Medical Slides

Hussain Yahya Al-Jorani

Medical Slides
Conjunctival pallor

It is a sign of anemia due to

the reduction of amount of
Hb
Medical Slides
Central cyanosis of the lips

Occur when there is mixture of venous blood

with arterial blood
The causes are either
1) Cyanotic congenital heart disease 
Tetralogy of fallot, Atrial or ventricular septal
defect, PDA
2) Pulmonary diseases  Pneumonia,
Cor pulmonale and COPD
3) Other causes  Right heart failure
4) Blood causes  Methemoglobinemia and
Sulphhemoglobinemia
Medical Slides
Vitiligo

bilateral symmetrical depigmentation,

commonly of the face, neck and extensor
aspects of the limbs, usually associated with
autoimmune diseases such as Diabetes
mellitus, pernicious anemia, adrenal disorders
Medical Slides
Haemochromatosis with increases skin pigmentation

Due to iron deposition and increased

melanin production, Iron deposition
in the pancreas causes diabetes
mellitus and the combination with
skin pigmentation is called ‘bronzed
diabetes’.
Medical Slides
Osteogenesis imperfecta

Blue sclera of osteogenesis imperfecta

Osteogenesis imperfecta is an autosomal
dominant
condition causing fragile and brittle
bones in which
the sclera are blue due to abnormal
collagen formation
Medical Slides
Telangiectasia around the mouth typical of hereditary hemorrhagic
telangiectasia
An autosomal dominant condition
associated with small
dilated capillaries or terminal
arteries (telangiectasia) on the lips
and tongue
Medical Slides
Systemic sclerosis with ‘beaking’ of the nose and taut skin around the
mouth
Medical Slides
Dystrophia Myotonica

Dystrophia myotonica is an autosomal

dominant condition with characteristic
features of frontal balding, bilateral
ptosis and delayed relaxation of grip
after a handshake
Medical Slides
Clubbing fingers
Clubbing is painless soft-tissue swelling of the
terminal Phalanges
Causes of Clubbing fingers
1) Respiratory
A) Tumors  Bronchial carcinoma, Pleural
effusion
B) Interstitial lung disease  Asbestosis and
Fibrosing alveolitis
C) Supportive lung diseases  Emphysema and
lung abscess
2) Cardiovascular  Bacterial endocarditis, Atrial
myxoma and Congenital heart disease
3) Alimentary  Ulcerative colitis, Crohn’s disease
4) Hepatic cirrhosis
Medical Slides
Large tongue (Macroglossia) of acromegaly
Macroglossia (enlargement of the tongue) may
occur in acromegaly, amyloidosis or tumor
infiltration
Medical Slides
Smooth red tongue and angular stomatitis of iron deficiency
Medical Slides
Leukoplakia
Leukoplakia is a thickened white patch that
cannot be scraped off the tongue. It may be
premalignant
Medical Slides
Neurofibromatosis
Multiple lumps may occur in
neurofibromatosis, skin metastases, lipomatosis and
lymphomas
Medical Slides
Petechiae

Examine for enlargement of the liver and spleen and

for other hematological Features such as pinpoint
(Petechiae)
Medical Slides
Scurvy (Bleeding Gums) + Bruising and perifollicular hemorrhages
Vitamin
C deficiency (scurvy) is less common and produces
extensive bruising, particularly in the elderly living
alone without access to fresh fruit and vegetables
Medical Slides
Marfan’s syndrome

Tall stature and reduced upper Long fingers Dislocation of the lens in the eye
segment to lower segment
ratio for aortic dissection
Medical Slides
Swollen right leg  Deep vein thrombosis or inflammation

Increased venous pressure increases

hydrostatic pressure within capillaries,
producing oedema in the area drained by
that vein
This is Known is Localized oedema, the
other causes of increased venous pressur
e are
1) Venous insufficiency
2) Pregnancy
3) Heart failure
4) Pelvic tumor
5) Intravascular volume expansion
Medical Slides
Lymphedema of the right arm following right-sided mastectomy and
radiotherapy
interstitial fluid returns to the central circulation
via the lymphatic system. Any cause of impaired
lymphatic flow (non-pitting)
1) Malignant infiltration
2) Congenital abnormality
3) Radiation injury
4) Elephantiasis-tropical worm infestation
Medical Slides
Angioedema following a wasp sting

