General examination

and
Related question

Dr . Shahidullah shamol

FCPS (MEDICINE )

1
What to see in general examination

First at a glance see

A—Appearance Oral cavity
ill looking or any specific Tongue
characteristic face (Cushing ) Anaemia
B—Behavior and body built Jaundice
C--co –operative or not Cyanosis
D-Dicubitus -- on choice or Candida
specific dicubitus --- propped up Ulcer
Then in eye Fasciculation
Anaemia Other change in tongue
Jaundice dehydration
Other abnormality in eye and lid Gum change
 subconjuntival haemorrhage Soft and hard palate
Arcus senilis Lip – cyanosis and angular
Xanthelasma stomatitis
2
Tip of nose and lip cyanosis
 Abdomen
NECK
Dehydration
Cervical lymphnode in lying position
Shape of abdomen
JVP
Distended or shrunken
Chest
Engorged vein
Look for boney tenderness
Pigmentation and scar marks
 gynaecomastia
In hand
Spider navei
Pulse
Body Axiliary hair and chest hair
Anaemia
Any scar mark and pigmentation
Jaundice
Arm
Cyanosis
Nutritional status ( some body don’t
Clubbing
like it )
Koilonychia
mid-arm circumference
Leuconychia
Skin fold thickness over triceps
Other deformities
BP – usually seen at last ( though it
Respiratory rate
part of general exam not usually seen
Temperature
in exam as most of the time sir don’t
Inguinal and popliteal lymphn
let to ) 3
Edema
Sole of the foot
Pre-sacral area– for edema
Spine for any deformities

Ask to patient to sit

 see thyroid
 lymph node

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1. first stand right side of the patient
2. give her/him salam
3. introduce yourself to him
a. I m a 5th year medical student of MMC
4. take permission
I will going to examine you it will not hurt
u .may I proceed?
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positioning of patient
usually lying in supine position
head is over the pillow
arm will be away from body

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exposure of the body

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first see with in second
Does the patient look ill?
appearance (any facial characteristic –see
appearance par of this chapter )
body build
obese or cachetic

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What to see on eye
 anemia
 jaundice
other only if present
(not routinely mention only if present )
 subconjuntival hemorrhage
 arcus senilis
 xanthelasma 11
Look for anemia

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anaemia
 place thumb just below the lower lid of both eyes and pull them
downward and ask the patient look up ward
 it expose the lower pole of conjunctiva
 look it pale or nor
o if pale ---anemia
o red / pinkish ---normal
o if dark red –polycythemia
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Look for jaundice

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site :is upper sclera

retract both upper eye lids

upward with left thumb
and index finger and
simultaneously ask the
patient to look his feet or
keep the right hand in
front of eye below the eye
level and ask the patient
to look at my palm
now look upper sclera for
jaundice

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nose ---obstruction 20
 Look at oral cavity & tongue

Anaemia
jaundice
cyanosis
dehydration
other condition--

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first ask the patient to open his mouth with the
torch see any abnormality of tongue
hydration (moist or dry crackle )
now look tongue , soft and hard palate for
ulcer , pigmentation , oral thrush (white patch )
also look lip for cyanosis and angular
stomatitis at the corners

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1. now ask the patient to protrude the tongue
a. aim to see anemia and cyanosis
b. in case of anaemia tongue become pale ,smooth and loss
papillae (dorsal surface)
c. cyanosis it become bluish

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CYANOSIS
&
Anaemia 25
 Jaundice

•Now ask patient to show the

under surface (ventral surface).
•if pt not understand then ask t o
touch the soft palate with tip of
tongue
•look for jaundice /yellow colour in
between venulam and lingual vein

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Jaundice

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1. now pull the both upper
and lower lip and look for
a.any gum bleeding and
b.gum hypertrophy
c. dental caries

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Cervical lymphnode

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Test bony tenderness
By pressing over the manubium sternum with
right thumb but look at the face of the patient
while pressing.
how much pressure apply
4dyne / or until nail become white
other sites
1. over clavicle
2. scapula 32
3. spine
gynaecomastia

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gyanecosmastia
inspection
o breast swelling present or not
o if yess
o symmetrical or asymmetrical
o unilateral or bilateral
now do pinch test to
 This can be examined by pinching breast tissue between the thumb and
forefinger –
 It differentiated gynaecomastia ( true breast tissue )from
pseudogynaecomastia or lipomastia (adipose tissue)
 true gynaecomastia can be felt as distinct disc of glandular tissues and in
case lipomastia (fat or adipose tissue )under the skin
Flat hand pressure portion of the examination.
 keep the hand flat with extend finger
 now with middle portion of palmer surface of hand with pressure roll
over breast
 also see tenderness

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Respiratory rate and rhythm
Spider navei
Chest deformity
Scar mark and pigmentation

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spider nevi
Site : usually found only above the nipples along the area of superior
vena cava distribution
if u suspect then see
With the help of pin head or glass slide
How will differentiate between purpura and spider nevi
Purpura does not blanch on pressure (as it extravascular )
Spider nevi : Blanch on pressure and when release the pressure it
will reappear

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look for any chest deformity
pectus carinatum pectus
pectus excavatum carinatum

pectus
excavatum

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 Nutritional status
Average and bellow average

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Pinch the skin with right thumb and index finger over
tricep 41
gently pinching a fold of skin on the
abdomen (over right iliac fossa)
with thumb and index finger,

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holding for a few moments

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now letting go.

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a

see dehydration
Skin turgor:
 Assess by gently pinching a fold of skin on the abdomen (over right
iliac fossa) with thumb and index finger, holding for a few moments,
and letting go.
Respond
 normal hydration
o the skin will promptly return to its original position,
 Dehydration-
o , skin turgor is reduced and the skin takes longer to return to its
original state.
 When unreliable
This sign is unreliable in elderly patients whose skin may have lost its
normal elasticity
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Step 1

See dehydration at a glance

Step 1. pinch with thumb & index
finger
Step 2: hold for few second
Step 3: release it

Step 2 Step 3

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Dehydration
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 Look at hand

Dorsum

keep the hand in

three position palmer

tip of finger upward

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In palmer surface
Anaemia
 jaundice ,
palmer erythema
At nail
cyanosis
clubbing
koilonychias
leuconychia
onycholysis
splinter hemorrhage
Nicotine staining
At dorsum --deformities— see exam of hand (for details)

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 palm of the hand

facing palmer surface upward and compare

with your hand for anaemia
then look palmer crease jaundice
thenar and hypothenar prominence to see
palmer erythema , wasting of muscle of hand
look for Dupuytren’s contracture
other
 Osler’s nodes –(Small painful, purplish
nodules at the finger pulps representing
digital microinfarction )
Janeway lesions (Pink palmar macules)

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Hold the hand like
This

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 Now give your hand in
between patient hand to
compare paleness of
patient palmer surface with
your palm

Anaemia

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See creases for jaundice
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ask the patient to hold
the hand with pointed
the fingertip upward
to see the cyanosis
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examination of clubbing

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step one :
first inspection ---
sit down and keep the patient both palm on your hand
now you sit or nil down to bring patient hands and your eyes in same
horizontal plane look at the angle between nail base and its adjacent57
skin ---- /
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step two:
now do fluctuation test
Place (examiner) your thumbs under the pulp of the distal
phalanx pts middle finger
now place you middle finger either side of DIP joint of pt middle
fingers to fix the joint
now place your index fingers at nail bed & press alternately
to feel Movement of the nail on the nail bed.
This is fluctuation

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Step 3:
Schamrotb's sign or Schamrotb's window test :
place the terminal phalanx / digit of thumb against each other facing
the nail
normally there is a diamond shape space between two nail bed
(schamrotb’s sign )
in clubbing space is disappear

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Step four
do only if clubbing present to see Hypertrophic
osteoarthropathy present or not
slightly press over distal surface of ulna and radius
and patient will feel pain

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 Now examine the pulse and respiratory rate

hand shake with patient with the right hand

if u do it the hand will automatically remain in semiprone and semiflex
position
Place your three middle fingers over the right radial artery .
ring finger will regulate the pulse
middle finger will feel the pulse
index will prevent retrograde pulsation
Count the pulse for 15 seconds and multiply by four to obtain the pulse
rate in beats per minute
The radial pulse is found at the wrist, lateral to the flexor carpi radialis
tendon and medial to the radial styloid process at the wrist.

