functions and serum drug levels during therapy to
whereby users can transact from home or office. A reduce the incidence of toxicity. MYCIN developed
user subscribing to internet services can visit at Stanford University assists medical students with
websites, access virtual private networks (VPNs) diagnosis and treatment of wide range of infections.
if authorized, e-mail, join discussion and social AI/RHEUM contains a structured knowledge based
networking sites, chat or conference online, send diagnosis criteria for 26 rheumatologic diseases,
and receive files and do business transactions designed by specialists for general physicians. It
through secure web applications. was developed and tested at University of Missouri,
Columbia and gave the correct diagnosis in 94% of
DECISION SUPPORT AND EXPERT SYSTEMS
the cases.
Software is increasingly used to help in decision Since expert systems require collaboration
making within a very small domain of knowledge. of many experienced clinicians, computer program
They use algorithm which is a simple step by step mers and extensive trials, only few solutions
decision making process which can be repeated that were first released in the 80s are in popular
(thousands of times) with a different dependent use today.
variable each time, to solve a complex real life
problem. The simplest method to mimic human CONTINUING MEDICAL EDUCATION AND
thinking is by data mining or recognizing patterns COLLABORATION
in the historical records. When the database is With good IT infrastructure, learning methods
sufficiently large the system can be quizzed to list based on CDs and websites are less expensive than
cause and effect relationship with a degree of classroom lectures. It is also self-paced so that
probability that is acceptable. Other artificial medical knowledge transfer progresses according
intelligence algorithms use artificial neural networks to the learning curve (ability) of the individual.
and fuzzy logic framework. ADAMS is a software for screen based teaching of
The earliest application of expert systems in anatomy without specimens, cadaver or actual
medicine was the clinical history questionnaire. dissection. ADAMS features organ systems, tissues
Collection of patient data is prone to errors and and body structure with 3-D rotation and zoom
distortions because of the subjective nature of views. It incorporates biomechanics during body
patient-doctor relationship. Besides, the consultation movement and anatomical changes due to several
754 Section 21: Information Systems in Medicine
pathological conditions. Latest version of ADAMS Projects involving multicenter research coll-
includes thin slice CT and MRI images of normal aborations are better managed by sharing clinical
males and females from head to toe. This software data and periodic review. Epi Info is a public domain
has interactive voice instructor and a dissection statistical analysis software for epidemiology
practice console that simulates a cadaver dummy developed by CDC, Atlanta, USA. Researchers can
on which the student can trace the incision line with use it to validate questionnaires, capture data and
mouse or stylus on touch screen. analyze. It can be freely downloaded from official
Today many workshops and hands on training
WHO website.
sessions are beamed worldwide as live video over
With more and more IT getting integrated
broadband internet (web cast). Web seminars and
into medical science and practice, it is important
Web conferencing help medical graduates and
practitioners participate in the academic programs for doctors to know about its applications and
offered by centers of excellence. In future, health benefits. Table 59.1 gives the common applications
care networks will invest in telemedicine to take in medicine which can be easily implemented by
superspecialty services to remote places. off the shelf, competitively priced solutions.
GLOSSARY
Application Software that manages a user task and not the computer hardware
Archive Files stored in back up disks and not in currently used (live) database
ASCII American standard code for information interchange
Attachment A file attached along with e-mail. For secure transmission of large files FTP is
recommended
Bandwidth The maximum data communication capacity in Mega or Giga Bits Per Second (MBPS/
GBPS) of a network connection. Applications that communicate using local cable or
dedicated WAN communication have very high bandwidth. Applications that
communicate using shared cable or Internet have much less bandwidth.
Boolean logic Used to define search criteria when using indexed databases such as MEDLINE.
AND, NOT and OR are Boolean operators, used to narrow the search, e.g. ‘Find
asthma NOT occupational’ or ‘Find asthma OR occupational lung’ or ‘Find asthma
AND allergic’.