Increased capillary permeability occurs in acute

allergic
conditions. The affected area is usually red and
pruritic (itchy)
Medical Slides
Demonstration of pitting oedema

Apply firm pressure with your fingers or thumb for at

least 15 seconds
Medical Slides
Atopic eczema in the popliteal fossae

Asymmetrical rashes that spread from one focus are

more likely to be due to fungal, bacterial or viral
infection
Medical Slides
Psoriasis of the Knees

Extensor plaques on elbows and knees, the

scalp and the sacrum suggest psoriasis, and
it is uncommon
Medical Slides
Seborrheic dermatitis
Seborrheic dermatitis, an inflammatory reaction to
a yeast, Malassezia
Medical Slides
Basal cell cancer showing pearly papules and telangiectasia
Medical Slides
Acne vulgaris

Acne vulgaris produces comedones (blackheads),

pustules and cysts and also affects the chest and
back
Medical Slides
Pityriasis rosea

Pityriasis rosea, which usually starts with one

lesion, the ‘herald patch’
Medical Slides
Urticaria

Urticaria, producing itchy wheals that clear

within 24 hours
Medical Slides
Necrobiosis lipodica

Lower leg lesions include necrobiosis

lipodica (associated with diabetes mellitus
and occasionally rheumatoid arthritis
caused by circulating immune complexes
damaging dermal blood vessels
Medical Slides
Vasculitis

Lower Leg lesions include vasculitis

caused by circulating immune complexes
damaging dermal blood vessels
Medical Slides
Fungal infection

Hands or feet can be affected by fungal

infection, typically ‘athlete’s foot’ (caused by
Trichophyton)
Medical Slides
Lichen planus

Discrete flat-topped Wickham’s striae visible White lacy network of striae

papules on the wrist on close inspection on buccal mucosa
Medical Slides
Herpes zoster (Shingles)
Medical Slides
Nodules

Seborrheic wart Squamous cell cancer

Medical Slides
Macule

Macule can be pigmented (a freckle),

erythematous (hemangioma) or
hypopigmented (vitiligo)
Medical Slides
Plaque

Lupus vulgaris (tuberculosis of the skin) Tuberculoid leprosy

Medical Slides
Bulla from an insect bite
Medical Slides
Dermatitis herpetiformis

Dermatitis herpetiformis shows Koebner

phenomenon (an eruption in an
area of local trauma)
Medical Slides
Granuloma annular
Medical Slides
Psoriasis: showing the Koebner phenomenon – lesions in an area of
trauma
Medical Slides
Viral warts: Koebner phenomenon
Actinic keratosis on the scalp
A skin graft from the removal of a
previous squamous cell carcinoma is
evident
Medical Slides
Male-pattern baldness with hair loss from the temples and vertex of
the scalp
Medical Slides
Alopecia areata with ‘exclamation mark’ hairs, which taper as they
approach the skin.
Medical Slides
Scalp ringworm with secondary bacterial infection and localized hair
loss
Medical Slides
Splinter hemorrhages

Small red streaks that lie longitudinally in the nail

plate caused by trauma and can signify infective
endocarditis
Medical Slides
Onycholysis with pitting in psoriasis
Nail separates from nail bed, caused by
1) Psoriasis
2) Fungal infection
3) Trauma
4) Thyrotoxicosis
5) tetracycline
Medical Slides
Beau’s lines

Any severe systemic illness which

affects growth of the nail matrix
Medical Slides
Leukonychia

White nails which occur in

1) Hypoalbuminemia
2) Chronic liver disease
3) Wasting diseases
Medical Slides
Dilated proximal nail fold capillaries in systemic lupus erythematosus
Medical Slides
Koilonychia

The nail becomes brittle and flat and

ultimately spoon shaped, it is a sign of
iron deficiency anemia, also it can
occur due to excessive use of
detergent and soap
Medical Slides
Kaposi Sarcoma