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NOW SEE inguinal and popleteal

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examine inguinal lymph node
Palpate over the horizontal
chain, which lies just below the
inguinal ligament, and
then over the vertical chain
along the line of the saphenous
vein

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Palpate horizontally just below the
inguinal ligament

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Now palpate vertically along
The femoral vein

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popliteal lymph node at
knee
•flex knee joint
•now place both thumbs on
tibial tuberosity
•with the forefinger palpate
lymphnode in popliteal
fossa
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Look for edema

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examination of edema / leg swelling unilateral /bilateral, pitting or non pitting
site:
 at shin of tibia just above the medial melleolus
 Apply firm pressure with boths thumb
 during pressing look at patient face for any tenderness /pain
 looking pitting or depressing present or not
 keep pressure at least for 15 seconds before telling edema is
absent
 in lying patient you also have to see edema in pre-sacral area if
absent in leg inspection leg are swollen shiny and tense

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Pitting edema

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 grading definition
"Absent" Absent or unilateral
Grade +/ Mild: Both feet / ankles
Grade ++ Moderate: plus lower legs, hands or lower arms
Grade +++/ Severe Generalised
Grade +++/ very Severe scrotal swelling

0+= no pitting edema

1+= mild pitting edema , 2 mm depression that disappears rapidly
2+= moderate pitting edema ,4 mm depression that disappears in 10-15 second
3+= moderately severs pitting edema ,6 mm depression that may last more than 1
minute
4+= severe pitting edema 8mm depression that can last more than 2 minutes 80
Look for sole of the foot
And inter-digital space

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82
now inspect the foot
1. anterior and lateral surfaces,
2. sole of foot—
3. heel –aks the elevate the foot
4. now spread the toes to expose
inter digital space between toes
to see fungal infection
look for
1. Ulcers
2. Erythema
3. Discolouration
4. Loss of hair
5. Amputation
6. Varicosities
7. Atrophy
8. Scars
9. gangrene
10.deformities 83
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now ask the patient to go semiprone
position
1. spine ----look for spinal deformities ---
kyphosis , scoliosis, gibbus
2. see pre sacral edema

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in lying patient you also have to see edema in pre-sacral area if absent
in leg inspection leg are swollen shiny and tense
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now ask the patient to sit down
1. look any neck gland swell present thyroid or lymphnode
2. now ask the patient to swallow
3. look for movement if the gland is thyroid then it will move
downward during deglutition

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examination of skin
1. pigmentation – in case of purpura –look the following
a. hypo or hyper  palpable or nor (palpable purpura in –vasculitis )
2. scar marks  pain full or painless (pain full in -- vasculitis)
3. rash and purpura  blanch on pressure or not (purpura –never blanch on
4. striea pressure )
5. scar marks examination
6. ulcer take a glass side and with it press over the purpura and
observe
if disappear ----then it is not purpura –it may be talengectasia
if no change occur ---then it is purpura

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Now ask the patient to sit down and swallow with extend
neck to see any enlarged thyroid gland

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EXAMINATION OF LYMPH NODE
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examination of cervical lymph node of th
patient
position of the patient and examiners
 patient should be in sitting position and
examiner go behind the patient
 look for visible lymphadenopathy
 always palpate with pulp of finger
 palpate as like you are rolling over
swelling or like massaging the muscle
 compare both side symmetrically
 specially attention give on consistency
tenderness fixed or not

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 First right sub-mandibular
With three or four fingers of
right hand except thumb

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Then left sub-mandibular lymphnode With three or four fingers of left hand
except thumb 96
 Alternate way
You keep head straight or
It can be inclined toward side
you gona palpate

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then
jogulo-digestic / tonsillar, palpate it with index finger both side simultaneously
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 Now palpate ant. Cervical chain of
both sides simultaneously with four
fingers
100
now palpate supraclavicular lymph node
with two or three fingers in
supraclavicular fossa 101
now palpate the post.cervical chain with four and ascend upward
102
 now palpate pre-auricular with thumb
or two or three fingers in front of ear of
both side simultaneously
103
now post auricular just behind the ear
with thumb both side simultaneously

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lastly with the both thumb
palpate sub occipital
nodes just below the occipital
prominence 105
 Now examination of Axillary lymph node

C=Anterior

B=lateral

A= apical & central

/medial
E= posterior
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 ■ From the patient’s
front or side, palpate the
right axilla with your left
hand and vice versa

if your r confused which hand

u will RT or left group of
lymph node.
just hand shake with the
patient free hand will use for
that side of lymph node

ask the patient to keep his

right forearm over examiner
(your) left forearm
107
Ant. Axillary lymph node:
ask the patient to keep right forearm over
examiner (your) left forearm .
 Using the left finger feel the right anterior
lymph node behind the ant.fold of axilla and
give support with left thumb

108
Using the left finger feel the
right anterior lymph node
behind the ant.fold of axilla and
give support with right hand

109
Now palpate the medial
surface of axilla with left
four fingers against scapula
for medial group of
lymhnode

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apical lymph node
 Gently place your
fingertips of left into the
apex of the axilla
 Give support with right
hand at tip of shoulder joint

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Lateral axillary lymph node
Hold the right hand of the patient with
your left hand
now with your left hand gently palpate
medial surface of arm from axilla to
downward

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now with your left hand
gently palpate medial
surface of arm from axilla
to downward

113
Epitrochlear nodes
■ Support the patient’s right wrist with your left hand, hold his
partially flexed elbow with your right hand and use your thumb
To feel for the epitrochlear node.
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Examination of left axillary
lymph node

115
if your r confused which hand u will
RT or left group of lymph node.
just hand shake with the patient free
hand will use for that side of lymph
node

116
ask the patient to keep his left forearm
over examiner (your) right forearm

Ant. Axillary lymph node:

Using the right finger feel the left anterior
lymph node behind the ant.fold of axilla and
give support with right thumb

117
 Or

Ant. Axillary lymph node:

Using the right finger feel the left
anterior lymph node behind the
ant.fold of axilla and give support with
finger of left hand

118
Now palpate the medial surface of axilla with right four fingers
against scapula for medial group of lymhnode 119
apical lymph node
 Gently place your fingertips of
right hand into the apex of
the axilla
 Give support with left hand at
tip of shoulder joint 120
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Lateral axillary lymph node
Hold the left hand of the patient with your right hand
now with your left hand gently palpate medial surface of arm from axilla
to downward

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Epitrochlear nodes
■ Support the patient’s left wrist with your right hand, hold his
partially flexed elbow with your left hand and use your thumb
To feel for the epitrochlear node.
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After palpation of rt and left
axillary group.
go behind the patient .
Ask her keep both hand behind his
head.