Bugs Error in system or software
CD-ROM/DVD Compact disk read only memory/ digital versatile disk
Chat Two way instant messaging
Database Data stored in a systematic, easy to identify and retrieve format
Digital signature A service provided by trusted sites to authenticate the communication send between
two secure addresses connected through internet
Part–II: Specialties
DNS Domain name system is a easy to remember name, word or phrase that can be
substituted in place of internet address.
EMR Electronic medical records
File compression Compressing the file size without loss of information. Usually compressed files are
used for sending and receiving over the internet. It is decompressed before user opens,
edits or updates and saves the file.
File encryption Files and information send through internet or public networks can be converted to
secret codes so that anyone viewing or copying illegally will not be able to read the
original message. It is decrypted by authorized recipient before using.
FTP File transfer protocol is a special service provided by free or paid sites for authorized
persons to upload and download important and confidential files without risk of public
disclosure or corruption.
HISA Health informatics service architecture
HR Human resources system
HTML/XML Hypertext markup language/Extended markup language
ICT Information and communications technology
Internet address Every connection on the internet is identified by internet protocol address or uniform
resource locator such as 158.152.64.237
Intranet A wide area private network that shares internet communication resources
Mac Apple macintosh operating system
MMS Multimedia messaging service
Netiquette A code of conduct and simple, polite writing style expected of users especially when
posting messages to mail and discussion groups.
Network traffic The total number of users, devices, medical equipment and online applications sending
and receiving data through network cables (or wireless modems)
PC IBM compatible personal computers
SQL Structured query language
TCP/IP Transmission control protocol/internet protocol
756 Section 21: Information Systems in Medicine
SERUM—NORMAL VALUES
Creatinine, serum
Female adult 0.5-1.3 mg/dL
Male adult 0.7-1.5 mg/dL
Folate, serum 1.9-14.0 ng/mL
Gamma-glutamyl transpeptidase
Male 12-38 IU/liter
Female 9-31 IU/liter
Gastrin 60-200 pg/mL
Glucose, serum 70-120 mg/dL
Glucose 6-phosphate dehydrogenase 5-10 IU/g Hb
G-6-PD screen, qualitative Negative
Haptoglobin 100-300 mg/dL
Hemoglobin A2 0.4% of total Hb
Hemoglobin F 0-2% of total Hb
Immunoglobulin, quantitation
IgG 700-1500 mg/dL
IgA 70-400 mg/dL
IgM
Male 30-250 mg/dL
Female 30-300 mg/dL
IgD 0-40 mg/dL
Insulin, fasting 6-26 U/mL
Iron binding capacity 250-400 g/dL
Iron, total, serum 40-150 g/dL
Iodine 3-6.5 g/dL
Iodine protein bound 4-8 g/dL
Lactic acid 0.6-1.8 mEq/liter
LDH, serum 20-220 IU/liter
LDH isoenzymes
LDH1 20-34%
LDH2 28-41%
LDH3 15-25%
LDH4 3-12%
LDH5 6-15%
Leucine aminopeptidase (LAP) 30-55 IU/liter
Lipase 4-24 IU/dL
Magnesium, serum 1.5-2.5 mEq/liter
5’-Nucleotidase 0.3-3.2 Bodansky units
Osmolality, serum 278-305 mOsm/kg serum water
Phenolsulfonphthalein (PSP) >25% excreted within 15 minutes after