In the mouth on the skin

Medical Slides
Stevens-Johnson syndrome
Medical Slides
Graves’ hyperthyroidism

Exophthalmos (proptosis) is
increased protrusion of the eyeball
from the orbit. It is caused by an
inflammatory infiltration of the
orbital contents, it also can cause
1) Conjunctival oedema
2) Conjunctivitis
3) Corneal ulceration
4) Ophthalmoplegia
5) Optic atrophy Typical facies Severe inflammatory
With led retraction thyroid eye disease
Medical Slides
Pretibial Myxoedema

Pretibial myxoedema is a raised,

discolored (usually pink or brown)
indurated appearance over the
lower legs and is associated with
Graves’ disease not with
hypothyroidism
Medical Slides
Thyroid acropachy

Thyroid acropachy is a periosteal hypertrophy

of the distal phalanges which looks like finger
clubbing
Medical Slides
Diffuse – Graves’ disease (Goiter)
Medical Slides
Uninodular – toxic nodule (Goiter)
Medical Slides
Multinodular (Goiter)
Medical Slides
Thyroid cancer

Papillary thyroid cancer with regional cervical

Lymphadenopathy, large firm lymph nodes
near a goiter suggest thyroid cancer
Medical Slides
Hypothyroidism

Before treatment After levothyroxine replacement

Medical Slides
Brown tumor of the phalanx (middle finger) in hyperparathyroidism

In hyperparathyroidism, the commonest symptoms

relate to hypercalcemia: polyuria, polydipsia, renal
stones, peptic ulceration, tender areas of bone
fracture deformity
Medical Slides
Corneal calcification in hyperparathyroidism

In long-standing hypercalcemia,
corneal calcification (band keratopathy) may
be present
Medical Slides
Pseudo hypoparathyroidism: short metacarpals

In moderate/severe hypocalcaemia, hyperreflexia

and a positive Trousseau’s sign may be present
In pseudo hypoparathyroidism the metacarpals of
the ring and little fingers are shortened
Medical Slides
Diabetic retinopathy

presence of yellow exudate due to

leakage of plasma from abnormal retinal
capillaries and multiple dot and blot
hemorrhages indicating widespread
capillary occlusion – a precursor of new
vessel formation
Medical Slides
Acanthosis nigricans

occurs in hyperinsulinism and is seen frequently

in patients with insulin-resistant type 2 diabetes
Medical Slides
Eruptive xanthomata

Xanthelasma and xanthomata indicate significant

hyperlipidemia
Medical Slides
Infected foot ulcer with cellulitis and ascending lymphangitis
(Diabetic foot complication)
Medical Slides
Ischemic foot – digital gangrene (Diabetic foot complication)
Medical Slides
Charcot arthropathy with plantar ulcer (Diabetic foot complication)

Disorganized foot architecture, acute

inflammation, fracture and bone thinning,
usually in a patient with neuropathy
It presents acutely as a hot, red, swollen foot
often impossible to distinguish clinically from
infection
Medical Slides
Neuropathic ulcer (pressure ulcer below metatarsal head)
Medical Slides
Acromegaly  Some pituitary tumors secrete excess GH
Medical Slides
Hypopituitarism

Hypopituitarism due to a pituitary

adenoma caused by gonadotrophin
deficiency
Medical Slides
Cushing’s syndrome  caused by excess exogenous or endogenous
corticosteroid exposure

Cushingoid facies After curative

pituitary surgery
Medical Slides
Cushing’s syndrome  caused by excess exogenous or endogenous
corticosteroid exposure
Typical features
1) Facial rounding
2) Central obesity
3) Proximal muscle wasting
4) Skin striae
Medical Slides
Cushing’s syndrome  caused by excess exogenous or endogenous
corticosteroid exposure
Skin thinning: purpura caused by wristwatch pressure
Medical Slides
Addison’s disease (Facial pigmentation) and (Buccal pigmentation)