124
now palpate both post .group
at a time with tips of four
finger and give support with
thumb

125
at last scalene nodes
 Palpate for the scalene nodes by placing your index finger
between the sternocleidomastoid muscle and clavicle.
 Ask the patient to tilt his head to the same side and
 press firmly down towards the first rib

126
 First identify the
sternal head of
sternocleidomastoid
muscle

127
 Now identified the
clavicular head of
sternocleidomastoid
muscle

128
 Now insert the index
finger in between two
head downward direction
behind the clavicle

129
Now ask the patient to turn his head
toward the direction of palpating
lymphnode ( in case rt scalene turn
the head right side )

130
Inguinal lymphnode

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examine inguinal lymph node
Palpate over the horizontal chain, which lies just
below the inguinal ligament, and then over the
vertical chain along the line of the saphenous
vein

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134
 Name some disease can be identified by only facial expression
A acromegaly
anxiety Agitated expression
B—blood thalassaemia haemolytic faces--
C CLD/hepatic faces sunken eye ball and malar
prominence
D Depression
E-Endocrine hypothyroid puffy face
hyperthyroidism
Cushing moon face ,plethoric and acne
F --Failure RENAL FAILURE ----puffy face
NS
G--Genetic disease Down syndrome
Turner’s syndrome
Marfan’s syndrome
H-Heart Mitral facies
I--immune – SLE facies
autoimmue disease Systemic sclerosis
M Myotonic dystrophica
P Parkinson’s disease Poverty of expression/ mask
135
face
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 Body build and nutritional status

body build rough estimate or visual estimation

about body configuration
it express usually
 average or below average
 obese or chachetic
 tall or short stature
nutritional status undernourished or not
both of this are seen 1. Body mass index
anthropometric 2. waist: hip circumference
measurement like 3. Skin fold thickness
4. Mid-arm circumference

141
BMI Body mass index usually seen generalized
obesity
How will you calculate the
Weight in Kg
BMI ==------------------------------ = kg/m2
(Height in meter) 2
WHO Classification
< 18.5 Underweight
18.5-24.9 Normal
25-29.9 Overweight
30-39.9 Obese
≥40 Morbid obesity

142
waist: hip circumference
to see central or abdominal obesity
it is the ratio of the circum ference
measurement of the waist and the hip
the waist  measure circumference at the
midpoint between the costal margin and the
iliac crest.
HIP-- measure circumference at the widest part
around the buttocks.
waist circumference
waist: hip==----------------------------------------
Hip circumference
what is significance of waist and
waist : hip in male = 1.0 hip ration
waist : hip in female =0 .9 high value is associated with a
waist circumference male =94 cm higher risk of morbidity and
waist circumference =80cm mortality from cardiovascular
female disease
Indication of t the risk of metabolic and cardiovascular in obese?
if A waist circumference of
> 102 cm in men or 143
> 88 cm in women
Skin fold thickness
It is seen over the triceps with slide
calipers
It is usually seen midway between the
olecranon and acromial processes
normal values are
 in male : 20 mm
 in female : 30 mm
Mid-arm circumference Mid-arm muscle circumference is measure at the
midpoint between the tip of the olecranon and
acromial with measuring tape.
muscle mass is estimated
by subtracting triceps skin
fold thickness from mid-arm
circumference

144
What is the type of obesity in male and female? Which one is more dangerous?
In male
 intra-abdominal fat causes 'central' ('abdominal', 'visceral', 'android' or 'apple-
shaped') obesity
In female
 subcutaneous fat accumulation causing 'generalised' ('gynoid' or 'pear-shaped')
central obesity is more dangerous :
 it closely associated with type 2 diabetes, the metabolic syndrome and
cardiovascular disease

A) Abdominal obesity (apple shape).

(B) Generalised obesity, where fat deposition is mainly on the hips and thighs
(pear shape). 145
 obesity is two type
1. Abdominal obesity
2. Generalised obesity
 abdominal obesity is more risk for heart
disease
medical causes of obesity
1. hypothyroidism
2. Cushing
3. metabolic syndrome
4. type II DM
5. hypothalamic lesion /tumor
6. drug –steroid

Drug causing weight gain COST-B

C— Corticosteroids
O— Oestrogen-containing contraceptive pill
S— Sulphonylureas
S— Sodium valproate
T— Tricyclic antidepressants
B— β-blockers 146
what is complication of obesity

increased appetite loss of appetite

with weight gain with weight gain
Cushing’s syndrome hypothyroidism
Diabetes(type--II)
hypothalamic
disease

147
weight loss weight loss with normal
appetite
THAT—DM  DM(type--I)
T--TB  Thyrotoxicosis
H—HIV  phaemchromocytoma
A--Anorexia nervosa  MND
T--Thyrotoxicosis  malabsorption
D--Diabetes mellitus(type--I) loss of appetite with weight
M--Malignancy loss
M--Malnurtrition  Addison
M--MND  anorexia nervosa
 gastrointestinal
malignancy
148
CSF --GES SHORT SATURE TALL STATURE
C--Constitutional Constitutional Constitutional
F—familiar familiar familiar
S—skeletal achrondroplasia marfans
G-genitics Down Klinefelter’s
turner’s syndrome
Endocrine pituitary Dwarfism Gigantism
juvenile hypothyroidism Thrytoxicosis
(Cretitism ) Kallmanns :
hypoparathyroidism homocystinuria
systemic illness asthma, malabsorption, X
renal failure
cystic fibrosis
Anorexia nervosa
short stature is typically Tall stature is
defined as an adult height that defined as height
is more than 2 standard above 97th
deviations below the mean for percentile for age
age and gender and sex or more
than 2SD above the
mean for a defined
population 149
How height is measure?
skeletal height is measure from crown to heel
upper segment = crown to pubis
lower segment = pubis to heel
normal
upper segment : lower segment is 1.8: 1---at birth , 1:1 at age 10 and 0.9: 1 in
adult
name tall and short stature according to upper and lower segment
short stature tall stature
upper= lower segment upper= lower segment
constitutional constitutional
familiar familiar
pituitary dwarf gigantism / hyperpituitary
upper segment > lower segment upper segment > lower segment
achondroplasia precocious puberty
cretinism adrenal cortical tumor
juvenile myxoema
lower segment > upper segment lower segment > upper segment
spinal deformity marfan’s
klinefelter’s syndrome
homocystinuria 150
kallman / hypogonadism
How height is measure?
skeletal height is measure from crown to heel
upper segment = crown to pubis
lower segment = pubis to heel
normal
upper segment : lower segment is 1.8: 1---at birth , 1:1 at age 10 and 0.9: 1 in adult
name tall and short stature according to upper and lower segment
short stature tall stature
upper= lower segment upper= lower segment
constitutional constitutional
familiar familiar
pituitary dwarf gigantism / hyperpituitary
upper segment > lower segment upper segment > lower segment
achondroplasia precocious puberty
cretinism adrenal cortical tumor
juvenile myxoema
lower segment > upper segment lower segment > upper segment
spinal deformity marfan’s
klinefelter’s syndrome
homocystinuria
kallman / hypogonadism 151
skin manifestation of
malnutrition
 cracked skin,
 loss of scalp and body hair
 bruise
 poor wound healing
 oedem (low albumin)
 atrophic glossitis== A
smooth, often sore tongue
without papillae --vitamin B
deficiencies
 Angular stomatitis
/cheilosis, --- a softening
of the skin at the angles
of the mouth followed by
cracking- iron or B
vitamins
 skin changes of pellagra---
Niacin deficiency

152
difference between cretinism and pituitary dwarf
cretinism pituitary dwarf
Depressed nasal bridge , idiotic , coarse Juveniles face or chubby face
face
Decrease IQ / lack of intelligence Normal intelligence
Normal genitalia Sexual infantilism / hypogonadism
present
Upper segment > lower segment Upper segment = lower segment

how will differentiate bleeding from VitK and scurvy

vitamin C deficiency causes scurvy, which is characterised by

small bleeds around the hair follicles (perifollicular haemor
rhages) as well as bruising. Vitamin K deficiency also causes
bruising but not perifollicular haemorrhages