injection of 1 mL dye
Phenylalanine 3 mg/dL
Phosphorus, inorganic, serum 2.0-4.3 mg/dL
Potassium, plasma 3.1-4.3 mEq/liter
Potassium, serum 3.5-5.2 mEq/liter
Protein, total, serum
2-55 years 5.0-8.0 g/dL
Above 55 years 6.0-8.3 g/dL
Appendix 759
URINE—NORMAL VALUES
Creatine
Male 0-40 mg/24 h
Female 0-100 mg/24 h
Creatinine 1.0-1.6 g/24 h or 15-25 mg/kg body
weight/24 h
Cysteine, qualitative Negative
Glucose,
qualitative Negative
quantitative 16-300 mg/24 h
Iron 40-140 g/24 h
Lead 0-120 g/24 h
Osmolality 50-1200 mOsm/kg
pH 4.6-8.0
Phosphorus 0.8-2.0 g/24 h
Porphobilinogen
qualitative Negative
quantitative 0-2.4 mg/24 h
Porphyrin
Coproporphyrin 50-250 g/24 h
Uroporphyrin 10-30 g/24 h
Potassium 25-100 mEq/24h
Protein
qualitative Negative
quantitative 10-150 mg/24 h
Sodium 130-260 mEq/24 h (varies with dietary
sodium intake)
Specific gravity 1.003-1.030
Uric acid 80-976 mg/24 h
Urobilinogen 0.05-3.5 mg/24 h
< 1.0 Ehrlich units/24 h
HEMATOLOGIC—VALUES
Basophilic normoblasts
Polychromatophilic normoblasts 7-32%
Orthochromatic normoblasts
Megakaryocytes in bone marrow 0.1%
Lymphoreticular cells
Lymphocytes 3-17%
Plasma cells 0-2%
Reticulum cells 0.1-2.0%
Monocytes 0.5-5%
Myeloid/erythroid ratio 3:1 to 4:1
Carboxyhemoglobin
Nonsmoker 0-2.3%
Smoker 2.1-4.2%
Folate, RBC 120-670 ng/mL
Fragility, osmotic
Hemolysis begins 0.45-0.38% NaCl
Hemolysis completed 0.33-0.30% NaCl
Haptoglobin, serum 100-300 mg/dL
Hemochromogens, plasma 3-5 mg/dL
Methemoglobin <1.8%
Reticulocyte count 25,000-75,000/mm3 or 0.5-2.0% of
erythrocyte count
Volume
Male Female
Blood 52-83 mL/kg 50-75 mL/kg
Plasma 25-43 mL/kg 28-45 mL/kg
Red cell 20-36 mL/kg 19-31 mL/kg
COAGULATION—NORMAL VALUES
Bleeding time
Duke 1-4 min
Ivy 1-9 min
Clot retraction, qualitative Apparent in 30-60 min, complete in 24 h,
usually in 6 h
Coagulation time (Lee-White)
Glass tubes 5-15 min
Siliconized tubes 20-60 min
Euglobulin lysis time 120-240 min
Fibrin degradation product < 10 g/mL or titer < 1.4
Fibrinogen 200-400 mg/dL
Partial thromboplastin time (PTT)
Standard technique 68-82 sec
Activated 24-38 sec
Prothrombin time (PT) 11-14 sec
Thrombin time 10-15 sec
Whole blood clot lysis time > 24 h
762 Clinical Medicine
Bilirubin 0
Cells 0-5/mm3, all lymphocytes
Chloride 110-129 mEq/liter
Glucose 48-86 mg/dL or >60% of serum glucose
pH 7.31-7.43
Pressure 7-20 cm water
Protein, lumbar CSF 15-45 mg/dL
Albumin 58%
Alpha-1 9%
Alpha-2 8%
Beta 10%
Gamma 10% (5-12)
Protein, cisternal CSF 15-25 mg/dL
Protein, ventricular CSF 5-15 mg/dL
Absorption
D-xylose absorption (25 g D-xylose
orally after an 8 h fast, urine collected
for 5 h following ingestion)
Urinary excretion > 5 g/5 h
Serum (1 h after ingestion) > 25 mg/dL
Vitamin A (200,000 U vitamin A orally;
serum level obtained 5 h after ingestion) > twice fasting vitamin A level
Hepatic function
Bromosulphalein (BSP) test
(5 mg/kg BSP intravenously: serum < 5% retention at 45 min
level 45 minutes later)
Appendix 763
Secretion
Gastric secretion
Volume (mean ± standard deviation)
Basal, fasting
Male 64 ± 21 mL/h
Female 54 ± 24 mL/h
Maximally stimulated (after 0.004 mg
histamine/kg body weight, subcutaneously)
Male 201 ± 53 mL/h
Female 153 ± 33 mL/h
Acid output (mean ± standard deviation)