Entire skin surface for abnormal or

excessive pigmentation: this is most
prominent in sun-exposed areas or
epithelia subject to trauma or
pressure – skin creases, buccal
mucosa and recent scars
Medical Slides
Addison’s disease (Vitiligo)

Vitiligo (depigmentation of areas of skin) occurs in 10–20%

of Addison’s disease cases
Medical Slides
Klinefelter’s syndrome
Klinefelter’s syndrome (47XYY) is the
most common cause of primary
hypogonadism in men
Look for soft, finely wrinkled, hairless
facial skin and gynecomastia and
examine the genitalia pubic hair is often
reduced/absent and the testes <3 ml
in volume
, other causes of Gynecomastia
1) Drugs
2) Liver cirrhosis
3) Interstitial cell tumor of testes
4) orchitis
Medical Slides
Polycystic ovary syndrome

Hirsutism is common in women with

polycystic ovary Syndrome, the
causes of hirsutism are
1) Hormonal imbalance
A) Polycystic ovaries
B) Ovarian Failure
C) Virilizing adrenal tumors
2) Drugs
A) Phenytoin
B) Progestogens
C) Cyclosporine
Medical Slides
Testosterone-secreting ovarian tumor (Clitoromegaly)

Virilisation is temporal recession of the

scalp hair, deepening of the voice, breast
atrophy, increased muscle bulk and
clitoromegaly If present in women with a
short history of severe hirsutism, it suggests
a possible testosterone-secreting tumor
Medical Slides
Carcinoid syndrome

Liver metastases from

mid-gut carcinoid tumor
release vasoactive chemicals
into the systemic circulation
which cause flushing, diarrhea
and bronchospasm

Acute carcinoid flush

Chronic
telangiectasia
Medical Slides
Clinical Features which may be presented in infective endocarditis

Janeway lesions on hypothenar eminence, it is uncommon

Feature of infective endocarditis
Medical Slides
Clinical Features which may be presented in infective endocarditis

Splinter hemorrhages are found in infective endocarditis

and some vasculitic disorders
Medical Slides
Clinical features which may be presented in infective endocarditis

Osler’s nodes  Uncommon feature of infective endocarditis

Medical Slides
Clinical features which may be presented in infective endocarditis

Roth’s spot on Fundoscopy  Can occur in anemia or

leukemia
Medical Slides
Clinical features which may be presented in infective endocarditis

Petechial hemorrhages on conjunctiva  A petechial

rash (caused by vasculitis), most often present on
the legs and conjunctivae
Medical Slides
Features of hyperlipidemia  Xanthelasma

Xanthelasma are an important predictor of

cardiovascular disease
Medical Slides
Features of hyperlipidemia  Skin xanthoma on the knees

Xanthoma are an important predictor

of cardiovascular disease, check the
patellar and Achilles tendons for
xanthomata
Medical Slides
Features of hyperlipidemia  Corneal arcus

Corneal arcus is a creamy yellow

discoloration at the boundary of the iris
and cornea caused by cholesterol
deposition. It is more common in men
and black patient
Medical Slides
Gangrene of foot (Acute Limb ischemia)

Large patches of fixed staining lead to

blistering and liquefaction, Fixed mottling
of an anesthetic, paralyzed limb, with
muscle rigidity and turgor, indicates
irreversible ischemia; amputation or
end-of-life care is the only option
Medical Slides
Raynaud’s syndrome

The acute phase, showing severe

blanching of the tip of one finger
Medical Slides
Raynaud’s syndrome

Primary Raynaud’s syndrome

occasionally progresses to fingertip ulceration
or even gangrene
Medical Slides
Venous ulceration

Chronic venous ulceration usually affects the medial

aspect, is shallow; is pink (granulation tissue) or
yellow/ green (slough); has an irregular margin; and
is always associated with other skin changes of
chronic venous insufficiency (varicose eczema,
lipodermatosclerosis)
Medical Slides
Axillary vein thrombosis

The arm is swollen and the skin is cyanosed

and mottled, especially when dependent
Look for superficial distended veins (acting
as collaterals) in the upper arm, over the
shoulder region and on the anterior chest
wall
Medical Slides
Central Cyanosis of the tongue