153
ANEMIA

154
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Q. Define Anaemia.
Anaemia is a clinical condition characterized by both qualitative and quantitative decrease in Hb below
the normal level irrespective to age and sex of a person.
Q. Where we look anemia?
 Lower palpebral conjunctiva.
 Dorsal surface of tongue.(tongue is smooth and loss of papilla )
 Palm and sole of feet.
 Whole body
Then what is your finding : tell with adjective such pt is mildly /moderately / severely anemic
Classify anaemia
Etiological Central cause Marrow failure  aplastic anaemia, anemia of chronic disease
Peripheral cause  blood loss, heamolysis
Morphological Microcytic (MCV<76 fl)
hypochromic to remember TISA
anaemia T— Thalassaemia
I— Iron deficiency
S— Sederoblastic anaemia
A-- Anaemia of chronic disease (in some case )
Macrocytic anaemia MCV>95 fl
to remember---MND
M--Megaloblastic: vitamin B12 or folate deficiency
N--Non-megaloblastic: alcohol, liver disease,hypothyroid
D--(dysplastic)--Myelodysplasia,
Normocytic to remember Triple A
normochromic Aplastic aneamia
anaemia Anemia due to acute blood loss
Anemia of chronic disease 157
–CRF, connective tissue disease
159
160
what is the normal Hb level ?
male: 13-18 gm/dl
Female: 11.5-16.5 gm/dl
Q. In which condition Hb level is 100% and ESR `0’?
Ans. Polycythaemia
what r causes of iron deficiency anemia?
In both male & In female- Other-
female •Pregnancy •malabsorbtion
PUD •Menorrheagia •Coeliac disease
Hook worm
Carcinoma stomach
Drug- NSAID
haemorrhoid

161
What are investigation of iron deficiency , thalassemia ,Megaloblastic anemia?
Iron deficiency thalassemia megaloblastic
blood blood blood
TC, DC, Hb%, ESR TC, DC, Hb%, ESR Hb%
PBF- Microcytic PBF- Microcytic hypochromic PBF- macrocytic RBC
hypochromic anaemia anaemia Bone marrow-
Iron profile: reticulocyte ↑ megaloblast
Serum ferritin ↓ S.bilirubin Vitamin B₁₂ level or red
Total iron binding capacity Iron profile: cell folate level
↑ Serum ferritin ↑ To see cause:
To find etiology: Total iron binding capacity ↓  Schilling test
Upper GI endoscopy To comfirm diagnosis:  Enodoscopy to see
Colonoscopy Heamoglobin electrophorosis atrophic gastritis
barium follow through  Anti-parietal cell
Stool for ova of antibody
helminthes
single test to dx single test to dx single test to dx
Serum ferritin ↓ Heamoglobin electrophorosis Bone marrow-
megaloblast
S. Vitamin B₁₂ level
162
163
What is the clinical feature of iron? thalassemia, megaloblastic?
iron thalassemia megaloblastic
HO of blood loss family history HO etiology
dietary HO --vegan
gastric/ intestine operation
pernicious anemia
malabsorption
eye :anemia face eye :anemia
tongue: smooth pale  heamolytic face tongue : glossitis
and loss of papillae eye neurological
Mouth: glossitis,  anemia Eye: optic atrophy
angular stomatitis  jaundice Loss of memory : dementia
nail : koilonychia abdomen sensory : Sensation loss in
 hepato- gloves and stocking pattern ,
splenomegaly loss of vibration and joint sense
position

164
165
Investigation of anemia ?
iron thalassaemia anemia of chr. disease
CBC Hb ↓ Hb ↓ Hb ↓
PBF microcytic microcytic normocytic
hypochromic hypochromic normochromic
reticulocyte N ↑ N
bone marrow iron ↓ ↑ ↑
s.feritin ↓ ↑ ↑
S.iron ↓ ↑ n/
Total iron binding ↑ ↓ ↓
capacity
Transferrin ↓
saturation
Soluble transferrin ↑ N/ N /↓
receptor
Hb electrophorosis not done confirm diagnosis not done
for etiology Upper GI endoscopy genetic study S.creatinine
Colonoscopy
Stool for ova of
helminthes
166
Q. What are the PBF findings in iron deficiency anaemia?
Ans. Microcytic hypochromic anaemia, anisocytosis, pencil cell, target cell,
nucleated RBC.
How will you differentiate PBF of iron deficiency anaemia and Thalassaemia.?
Iron deficiency anaemia Thalassaemia
Few target cell Plenty of target cell
No features of heamolysis Features of heamolysis present
eg. Fragment cell, Pencil cell
What are the PBF findings of Vitamin B₁₂ and Folic acid deficiency?
Ans. Pancytopenia with Macrocytosis with hypersegmented neutrophil.
Megaloblast & Howel-jolly body may present.
Q. Bone marrow findings of Vitamin B₁₂ deficiency?
Ans. Megaloblastic change in erythoid series .
Q. what are the other causes of macrocytosis?
Ans.
Alcohol
Liver disease
Hyperlipidaemia
Hypothyroidism
167
Name the sites of iron and Vitamin B₁₂ absorption.?
Iron absorbed in jejunam. &Vitamin B₁₂ absorbed in ileum
Q. What are the causes of megaloblastic anaemia?
Deficiency of Vitamin B₁₂ and Folic acid.
Q. Vitamin B₁₂ and Folic acid deficiency- which one is more common? Why?
Ans. Folic acid deficiency is more common than vitamin B12 deficiency.
Point Vitamin B₁₂ Folic acid
Store 3years 3 months
Sources Animal plant
Effect of cooking Not destroyed Destroyed during cooking
Q. in which anaemia causes neurological manifestation ?
Megaloblastic anaemia due to Vitamin B₁₂ deficiency
Q. Name causes of Vitamin B₁₂ and Folic acid deficiency
causes of Vitamin B₁₂ and Folic acid deficiency:
Vitamin B₁₂ Folic acid
 Diet: vegan diet:
 Stomach: Increased demand,
o pernicious anaemia, poor intake of vegetables
o partial/ total gastrectomy Intestine: malabsorption, coeliac disease
 Intestinal: malabsorption Drug: phenytoin, MTX
o tropical sprue, Other
o coeliac disease, haemolysis,
o crohn’s
Q. How Vitamin B₁₂ absorbed in GIT?
Ans. Vitamin B₁₂+food stomach acid causes release of Vitamin B₁₂ from food  Vitamin B₁₂ + intrinsic
factor(secrete from parietal cell)  absorption at terminal ileum.
What is pernicious anaemia? 168
It is an autoimmune disease in which antibody is formed against parietal cell (which secrete intrinsic factor)
Q. Tell me the one investigation to diagnose iron deficiency anaemia.
Ans. Serum Ferritin
Q. Mention the treatment of iron deficiency anaemia
Ans. Tab. Ferus Sulphate (200mg), tds, for 3-6 months.
how will follow uP / how will understand that anemia is improved?
Follow up:
 Hb will increase 1gm/dl in every 7-10 days.
 Reticulocyte count will increase after 1 week
What are the indications of blood transfusion in anaemia?
 Angina
 Heart failure
 Evidence of cerebral hypoxia.
What are the complications of oral iron therapy?
Dyspepsia, Altered bowl habit.
What is the indication of Parenteral iron therapy?
Malabsorption.
severe anaemia
. Infusion of 1 unit of blood causes how much increase in Hb level?
Infusion of 1bag blood causes 1gm/dl increment of Hb level.
name iron therapy ?
oral parental
 Ferrous sulphate 200 mg times (195 mg of old preparation
elemental iron per day) iron dextran
 ferrous gluco-nate 300 mg twice daily (70 iron sucrose
mg of elemental iron) new preparations
iron isomaltose and 169
iron carboxymaltose
what is the treatment of Vitamin B₁₂ deficiency anaemia?
Vitamin B₁₂ supplementation:
Inj. Hydroxycobalamine 1000 µgm , 1 ampule, I.M. every 2 day for 5 days.
Maintenance: 1 amp, I.M. 3 monthly for lifelong.
What is the treatment of folic acid deficiency?
Tab. Folic acid 5 mg, (1+0+0) for 3 weeks, than lifelong
What is the importance of folic acid in pregnancy?
Deficiency of folic acid during pregnancy causes neural tube defect in fetus.
To prevent neural tube defect in fetus, when folic acid supplementation
should be started ?
Folic acid supplementation should be started before conception, because,
neural tube development occur within 1-3 weeks of conception.