Basal, fasting (BAO)
Male 3.7 ± 2.1 mEq/h
Female 2.2 ± 1.7 mEq/h
Maximal stimulated output/mt (MAO)
(after 0.004 mg histamine/kg body weight, subcutaneously)
Male 23 ± 7 mEq/h
Female 18 ± 5 mEq/h
Basal acid output/maximal acid output ratio <0.6
Pancreatic secretion
Basal
Bicarbonate 25-150 mEq/h
pH 7.5-8.8
Volume 1-99 mL/h
Secretion stimulated (2 unit secretin
per kg body weight, intravenously)
Bicarbonate 60-90 mEq/liter
Volume 38-314 mL/h
SEMEN—NORMAL VALUES
Volume 2.0-6.6 mL
Spermatocyte count >50 million/mL
Liquefaction Complete in 15 min
Morphology of sperms >60% normal forms
Motility >75% activity motile
pH 7.2-8.0
Spermatocrit 10%
MR N Nerve
angiography 53 biopsy 521
Nail 580
spectroscopy 53 conduction studies 512
changes 33
Mucocele of supply 166
in systemic disease 580
gums 711f to orbital structures 619
patella syndrome 34
lacrimal sac 633 Nervous system 281, 283, 373
Nails 322, 550
Mucoid sputum 122 and special senses 551
koilonychia 282
Mueller’s muscle 620 Neural control of sexual functioning
Narco test 612
Multifactorial disorders 315 male 479
Nasal
Multiple Neuroblastomas 323
airway patency test 673
ectopic beats 173 Neurocysticercosis 383
cavity and paranasal sinuses 113
endocrine Neurofibromatosis 35
discharge 662
neoplasia 315 Neurogenic
syndrome 314 endoscopes 690f causes 501
myeloma 277 septum, anatomy of 657f dysphagia 61
sclerosis 383 stuffiness 592 Neurolathyrism 384
Multislice CT coronary angiography symptoms 592 Neuroleprosy 383
228 voice 663 Neurological
Mumps 318 Nasality of voice 398 causes of pain in
Murmurs 197 Nasolabial fold in SLE 244f feet 259
Murphy’s sign 74 Nasopharyngeal carcinomas 501, upper limb 502
Muscle 664 fixation nystagmus 422
biopsy 521 Nasopharynx 675 symptoms 318
enzymes 504, 514 National Neurosis 599
pain 241 Council for Applied Economic Neurotic and stress related mental
power 451 Research 737 disorders 600
in different neurological Health Policy 734 Neurotuberculosis 383
disorders 452 Library of Medicine 729 Neutrophil leukocytosis 286
tone 447 Rural Health Mission 735 Neutrophilic dermatosis See Sweet’s
Muscular dystrophies 383, 515 Sample Survey Organization 737 syndrome
Musculoskeletal Nature of sexual partner 594 Nevus of OTA 632
disorders 501 Nausea 61 New Bellard score 542
system 282 Near New England Journal of Medicine
ultrasonography 269 reflex 631 738
Myasthenia 321 vision 401 New growths 637
gravis 413 Necator americanus 278 Night blindness 622
Mycobacterium leprae 592 Neck 250, 530 Nikolsky’s sign 587
Mycosis fungoid 282 and back pain, causes of 501 Nixon’s method 76
Myeloblast 292f rigidity 475 Nocturia 318, 352
Myelodsyplastic syndromes 277, sign 476 Nodule 582
295 Necrobiosis lipoidica 35 Non ST elevation myocardial
Myelography 47, 516 diabeticorum 320, 581 infarction 172
Myoclonic Necrotic lesions 282 Nonalcoholic fatty liver disease,
seizures 496 Needle/trephine/drill biopsy 714 primary sclerosis 108
triangle 424 Negativism 603 Non-Hodgkin’s lymphoma 701
Myoclonus 450 Neologism 604 Nonketotic hyperosmolar coma 318
Myoglobin 218 Neonatal Nonprojective tests 615
Myoglobinuria 350 jaundice, causes of 543t Non-secretory myeloma 305
Myopia 353, 622, 640 period 542 Nonsteroidal anti-inflammatory