Purplish blue discoloration in

natural light
Medical Slides
Skin lesions associated with respiratory conditions

Erythema nodosum on the shins is a feature

of acute sarcoidosis and tuberculosis
Medical Slides
Skin lesions associated with respiratory conditions

Metastatic skin nodes of lung cancer

Raised, firm, non-tender subcutaneous
nodules may occur in patients with
disseminated cancer
Medical Slides
Tobacco ‘tar’-stained fingers

A brownish stain on the fingers and nails in

cigarette smokers is caused by tar,
not-nicotine
Medical Slides
Yellow nail syndrome

The rare
‘yellow nail syndrome’ is associated with
lymphedema and an exudative pleural
effusion
Medical Slides
Superior vena caval obstruction

the JVP is raised and non-pulsatile,

and the abdomino-jugular reflex is
absent. Most cases are due to
lung cancer compressing the
superior vena cava

Distended neck veins Dilated superficial veins over chest

Medical Slides
Hyper inflated chest with intercostal in drawing  Barrel shaped

When the anteroposterior diameter is

greater than the lateral diameter, the
chest is ‘barrel-shaped’ associated
with lung hyperinflation in patients
with severe COPD
Medical Slides
Kyphoscoliosis

Kyphoscoliosis, involving both

deformities, may be idiopathic or
secondary to childhood poliomyelitis or
spinal tuberculosis, and may be grossly
disfiguring and disabling. It may reduce
ventilatory capacity and increase the
work of breathing
Medical Slides
Pectus carinatum with prominent Harrison’s sulcus (Pigeon chest)

Pectus carinatum (pigeon chest) is a localized

prominence of the sternum and adjacent
costal cartilages, often accompanied by
indrawing of the ribs to form symmetrical
horizontal grooves (Harrison’s sulci) above
the costal margin
Medical Slides
Pectus excavatum  Funnel chest

Pectus excavatum (funnel chest) is a

developmental deformity with a localized
depression of the lower end of the sternum
or, less commonly, of the whole length of
the sternum
Medical Slides
Small punched-out Aphthous ulcer

There are many causes of sore lips, tongue

or buccal mucosa, including iron, folate,
vitamin B12 or vitamin C deficiencies,
dermatological disorders
Medical Slides
Abdominal distension due to ascites
Causes of Abdominal distension Causes of ascites
1) Fat  Obesity 1) Hepatic cirrhosis with portal
2) Flatus  Pseudo-obstruction, Hypertension
obstruction 2) Intra-abdominal malignancy
with peritoneal spread
3) Faeces  Subacute obstruction, 3) Hepatic vein occlusion
constipation 4) Constrictive pericarditis
4) Fluid  Ascites, tumors 5) Hypoproteinemia
(especially ovarian), distended 6) Tuberculosis peritonitis
bladder 7) Pancreatitis
5) Fetus  Check date of the last
menstrual period
6) Functional  Bloating, often
associated with irritable bowel
syndrome
Medical Slides
Yellow sclera of jaundice
Common causes of jaundice
1) Increased bilirubin production 
Hemolysis
2) Impaired bilirubin excretion
A) Congenital  Gilbert’s syndrome
B) Hepatocellular  Viral hepatitis,
Cirrhosis, Drugs and Autoimmune
hepatitis
C) Intrahepatic cholestasis  Drugs
and Primary biliary cirrhosis
D) Extrahepatic cholestasis 
Gallstones and Cancer (pancreas,
cholangiocarcinoma)
Medical Slides
Spider naevi (chronic liver disease)

Spider naevi are due to excess estrogen as

sociated with reduced hepatic breakdown of
sex steroids, also it isolated telangiectasia
that characteristically fill from a central
feeding vessel found in the distribution of
the superior vena cava on the upper trunk,
arms and face
Medical Slides
Palmar erythema (chronic liver disease)

Palmar erythema are due to excess

estrogen associated with reduced hepatic
breakdown of sex steroids
Medical Slides
Right inguinal hernia