170
In witch conditions folic acid is used prophylactically?
Haemolytic anaemia
Pregnancy
With MTX therapy
Q. If a patient with Vitamin B₁₂ deficiency is given folic acid without giving Vitamin B₁₂, what will
happen
Ans. It will cause subacute combined degeneration of spinal cord.
Q. . What are the neurological feature of subacute combined degeneration of spinal cord?
Ans. Jerks absent but planter extensor .
Q. what is the daily requirement of Vitamin B₁₂?
Ans. 1µgm/ day
what are the sources of Vitamin B₁₂?
Animal source.
What are the causes of anaemia of chronic disease?
Renal failure
Connective tissue disease
Q. What are the PBF findings of anaemia of chronic disease?
Ans. Normocytic normochromic RBC.
Q. what is the mechanism of anaemia of chronic disease
Ans. IL₆ suppresses the bone marrow.
Q. What biochemical abnormality occurs in heamolytic anaemia?
Ans. Mnemonic: BDR- Head- quarter
B- ↑billirubin
D- ↑LDH
R-↑Reticulocyte
Head-↓heptoglobin
171
Quarter-↑urobillinogen
Jaundice

172
Define jaundice?
•Jaundice refers to the yellow appearance of the skin, sclerae and mucous membranes resulting from an increased
bilirubin concentration in the body fluids.
Normal bilirubin level ?

When will jaundice detectable clinically?

it is usually detectable clinically when the plasma bilirubin l > 3 mg/dl) or 50 μmol/
What do u mean by latent jaundice ?
when serum bilirubin is in between 1—3mg/dl then then jaundice cant detect clinically this called latent jaundice
How will examine the jaundice?
 it is always seen in bight day light
 not seen is night or artificial light
 so ask the sir I need to day light / or take the patient to the window
site where we look for
1. sclera –sclera is examined by retracting the upper eyelids upwards and ask the patient to look downward to his
feet
2. undersurface of tongue (ventral ) ---it looks in between venulam and lingual vein
3. palms (mainly palmer crease)and soles
4. skin of whole body
Why jaundice seen in sclera ?
sclera contain a lot of elastin –which have great affinity for bilirubin &white back ground of sclera
in which fluid jaundice appear ?
found in body fluid—CSF, joint fluid
absent in tear and saliva
How will differentiate it from carotenaemia?
in carotenaemia, there is yellow discolouration of the skin, but the sclerae remain white.
Classify jaundice?
 Prehepatic or Haemolytic jaundice
 Hepatocellular
 Post Hepatic or Obstructive jaundice 173
174
Mention the cause of haemolytic jaundice? Mention the cause of hepatocellular jaundice?
Haemolysis.— 3ADC
 thalassamia , A--Acute viral hepatitis,
 autoimmune haemolytic anaemia A--Alcoholic,
Falciparam malaria A--Autoimmune,
congenital D--Drug-induced—anti-tubercular drugs
 Gilbert's disease. C--Cirrhosis
 Dubin-Johnson syndrome.
 Rotor syndrome
Mention the cause of obstructive jaundice? Name some causes of viral hepatitis?
Extrahepatic bile duct Common causes:
 Choledocholithiasis  Hepatitis A
 Carcinoma  Hepatitis B ± hepatitis D
o Primary  Hepatitis C
 Ampullary  Hepatitis E
 Pancreatic Uncommon causes:
 Bile duct (cholangiocarcinoma)  Cytomegalovirus
o Secondary  Epstein-Barr virus
 Metastasis in porta hepatis  Herpes simplex
 Parasitic infection  Yellow fever
Intrahepatic
 Viral hepatitis
 Primary biliary cirrhosis
 Primary sclerosing cholangitis
 Alcohol
 Drugs
175
 Autoimmune hepatitis
How will u differentiate these three types of jaundice?
Haemolytic Hepatocellular obstructive
Jaundice less moderate to severe severe
Anemia more marked absent absent
Hepatospleno present absent absent
megaly
Stool pale normal color normal color
Itching absent usually not present
Viral prodome absent present absent
Nausea ,
malaise
investigation
Bilirubin unconjugated mixed conjugated
SGPT/ ALT >6 times <6
Alk.phosphatate <2.5 > 2.5 times
What are the causes of recurrent jaundice? Fluctuating jaundice?
 gilbert syndrome
 stone in common bile duct
 haemolytic anaemia
 CLD
 willson disease SN: first three common only for MBBS
176
What do u mean by courvoisier’s law?
palpable nontender smooth surface gall bladder in patient with jaundice is due to neoplastic
obstruction of common bile duct such as carcinoma of head of pancrease but due to stone in
CBD in which gall bladder become small
What do u mean by charcots triad?
Obstructive jaundice with abdominal pain is usually due to gallstones, and if fever or rigors are
present suggests ascending cholangitis (Charcot's triad).
What are the cause of Painless obstructive jaundice?
Malignant biliary obstruction, e.g.
 pancreatic cancer or
 cholangiocarcinoma.
How will differentiate between cholestatic jaundice t due to stone and carcinoma of head of
pancrease
stone carcinoma
pain full painless
jaundice is fluctuating static or progressively increased
gallbladder not palpable gallbladder is palpable

177
What is the feature of haemolytic jaundice ?
 sever anaemia
 mild jaundice
 hepato-splenomegaly
 haemolytic faces and family HO
what is feature hepatocellula rjaundice ?
 viral prodome –nausea , anorexia , vomiting
 fever
 joint pain , malaise
 tender hepatomegaly
Feature of obstructive jaundice ?
 deep jaundice
 dark urine
 pale stoot
 itching
other : uncommon
 pulse ----bradycardia
 xanthelasma ---
 bleeding manifestation ---petechae, purpura , echymosis
 steatorrhoea –due to fat malabsorption
 osteomalacia---in prolong case causes ----osteomalacia
what are the causes of fever with jaundice ?
1. viral hepatitis
2. leptosiprosis
3. malaria
4. cholangitis
5. Liver abscess
What are the medical cause extrahepatic obstruction?
 sclerosing cholangitis
 obstruction by round worm in CBD 178
 enlarge lymphnode at porta hepatis in lymphoma
What history u will take in a patient with jaundice:
 Viral prodome ---development of viral prodome –associate with
nausea and vomiting , fever ,
 The colour of the urine (dark in cholestatic jaundice).
 The colour and consistency of the stools (pale in cholestatic
jaundice).
 Abdominal pain (e.g. caused by gallstones).
 Appetite and weight change
 fever
 Gastrointestinal bleeding
 Itching
 Previous blood transfusions.
 Past history of jaundice.
 Drugs (e.g. antibiotics, NSAIDs, oral contraceptives,
phenothiazines).
 IV drug use.
 Tattoos and body piercing.
 Foreign travel.
 Sexual history.
 Family HO of liver disease.
 Alcohol consumption.
 Any personal contacts who also have jaundice.
Young patient with recurrent jaundice what may be the cause ?
gilbert syndrome
willson disease 179
billirubin metabolism ?
 billirubin is create from haemoglobin , myoglobin by RBC destruction in reticulo
endothelium system
 Within macrophage Haem -> biliverdin ->bilirubin -> Unconjugated bilirubin
 Unconjugated bilirubin is bound to albumin in the plasma and
 transported bound to albumin to the liver and
 it is conjugated with glucuronic acid in the hepatocytes by glucuronyl transferase.
 Conjugated bilirubin is secreted into the bile and enters the duodenum.(80%)
 Most of stercogbilinogen enter portal circulation goes to liver
 Small amount Into the intestine convert in to stercobilin excrete in to the stool
 A small amount by the kidneys as urobilinogen.