Myotonia 514 reflexes 543t drugs 279
congenita 448 seizures 497 Norepinephrine 313
Myotonic reaction 447 Nephroblastoma 346 Normal
Myringitis bullosa 660, 668 Nephrogenic systemic fibrosis 53 appearance Shamroth’s sign 33f
Mytonias 243 Nephrogram 364 auscultatory events 193
Myxedema 320, 321 Nephrolitiasis 346 drainage of urine 344
jerk 323 Nephrotic syndrome 37, 347 electrocardiogram 209
Index 781
iron binding capacity 298 Oculocephalic reflex 429 Oropharynx, anatomy of 658f
scaphoid 70 Oculomotor 409 Orthodontic treatment 707f
tympanic membrane 656f, 691f nerve 620 Orthopantomograph 713
values for nerve conduction 513 Oculovestibular reflex 428 Orthopnea 170
variation 703 Odds ratio 720 Orthotoluidine test 83
Normally palpable structures in Odynophagia 60, 69, 663 Ortolani’s sign 256
abdomen 72t Offensive breath See Halitosis Osler’s nodes 178
Normoblasts 286, 288f, 290 Olecranon bursitis 251 Osler-Weber-Rendu disease 35
Normocytic normochromic anemia Olfactory Osmolality 354
361 nerve 400 Osseoarticular tuberculosis 238
Nose 530, 578 spectrogram 673 Ossicles of ear 250
anatomy of 657 Oliguria 318, 345, 349 Osteitis fibrosa cystica 330
finger-nose test 471 One-and-half syndrome 422 Osteoarthritis 238, 246
Nuclear Onuf’s nucleus 476 Osteogenesis imperfecta 241
imaging 53, 228 Onycholysis 34 Osteoporosis 239
lesion 437 Onychomycosis 34 Otic ganglion 439
Nucleotidase gamma glutamyl Oophoritis 318 Otitis externa 660
transpeptidase 105 Opacities in media 634 Otoendoscopes 691f
Nucleus ambiguous 439 Opening Otogenic cough 121
Null hypotheses 722 of jaws 432 Ova in stools 85
Nutrition 28, 278, 387 snap 196 Ovaries 313
and pallor 282 Ophthalmodynamometry 643 Overproduction of hormones 327
Nutritional Ophthalmoscopy 204, 633 Overweight and obesity,
anemias 298 Oppenheim’s sign 462 classification of 29
macrocytic anemia 277 Opportunistic infections 283 Ovulatory cycle 336
obesity 316f Opsoclonus 424 Oxycephaly 27
Nystagmoid movements 421 Optic Oxytocin 312
Nystagmus 420, 475 atrophy 635
to defective chiasma 401, 405 P
convergence-divergence 423 disk 400, 634
gaze mechanism 422 nerve 400, 405 P wave 209
visual fixation 421 glioma 402 Pachymetry 646
neuritis 402, 622, 636, 649 Pacinian corpuscles 379
O tract 405 Packed cell volume 294
Optochiasmatic arachnoiditis 383 Paget’s disease 243
Obesity 28, 316 Optokinetic nystagmus 424, 686 of bone 27
Obligatory urine volume 345 Oral Pain 240, 351, 499
Obsessive cavity and oropharynx, arising from urinary bladder 351
compulsive disorders 609 examination of 675 in ear, otalgia 660
ideas 604 glucose tolerance test in in meralgia paresthetica 242f
Obstetric examination 562 acromegaly 338 in throat 663
Obstructions, stone disease 347 mucosa, examination of 695 occurring in
Obstructive mucosal disease 714 neck 501
jaundice 102 Orbicularis oculi 620 region of face 500
nephropathy 346 reflex 435 region of throat 500
Occipital neuralgia 500 Orbital of sciatica 242f
Occipitalization of atlas 254 cellulitis 622, 641 Painful
Occupational or Miner’s nystagmus osteoperiostitis 641 conditions 242
422 tumors 281, 641 hematuria 350
Ocular Orchitis 318 Painless
bobbing 424 Order of palpation 72t enlargement of gallbladder 73t