A direct inguinal hernia forms at a site of

muscle weakness in the posterior wall of
the inguinal canal and rarely extends into
the scrotum. It is more common in older
men and women
Medical Slides
Acute pancreatitis  Bruising over the flanks (Grey–Turner’s sign) or
Bruising round the umbilicus (Cullen’s sign)
Associated with
1) Hemorrhagic pancreatitis
2) Aortic rupture
3) Ruptured ectopic pregnancy
Bleeding into the falciform ligament;
bruising develops around the
umbilicus (Cullen) or in the loins
(Grey–Turner)
Clinical features  Anorexia, nausea,
vomiting, constant severe epigastric
Grey–Turner’s sign Cullen’s sign
pain, previous alcohol abuse
cholelithiasis
Medical Slides
Pruritus/excoriation in chronic kidney disease

Chronic kidney disease may be associated

with bruising and excoriation secondary
to pruritus, the patient is often anemic
and have a urine-like smell on the breath
(uremic fetor)
Medical Slides
Brown nail banding

Chronic kidney disease may be associated

with nail changes include a brownish
discoloration of the distal nail bed
Medical Slides
Arteriovenous fistula showing sites of needle cannulation for
hemodialysis
Measure the pulse and blood pressure
(do not use an arm with an AV fistula
for blood pressure measurement
Medical Slides
Sacral oedema showing pitting Chronic kidney disease

Peripheral oedema usually signifies fluid

retention and expanded extracellular
fluid volume
Medical Slides
Accessory breast tissue in the axilla

Accessory breast/nipple tissue may develop a

nywhere down the nipple line (axilla to groin)
Medical Slides
Mamillary fistulae at the areolocutaneous border

A non-lactating abscess may discharge

spontaneously through a fistula,
classically at the areolocutaneous
border
Medical Slides
Skin dimpling due to underlying malignancy

The skin remains mobile over the cancer

Medical Slides
Peau d’orange of the breast

The skin is swollen between the hair

follicles and looks like orange peel in the
Lymphedema of the breast , the most com
mon causes are infection or tumor and it
may be accompanied by redness, warmth
and tenderness
Medical Slides
Paget’s disease of the nipple (Eczema of the nipple)

This may be part of a generalized skin

disorder, If it affects the true nipple, it
may be due to Paget’s disease of the
nipple, or invasion of the epidermis by
an Intraductal cancer
Medical Slides
Breast cancer presenting as indrawing of the nipple

Causes of nipple inversion

1) Benign
A) Symmetrical
B) Slit-like
2) Malignant
A) Asymmetrical
B) Distorting
C) Nipple pulled to the side
Medical Slides
Drug-induced gynecomastia caused by cimetidine
Causes of gynecomastia
1) Drugs
A) Cannabis
B) Estrogens used in treatment of prostate cancer
C) Spironolactone
D) Cimetidine
E) Digoxin
2) Decreased androgen production  Klinefelter’s
syndrome
3) Increased estrogen levels
A) Chronic liver disease
B) Thyrotoxicosis
C) Some adrenal tumors
Medical Slides
External prolapse of the uterus

Women feel something ‘coming down’,

particularly when standing or straining. It is
associated with previous childbirth
Medical Slides
Bartholin’s abscess

Skin abnormalities, discharge or swellings of the

vulva, such as the Bartholin’s glands on each side
of the fourcheette
Medical Slides
Paraphimosis

This is an inability to pull the foreskin forward,

after retraction, because of a constriction ring
in the prepuce which jams behind the corona
of the glans
Medical Slides
Left testicular torsion

There is shortening of the cord with

retraction of the testis and global swelling of
the scrotal contents, Refer the patient
urgently to a surgeon for scrotal exploration
A retracted testicle accompanied by acute
pain and swelling occurs in testicular torsion
Medical Slides
Herpes zoster  The ophthalmic division of the left trigeminal (V)
nerve is involved
Reactivation of herpes varicella zoster virus
(chickenpox)
can affect any sensory nerve, but typically
either a thoracic dermatome or V1
Clinically significant  weakness of the
muscles of mastication is unusual, but may
occur in myasthenia, with fatigable chewing
Medical Slides
Herpes zoster  The maxillary division of the left V nerve