Gilbert syndrome
 it is genetic disease Autosomal investigation –
dominant  bilirubin --mild increase
 defect in conjugation of bilirubin –  SGPT/Alkaline phosphate –N
increase Unconjugated confirm DX— calori test
hyperbilirubinaemia fasting ---hyperbilirubinaemia
presentation :
 mild jaundice –more marked in fasting
 dark color urine –due to haemolysis
180
 Hands
Stigmata of CLD  Clubbing
 Dupuytren’s contracture
 Leuconychia
face
 Palmar erythema
Hepatic faces (sunken eye,
 Flapping tremor(hepatic encephalopathy)
Malar prominent)
abdomen
eye
 Ascites
 anemia
 Engorged vein
 jaundice
 Loss pubic hair
 Kayser–Fleischer ring
 Testicular atrophy
mouth
 Ascites
 cyanosis (hepatopulmonary
 Hepatomegaly
syndrome)
 Splenomegaly
 fetorhepaticus
 Hepatic bruit
chest
 Palpable gallbladder
 Spider nevi
leg
 gynaecomastia
 Legs
 Female breast atrophy
 Bruising
 loss of axillary and pubic
 Oedema
hair,
 planter extensor (if patient in
encephalopathy) 181
182
183
CYANOSIS

184
cyanosis is defined as a bluish discoloration of the skin and mucous membranes, due to
excessive concentration of deoxyhemoglobin in the blood
Classification?
Central cyanosis
peripheral cyanosis
mechanism of central and peripheral cyanosis ?
Central: either due to imperfect oxygenation of blood in lung or admixture of venous
and arterial blood.
Peripheral: due to localised reduction of blood flow on exposure to cold, causing
capillary vasoconstriction
example of central and peripheral cyanosis ?
central cyanosis peripheral cyanosis :
heart causes:  peripheral arterial disease and
 Congenital cyanotic heart disease e.g.  Raynaud's phenomenon,
Fallot's tetralogy,  venous obstruction
 Eisenminger's syndrome,
 Cardiogenic shock
lung causes
 COPD
 acute severe asthma
 Pulmonary embolism
 severe pneumonia 185
 Central
Cyanosis

Peripheral
Cyanosis

186
Difference between central and peripheral cyanosis?
Central cyanosis peripheral cyanosis
Cyanosis Generalised Localised
Affected part Warm Cold
Application of Does not disappear Disappears
warm
Oxygen Cyanosis may disappear not Disappears
Tongue Always involved Never involved
site It affects skin, nail, lips, tongue It affects the skin only i.e. nails,
and mucus membranes tip of nose or ears
How will bed side differentiate central and peripheral cyanosis?
by giving O2
if central cyanosis it will disappear and but peripheral cyanosis will not
Why tongue is not involved in central cyanosis ?
A: Because tongue is always warm, and circulation is good in tongue
Can u seen cyanosis in severe anaemia ?
NO,
Because in severe anaemia, Hb is low and fully saturated, no excess deoxygenated Hb.
To see cyanosis Hb need to be more than 5 mg /dl
what do u mean by differential cyanosis ?
when cyanosis present only on the lower limb but not in upper limb is called
differential cyanosis e.g.P.D.A. with reversed shunt 187
188
 Central
Cyanosis

189
Dehydration

190
191
DEHYDRATION
Type deficit physical signs
Mild (<5%): = 2.5 L thirst
Dry mucous membranes
Concentrated urine
Moderate (5%–8%): = 4 L deficit Reduced skin turgor (elasticity),
arms, forehead,
chest, abdomen
Tachycardia
Severe (9%–12%): = 6 L deficit decreased eyeball pressure
Collapsed veins, sunken eyes,
‘gaunt’ face
Postural hypotension
Oliguria (<400 mL urine/24 hours)
Very severe (>12%): >6 L deficit Comatose
Moribund
Signs of shock
Note:Total body water in a man of 70 kg is about 40 L

192
 Capillary refill:

•keep the finger at heart level

•press over the nail bed with thumb and index finger until it turn
white
•now measure the time that is required to return normal color
•normally it require less than 2 second
•A prolongation is indicative of a poor blood supply to the peripheries

193
Lymph node:

194
Cervical glands
submental,
submandibular,
tonsillar,
preauricular and posterior auricular
anterior chain
supraclavicular
Palpate deeply for the scalene nodes
posterior chain
occipital nodes
and deep cervical glands in the anterior triangle of the neck
Axillary glands
Anterior
Posterior.
'Lateral,
Central./ medial
Apical
Epitrochlear glands
Inguinal glands
Popliteal glands
195
196
197
what will see if u got lymph node palpable ?
SSN CT MRI
 S--Site (cervical – anterior or posterior , supraclavicular , axillary –
anterior or posterior )
 S--Size---2 X 2 cm
 N--Number (single or multiple)
 C--Consistency (soft or firm or rubbery or hard).
 T--tenderness
 M--matted or Discrete
 R--Rto underlying structure or overlying skin) /Fixation
 I—Incision mark over lying skin /-- sinus, ulcer, biopsy mark

what do mean by generalized lymphadenopathy

3 or more lymphnode area
Localised lymphadenopathy means single analom¬ical area of LN
involvement