dysmetria 424 Ordinal 721 hematuria 350
fixation 425 Organic mental disorders 600 Palapating right axillary nodes 41f
nystagmus 421 Orientation 392 Palatal myoclonus 424
flutter 424 to persons 392 Palindromic rheumatism 246
myoclonus 424 to place 392 Palinopsia 408
myopathy 413 to time 392 Pallor 30
782 Clinical Medicine
in patient with severe anemia Paragonimus 147 Patients with upper GI bleed,
30f Paralysis 281, 378 assessment of 65t
Palmar Paralytic ptosis 626 Patrick’s sign 256
creases in normal and Down Paramyotonia and chondrodystrophic Pattern of
syndrome 529 myotonia 448 cardiovascular diseases in India
erythema 67 Paranasal sinuses 658 167
Palmomental reflex 435, 463 anatomy of 657 diseases affecting the liver and
Palms 531 Paraneoplastic biliary 103
Palpable heart sounds 191 manifestations of malignancy fall temperature 23f
Palpating 315 fever 22f
cervical 40 syndromes 315 rise temperature 23f
for right supratrochlear, Paranoid delusion 604 Patterson-Kelly syndrome 61
epitrochlear 41 Parapharyngeal abscess 676 Pauciarticular arthritis 245
radial pulse 21f Paraplegia 453 Paw hand 322
scalene nodes 40f in extension 453 Pawlik’s grip 563
submental nodes and Paraplegic gait 445 Peak expiratory flow rate 160
submandibular nodes 40f Parasitology 505 Pectoriloquy 140
to detect fever 21f Parathormone 312 Pectus
Palpation of Parathyroid carinatum 133, 530
chest 135 disorders 334 excavatum 128, 133, 185, 530
expansile palpation of liver 187f glands 312 Pedal edema 68
femoral pulse 180f Parathyroids 323 Pediculosis 628
larynx 677 Paresthesia 281, 466 Pel-Ebstein fever 23, 279
liver for expansile pulsation 73f Parinaud’s syndrome 328, 423, 424 Pemphigus 699, 699f
MCP joints 252f Parkinsonism 243, 383, 444 Pendred’s syndrome 311
popliteal artery 180f gait 445 Pendular
precordium 187 Parosmia 400, 658 knee jerk 475
pulse 20f Parotid nystagmus 420
radial pulse 179f enlargement 67 Penicillin 279
right hypochondrium 72 salivary glands 696 Penile
second left intercostal space 190 Paroxysmal arteries 325
trachea 135, 135f atrial tachycardia 174 erection 480
wrist joint 251f hemicranial cephalalgia 500 Penis 324
Palpebral-oculogyric reflex 436 nocturnal Pentagastrin stimulation test 334
Palpitating anterior cervical lymph dyspnea 120, 170 Peptide hormones of gastrointestinal
nodes 40f hemoglobinuria 300 tract 58
Palpitation 173 tachycardias 173, 180 Percussing
Pancoast tumor 150 Pars left border of heart 192f
Pancreas 312 flaccida 656f, 668 right border of heart 192f
Pancreatic tensa 668 upper border of liver 192
calculi 330 Partial Percussion
enzymes 97 loss of smell 658 myotonia 448
polypeptide 312 motor seizures 496 of abdomen 75
Panic anxiety disorders 609 seizures 494 of chest 136
Pap smear See Papanicolaou smear sensory seizures 496 of precordium 191
Papanicolaou tendon rupture 251 of tooth 705f
smear 562 thromboplastin time 303 Percutaneous
stain 148 Passive needle biopsy 156
Papilledema 283, 402, 409, 636 movements 249 nephrolithotomy 344
Papule 582 smoking 11 renal biopsy 367
Paracrine action 311 Patch test 588 transhepatic cholangiography 108
Paradoxical Patellar transluminal renal angioplasty 366
breathing 134 clonus 459 Perfusion