Reactivation of herpes varicella zoster virus

(chickenpox)
can affect any sensory nerve, but typically
either a thoracic dermatome or V1
Clinically significant  weakness of the
muscles of mastication is unusual, but may
occur in myasthenia, with fatigable chewing
Medical Slides
Herpes zoster  Cervical spinal root left C5

Reactivation of herpes varicella zoster virus

(chickenpox)
can affect any sensory nerve, but typically
either a thoracic dermatome or V1
Clinically significant  weakness of the
muscles of mastication is unusual, but may
occur in myasthenia, with fatigable chewing
Medical Slides
Herpes zoster  Thoracic spinal root right T8

Reactivation of herpes varicella zoster virus

(chickenpox)
can affect any sensory nerve, but typically
either a thoracic dermatome or V1
Clinically significant  weakness of the
muscles of mastication is unusual, but may
occur in myasthenia, with fatigable chewing
Medical Slides
Left hypoglossal nerve lesion

Unilateral lower motor XII nerve lesions

lead to tongue wasting on the affected
side and deviation to that side on
protrusion
Bilateral lower motor neuron damage
results in global wasting, the tongue lies
thin and shrunken and fasciculation may
be evident
Medical Slides
Left sixth-nerve palsy causing weakness of the lateral rectus muscle

The patient is shown here attempting to look

to the left
Sympathetic stimulation causes pupillary
dilatation and upper and lower eyelid Retraction
With parasympathetic stimulation
Medical Slides
Senile entropion of the lower lid

Entropion (an inverted eyelid) leads to painful

corneal erosion
Medical Slides
Inflammation of the eye  Acute iritis (Irregular pupil and circumciliary
injection)
Acute iritis produces a small, irregularly
shaped pupil and redness around the
limbus
The inflamed iris becomes stuck to the
underlying lens
Medical Slides
Inflammation of the eye  Necrotizing scleritis (Areas of pallor within
diffuse areas of redness, indicating ischemia)
Pain on moving a red eye indicates scleritis
and may be the first manifestation of
systemic vasculitis
The redness is frequently bilateral and
involves the whole sclera or a sector of the
sclera
Medical Slides
Inflammation of the eye  Giant papillary conjunctivitis (seen on
everting upper lid. A form of allergic conjunctivitis induced by contact)
Conjunctivitis is an uncomfortable
inflammation of the conjunctivae
There is always associated discharge or
watering
The inner eyelid is inflamed and red, unlike
scleritis or episcleritis
Medical Slides
Ptosis  Complete right ptosis in III nerve palsy
Medical Slides
Ptosis patient looking down and to the left; the right eye has rotated
medially, demonstrating that the trochlear (IV) nerve is intact
Medical Slides
Ptosis  Left Horner’s syndrome

Horner’s syndrome (damage to sympathetic

ocular innervation): paralyses Müller’s
muscle and lower lid retractors, producing
a partial ptosis and a pseudoenophthalmos.
Miosis (small pupil) is present due to lack of
sympathetic innervation to the iris
Medical Slides
Ptosis  Myasthenia gravis

myasthenia gravis causes bilateral

variable ptosis due to fatigability of
the levator muscle
The patient may be unable to ‘bury
the eyelashes’ (orbicularis muscle, VII
nerve innervation), which suggests
a neuromuscular junction disorder,
a myopathy or a meningeal disorder
Medical Slides
Swollen optic disc

Papilledema is suggested if visual acuity

is unaffected, color vision is normal and
there is an enlarged blind spot
Medical Slides
Retinitis pigmentosa

A triad of optic atrophy, attenuated

retinal vessels and pigmentary changes.
Pigmentary changes typically start
peripherally in association with a ring
scotoma and symptoms of night
blindness
Medical Slides
Concomitant right convergent squint in a child

Acquired paralytic squints cause diplopia,

in which the images are maximally
separated and squint is greatest in the
direction of action of the paretic muscle.
Concomitant squints are the same in all
positions of gaze
They usually become manifest in
childhood when they are not associated
with diplopia
Medical Slides
Angular stomatitis