198
what is causes of generalized lymphadenopathy ?
Ans. Common causes of lymphadenopathy:
 Lymphoma
 Leukaemia
 Disseminated TB
Causes of lymphadenopathy as a whole:
Infective:
 Bacterial: streptococcal, TB, brucellosis
 Viral: EBV, HIV, CMV
 Protozoal: toxoplasmosis
 Fungal: histoplasmosis, coccidiomycosis.
Neoplastic:
 Primary: lymphoma, leukaemia(ALL (child),CLL (old))
 Secondary: lung, breast, thyroid, stomach
Connective tissue disease: RA, SLE
 Sarcoidosis
 Amylodosis
Drugs: Phenytoin
what is the importance of consistency
 Rubbery - lymphoma.
 Firm and matted - TB.
 Hard and craggy - malignancy.
 Stony hard - calcified LN. 199
 Soft, cystic - cold abscess.
what is the importance of matted or discrete
 matted ---TB
 discrete –lymphoma
what is cause of discharging sinus of lymphnode ?
 Tuberculous lymphadenitis.
 Actinomycosis
how will differentiate these two
in actinomycosis ---secretion of color granule with pus
name one drug causes lymphadenopathy
phenytoin
If lymphadenopathy is immobile,hard , fixed to skin, the cause?
metastasis.
Unilateral axillary lymphadenopathy?
 Local infection in upper extremity.
 Carcinoma of breast with metastasis.
 Lymphoma (non-Hodgkin's commonly).
what is causes of supraclavicular lymphadenopathy
 bronchial carcinoma
 lymphoma
 in case of left supraclavicular lymphnode --- CA stomach
200
What is Troisier's sign? what does it indicate ? what will want to see next ?
 IF only left supraclavicular LN is palpable, it is called Troisier's sign
 it indicated Metastasis from carcinoma stomach
 I want to palpate abdomen to see see any epigastric mass carcinoma of stomach
what is caused of Scalene LNs involvement
it indicated Metastasis from carcinoma of bronchus
what will do if a lymphnode is palpable ?
examine the drainage area of that lymphnode
 Cervical lymphadenopathy (examine the mouth, tonsil, teeth, face, ears and scalp).
 Axillary lymphadenopathy (examine the breasts, chest and upper limbs).
 Supraclavicular lymphadenopathy (examine the chest for bronchial carcinoma).
 Left supraclavicular lymphadenopathy or Virchow's gland palpate for epigastric
mass, carcinoma of stomach).
 Inguinal lymphadenopathy (examine the lower limbs for any septic focus, genitalia
and perineum).
causes of epitrochlear lymphadenopathy ?
 lymphoma Nonhodgkin
 sarcoidosis
 secondary syphilis
 localized infection of hand or arm
if lymphnode is tender than what does it indicate ? 201
it indicate the reactive hyperplasia due to infection
How to treat tuberculous lymphadenitis?
with standard anti-tb therapy –CAT I ( if sir don’t agree then say--- for 9 months to I year --)
What may happen following anti-tb in case of tuberculous lymphadenitis ?
Following anti-TB drug therapy, the LNs maybe enlarged. It is due to hypersensitivity reaction
to tuberculoprorein, released from dead mycobacteria
Which organism is responsible for cervical lymphadenopathy ?
the atypical mycobacteria
What are the atypical mycobacteria?
Atypical mycobacteria, also called non-tuberculous mycobacteria (NTM) or mycobacteria
other than TB (MOTT). The following are atypical mycobacteria---to remember ABC
A---mycobacterium avium intracellulare complex (MAC)
B---M. bovis
C--M. chelonei
M. xenopi
M. kansasii
what are the Rx of atypical mycobacteria ?
: If there is localised involvement in cervical LN, perform surgical excision.
Most organisms are resistant to standard anti-TB drug.
treatment is ---CER
 Clarithromycine 500 mg BD
 Ethambutol 15 mg / kg
 Rifabutin 3000 mg
202
if biopsy mark present what is diagnosis ? could it be leukaemia
 TB
 lymphoma
 malignancy
no it could not be leukaemia ---becauses in leukemia biopsy and FNAC is contra indicated
what investigation you want to do ?
 CBC and ESR & PBF
 MT
 FNAC and biopsy LN
 CXR—to see hilar lymphadenopathy
 USG—to see hepato-splenomegaly and intraabdominal lymphadenopathy
How will u exclude leukaemia ?
by seeing the PBF
causes of unilateral and bilateral hilar lymphadenopathy
Unilateral Bilateral hilar LN
 TB( primary TB)  sarcoidosis
 bronchial carcinoma  lymphoma
 lymphoma  TB
How MT help in diagnosis ?
in TB—MT positive
in sarcoidosis and lymphoma –MT negative
what is the normal size of lymph node ?
Normal LNs may be palpable in axilla, groin, usually up to 0.5cm, which are soft,
Submandibular LNs < 1 cm is normal in children 203
inguinal LNs<2cm is normal in adult
A patient have goiter and lymphadenopathy what is the diagnosis ?
papillary carcinoma of thyroid
what is Lyrnphoreticullar system?
Lyrnphoreticullar system includes LNs, spleen, tonsil, adenoid, Peyer's patch of ileum and Kupffer
cells in liver
if find LN palpable what else u want to examine ?
 LNs in other parts (axillary, inguinal, para-aortic, when asked to examine the neck only).
 Geneal examination – Anaemia and bony tenderness (leukaemia).
 Liver and spleen (lymphoma and leukaemia).
 Purpura or-bruise or petechiae (haematological malignancy).
 Palatal petechial haemorrhage (infectious mononucleo¬sis and leukaemia)
 draining of that lymphnode ---eg. If axilla LN  breast
how will describe lymph node finding
 examination of this patient reveals that patient have generalized lymph adenopathy
involving cervical, right axillary group and left inguinal group . There multiple, discrete,
rubbery ,nontender lymph node of variable size and shape largest of them in cervical region
is 2x 1 cm and in right axillary’s region is 1.5x1 cm and left inguinal region is 2x 1.5 cm .these
lymph node are not fixed with underlying structure or over lying skin and having no
discharging sinus
 examination of this patient reveals that patient have cervical lymph adenopathy involving
right submandibular both anterior chain and right supraclavicular lymph node . There
multiple, discrete, rubbery ,nontender lymph node of variable size and shape largest of them
in is 2x 1 cm these lymph nodes are not fixed with underlying structure or over lying skin
and having no discharging sinus 204
oedema

205
206
define oedema
oedema is an abnormal accumulation of fluid in the interstitium or in one or more cavities of the body
classification with example
according to distribution
 generalized and localized
according to depress on pressure
 pitting and nonpitting edema
generalized edema localized
 heart causes –CCF lymphatic obstruction/ lymphoedema
 liver causes –CLD  Filariasis
 renal cause -- nephrotic syndrome Venous causes
 other causes  Deep venous thrombosis or chronic venous
o mal absorption / malnutrition insufficiency
o protein-losing enteropathy Inflammatory causes.
o pregnancy Allergic causes
o drug  Angio-oedema (the face, lips and mouth )
What do u mean by pitting edema ? name some causes of non pitting edema ?
the oedema that leaves an indentation after pressure on the affected area is called 'pitting' oedema,
non pitting edema
lymphatic obstruction/ lymphoedema
 Infection: filariasis,
 Malignancy
 Radiation injury
 Congenital abnormality
myxoedema in hypothyroidism
pitting edema ---rest causes r pitting edema (eg heart , liver , kidney causes ) 207
in which malnutrition edema occur ? name some drug causes edema
Kwashiorkor
drug causes edema
 calcium channel blocker –Amlodipine , NSAID, steroid , OCP
name two endocrine disease where we get edema
 Conn
 hypothyroidism
if a diabetic patient come with edema what may be causes
o nephrotic syndrome
o due to loss of vasomotor tone
what is the mechanism of edema
there several causes –
 Decrease colloid osmotic (or oncotic) pressure due to hypoalbuminea ---(eg. Renal , git
causes)
 Increase hydrostatic pressure (heart failure)
 Increase capillary permeability (inflammatory causes )
 Secondary hyperaldosteronism (mainly in heart failure )
 Lymphatic obstruction
Where we see edema?
over the shin of tibia just above the medial maleolus …. Press with both thumb over both leg
for 10/ 15 sec ..during pressing you should look at patients face to pain
in case bed ridden patient
ask the patient to sit down see over sacrum or
zygomatic arch of face (tell only if ask where we see also) 208
mechanism of edema in different disease
heart failure due to increase hydrostatic pressure
Secondary hyperaldosteronism
nephrotic syndrome decrease colloid osmotic (or oncotic) pressure due to
hypoalbuminea
CLD portal hypertension
decrease colloid osmotic (or oncotic) pressure due to
hypoalbuminea
How will differentiate different type of edema?
heart failure HO
 Respiratory distress or breathlessness. orthopnea
 HO heart disease
 Edema first appear at dependent part (leg)
examination :
tachycardia
JVP raised
tender hepatomegaly
investigation :
ECG , ECHO , CXR—feature of heart failure
unrine RME—normal

209
nephrotic syndrome HO
edema first appear at face
HO of renal disease ---frothy urine . oliguria
no HO breathlessness
examination :
normal
investigation
urinary –protienuria (massive )
24 hr total urinary protein
serum albumin –decrease
CLD HO
 history jaundice , Alcohol , risk factor for HBV (sexual exposure
)
 swell first appear at abdomen / ascites
examination
 feature of hepatic insufficiency –hepatic faces ,
gynaecomastia , spider navi, loss body hair , engorged vein ,
splenomegaly , testicular atrophy
investigation
 viral marker (HBS ag) (anti-HCV)
 USG
 liver function test –Albumin , AG ratio
 endoscopy to see varices 210
tell one bed side test that can help u to diagnosis of cuases of edema
heat coagulation test --- nephrotic syndrome
what is lymphedema and why it is non pitting and causes ?
Normally, small amount of albumin filtered through the capillaries is absorbed
through lymphatics. In lym¬phatic obstruction, water and solutes are reabsorbed
into the capillaries, but the protein remains. Fibrosis occurs in the interstitial space
and the area becomes hard or thick. Non pitting on pressing .
causes of lymphoedema is due to lymphatic obstruction such as
 Infection: filariasis,
 Malignancy
 Radiation injury
 Congenital abnormality—turner , yellow nail syndrome
what investigation you will do in patient with edema ?
urine RME
24 hr total urinary protein
S.creatinine
RBS
ECG
CXR
ECHO
USG of whole abdomen
s.Albumin , A/G ration
211
What are the causes of unilateral leg swell?
 Deep venous thrombosis.
 cellulitis.
 Lymphoedema---filariasis
 Ruptured Baker's cyst.
How will differentiate DVT and cellulitis ?
DVT cellulitis
less erythemous , non toxic , less more erythemous , pt toxic , fever ,
rise of temperature high rise of local temperature