incontinence 352 tap 257, 257f of blood in the pulmonary
MSR 459 Patellofemoral lesions 257 capillaries 117
Parageusia 435 Patent ductus arteriosus 191 studies 160
Paragonimiasis 124 Paterson-Kelly syndrome 280 Periapical abscess 709
Index 783
Rorschach ink blot test 614 Sebaceous glands 578 complement levels 267
Rose-Waaler 265 Seborrheic copper 504
Rotation test 686 dermatitis 627 creatinine 362, 369
Rotator cuff 250 keratoses 35 electrolytes 362, 612
Roth’s Second ferritin 298
septic retinitis 639 aortic area 193 folate 299
spots 178 cranial nerve See Optic nerve gastrin 97
Rothera’s test 357 heart sound 193 glutamic oxaloacetic
Routine pelvic grip 563 transaminase 105
blood counts 265 Secondary iron levels 298
dental tests 712 bacterial peritonitis 87 lipase 97
Rubeosis iridis 631, 632 delusion 604 phosphorus 369
Rubs 197 gout 283 potassium 369
Ruffini’s corpuscles 379 headaches 489 proteins 363
Rumination 61 polycythemia 32, 178, 361 prothrombin time 106
Russell’s viper venom See Rusven Secretin-pancreozymin test 97 sodium 369
Rusty sputum 122 Secretion of bile 102 test 300
Rusven 303 Secretory otitis media 668 transferrin receptor 299
Selection of trypsinogen 97
S diagnostic tests 14t uric acid 267, 362
respiratory function tests 159 vitamin B12 299
Saccadic mechanism 425, 426 Selective Severe
Sacroiliac joint involvement 242f angiography 90, 330 anemia 307
Salaam spasms 496 renal arteriogram 365 hemolytic crisis 308
Salivary Semi-coma 389 mitral stenosis 174
glands 696 Sense of pulmonary hypertension 173
reflex 431 passive movement 467 Severity of jaundice 543t
Scabies lesions on interdigital space position 467 Sex
587f Sensorineural deafness 672 chromosomal disorders 7
Scalar electrocardiography 208 of left ear 679f chromosome linked disorders 6
Scalene nodes 39 Sensory Sexual
Scales 584 bladder 479 dysfunctions 600
Scaphocephaly 27 disturbance 610 exposure 594
Schäffer’s sign 462 extinction 470 precocity 325
Schiotz tonometer 633 loss 433 problems 325
Schirmer’s test 481 from compression of tibial Sézary syndrome 35
Schistocyte 286, 287, 290f nerve 260 Shadow test See Retinoscopy
Schistosoma hematobium 360 pathways 380f Shamroth’s sign 33
Schizophrenia 600, 608 suppression 470 Shape of
Schober’s test 254 Sentence completion test 614, 615 neck 321
in ankylosing spondylitis 255f Sequence of cardiac contraction 166 precordium 185
Schultz’s sign 323 Serial deduction test 606 Sheehan’s syndrome 325
Schwartze sign 668 Serological Shifting dullness 78, 138
Sciatica See Girdle pain markers of HBV infection 106t Shin spots 320
Sciatica osteoporosis 238 tests 218, 265, 505 Shiny nails 67
SCL-70 267 for syphilis 267 Short fevers 25
Sclera 619, 630 Serology 98 Shoulder 250
Scleredema 320, 581 Seronegative spondyloarthritis 246 pain 282
Sclerosis 584 Serous otitis 656 Shrapnel’s membrane 668
Scotoma 405, 621 Serum Sialography 713
Scratch acid phosphatase 363 Sibutramine 177
marks 67 alkaline phosphatase 363 Sick
test 588 amylase 97 euthyroid syndrome 333
Screening ascites-albumin gradient 87 sinus syndrome 168
for gestational diabetes 567 bicarbonate 369 Sickle
tests in urine 612 bilirubin 105 cell anemia 281
Scurvy and senile purpura 279 calcium 369 cells 287, 290f
Index 787