Inflamed painful cracking of the skin at

the corners of the mouth may be due to
excess saliva, chronic atrophic candidiasis
or iron deficiency
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Oral thrush

White plaques of candidiasis on the tongue

or mucosa come away easily when scraped
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Leukoplakia

Leukoplakia (a keratotic precancerous condition)

does not and requires excision biopsy
Medical Slides
Aphthous stomatitis causing a deep ulcer in a patient with
inflammatory bowel disease
Aphthous ulcers are small and painful, occur
in crops and usually heal within a few days
Ulcers may be the presentation of Crohn’s or
other inflammatory bowel diseases
Medical Slides
Dental caries

Rotten teeth (dental caries) are common in

patients with poor oral hygiene
Medical Slides
Acute gout of the first metatarsophalangeal

This causes swelling, erythema, and extreme

pain and tenderness (podagra)
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Olecranon bursitis (Joint swelling)

When vascular structures, e.g. bone and

ligament, are injured, bleeding into the
joint or soft tissues produces tense
swelling within minutes
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Right-knee haemarthrosis (Joint swelling)

When vascular structures, e.g. bone and

ligament, are injured, bleeding into the
joint or soft tissues produces tense
swelling within minutes
Medical Slides
Systemic sclerosis in the hand  Calcium deposits ulcerating through
the skin
In systemic sclerosis, the thickened, tight
skin produces a characteristic facial
appearance In the hands, flexion
contractures, calcium deposits in the
finger pulps and tissue ischemia leading
to ulceration may occur
Medical Slides
Rheumatoid nodules and olecranon bursitis

Subcutaneous nodules in rheumatoid arthritis

most commonly occur on the extensor
surface of the forearm
They are firm and non-tender, and may also
be felt at sites of pressure or friction  the
sacrum or Achilles tendon
Medical Slides
Lesions on the glans penis and ulcerated tongue

Reactive arthritis has extra-articular features

and is associated with skin and nail changes
similar to those of psoriasis, together with
conjunctivitis, circinate balanitis (painless
superficial ulcers on the prepuce and glans;
urethritis and superficial mouth ulcers
Medical Slides
Osteoarthritis of the hand

At the DIP joints they are called Heberden’s

nodes, and at the proximal interphalangeal
(PIP) joints, Bouchard’s nodes
Medical Slides
Gouty tophus

Gouty tophi are firm, white, irregular

subcutaneous crystal collections
(monosodium urate monohydrate).
Common sites are the olecranon
bursa, helix of the ear and extensor
aspects of the fingers, hands, knees
and toes
Medical Slides
Scleritis and scleromalacia

Scleritis and episcleritis are found in

rheumatoid arthritis and psoriatic
arthritis
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Ankylosing spondylitis

Important spinal conditions are acute disc

protrusion, spinal stenosis, ankylosing
spondylitis, osteoporotic fracture, infection
and tumors
Infection and tumors are associated with
fever or weight loss
Medical Slides
Carpal tunnel syndrome  Thenar muscle wasting

If PIP or MCP joint swelling is prominent

consider inflammatory arthritis
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Rheumatoid hand

showing ulnar deviation of the fingers,

small-muscle wasting and synovial
swelling at carpus, metacarpophalangeal
and proximal interphalangeal joints
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Right anterior glenohumeral dislocation

the deformities of anterior glenohumeral and

complete acromioclavicular joint dislocation
are obvious but the shoulder contour in
posterior glenohumeral dislocation may only
appear abnormal when you stand above the
seated patient and look down on the
shoulder
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Winging of the left scapula due to paralysis of the nerve to serratus
anterior
the size and position of the scapula, elevated,
depressed or winged
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Hallux valgus overriding the second toe

Hallux valgus is common, familial and may be

aggravated by footwear and activities such as
ballet dancing
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Ruptured Achilles tendon

Achilles tendon rupture is often palpable as

a discrete gap in the tendon about 5 cm
above the calcaneal insertion
Medical Slides
Colles’ fracture

Any osteoporotic bone can fracture, common

sites are the distal radius