tenderness along the distribution of deep diffuse

venous system
infective foci absent present
leg swelling entire leg swelling localized swelling
calf swelling > 3 cm than opposite limb < 3 cm than opposite limb
collateral superficial present absent
vein
investigation CBC –normal CBC—leucocytosis
color dopplor --- + color dopplor --- negative
risk factor present immobilization DM
surgery
pregnancy
malignancy
212
ocp
What are thrombophlebitis and phlebothrombosis ?
Thrombophlebitis (superficial vein thrombosis): inflammation involving superficial veins (after
intravenous fluid or injection . Pain, Increased local temperature ,prominent superficial vein
Phlebothromhosis (DVT): thrombosis in deep veins is non-inflammatory in nature. Present with
unilateral swell
investigation of unilateral leg swelling
 CBC—
o eosinophil may be high in filariasis,
o leucocytosis---cellulitis
 Blood film to see microfilaria (usually at night)
 Compliment fixation test (CFT) or ICT for filaria.
 Lymphoscintigraphy
 FOR DVT
o D-dimer & Doppler USG of lower limb vessels
treatment of DVT
General measure
 Bedrest.
 Intermittent elevation of foot during day and night (above the heart level).
 Use of elastic 'stockings from midfoot to below knee (in calf thrombosis).
 Relief of pain by analgesic.
specific :
 Anticoagulation: low molecular wt heparin followed by warfarin
 If anticoagulation is contraindicated--- IVC filter(inferior venacava filter )
Complication OF DVT ? if patient comes with breathlessness what is the Dx? 213
grading definition
"Absent" Absent or unilateral
Grade + Both feet / ankle
Mild:
Grade ++ Both feet, plus lower legs,hands or lower arms
Moderate:
Grade +++ Generalised
Severe bilateral pitting edema,
including both feet,legs, arms and face
00+= no pitting edema
1+= mild pitting edema , 2 mm depression that disappears rapidly
2+= moderate pitting edema ,4 mm depression that disappears in 10-15 second
3+= moderately severs pitting edema ,6 mm depression that may last more than 1
minute
4+= severe pitting edema 8mm depression that can last more than 2 minutes 214
CLUBBING

215
216
217
Define clubbing?
It is a selective bulbous enlargement or swelling of the terminal phalanges of the fingers and
toes particularly on the dorsal surface due to proliferation of the soft tissue of the nail
Causes
Respiratory
 Bronchial carcinoma (squamous cell).
 Suppurative lung disease
o bronchiectasis,
o lung abscess and
o empyema thoracis
 Fibrosing alveolitis or ILD
 Pulmonary TB (in advanced stage with fibrosis).(don’t tell in viva)
 Pleural mesothelionna.
Cardiac
 SBE.subacutbacterial
 Conqenital cyanotic heart disease.
o Fallot's tetralogy (clubbing with cyanosis).
o Eisenminger's syndrome
Chronic abdominal disorders
 IBD
o Crohn's disease
o Ulcerative colitis
 Cinhosis of the liver
Familial 218
if sir want to know more then thyroid ---graves disease
What is differential clubbing? What are the causes?
It means clubbing in the toes, but not in the fingers
Causes of differential clubbing
 Patent ductus arteriosus with reverse shunt (also there is cyanosis in toes, not
in finger called differential cyanosis).
 Infected abdominal aortic aneurysm.
 Coarctation of abdominal aorta
Causes of unilateral clubbing
 Axillary artery aneurysm.
 Bronchial arteriovenous aneurysm.
 Others: aneurysm of ascending aorta, sub¬clavian or innominate artery.
Causes of clubbing in a single finger
 Trauma (the commonest cause).
 Chronic tophaceous gout.
 Sarcoidosis.
Causes of clubbing with cyanosis
 Fibrosing alveolitis./ILD
 Cyanotic heart disease (Fallot's tetralogy).
 Cystic fibrosis.
 Bilateral extensive bronchiectasis.
219
220
221
staging of clubbing
1. Stage one: increased sponginess of proximal nail bed (fluctuation is positive). due to increased
prolif¬eration of cells at nail base
2. Stage two: Obliteration of the angle of the nail (i.e. the angle between nail base and its adjacent skin,
the angel of Lovibond).
3. Stage three: Increased curvature of nails. Hence nails become convex
4. Stage four: Drumstick appearance
5. Stage five:Hypertrophic osteoarthropathy
what is Hypertrophic osteoarthropathy
This is the combination of clubbing and Thickening of the distal ends of the long bones especially at wrists
and ankles.It is due to subperiosteal new bone formation.
found in bronchial carcinoma
how will examination of clubbing
step one :
first inspection ---
sit down and keep the patient both palm on your hand and look at the angle between nail base and its
adjacent skin ----patient hands and your eyes will remain same horizontal plane /
step two:
now do fluctuation test
step three
now do
Schamrotb's signor Schamrotb's window test :
place the terminal phalanx / digit of thumb against each other
normally there is a diamond shape space between two nail bed
in clubbing space is disappear
Step four
do only if clubbing present to see Hypertrophic osteoarthropathy present or not 222
slightly press over distal surface of ulna and radius and patient will feel pain
223
What are the mechanisms of clubbing?
exact causes is not known
 Arterial hypoxaemia
 Vasodilatation ( due to some humoral factor
bra¬dykinin, prostaglandins, 5-hydroxytryptamine)
 secretion of growth factors (such as Platelet-derived
growth factor (PDGF) released from megakaryocyte)
Causes of acute clubbing ?
lung abscess
infective endocarditis

224
225
Upper limb –is normal
Lower limb ----clubbing

differential
clubbing

226
 koilonychias
What are the causes of koilonychias?
Iron-deficiency anaemia
if sir want to know other causes then only say the following otherwise not :
 Trauma
 Thyrotoxicosis.
 Fungal infection
Q: What is koilonychia?
A: A disorder in which nail is concave or spoon shaped.
Q: What is the mechanism of koilonychia?
A: Unknown, result from slow growth of nail plate.
What are the stages of koilonychia?
 Dryness, brittleness and ridging (first stage).
 Flattening and thinning (second stage).
 Spooning or concavity (third stage).

227
228
229
230
 leuchonychia

What is leuchonychia ?
Whitish discoloration of nail.
Leuconychia indicates hypoalbuminaemia
What are causes of leuconychia ?
 Renal cause (nephrotic syndrome)
 Liver diseases (CLD, cirrhosis of liver).
 Malnutrition (malabsorption,).
 May be normal finding

231
 what information or disease u can diagnose by The
handshake ?
Features Diagnosis
Cold, sweaty hands Anxiety
Hot, sweaty hands Hyperthyroidism
TO REMEMBER
cold calmy skin shock
Large, fleshy, Acromegaly
DR .SHARMA
sweaty hands D- Dupuytren’s contracture
Dry, coarse and Hypothyroidism R- Rheumatoid arthritis
rough skin S— shock
Cold, dry hands Raynaud’s phenomenon H— Hyperthyroidism &
Deformed Rheumatoid arthritis Hypothyroidism
hands/fingers Dupuytren’s contracture A- Anxiety
Delayed relaxation Myotonic dystrophy R- Raynaud’s phenomenon
of grip M— Myotonic dystrophy
A-- Acromegaly

232
What information you may get from the nail
SHE BLOCK MY RIB
S--Splinter haemorrhages Infective endocarditis, vasculitis

H-- Half and half naIL proximal portion white to pink and distal portion red orbrown:
Terry’s nails)
Chronic renal failure, cirrhosis
E-- Nail fold erythema Systemic lupus erythematosus
and telangiectasia
B -Beau’s lines Non-pigmented transverse bands in the nail bed
found in Fever, cachexia, malnutrition
L -Leuconychia Hypoalbuminaemia
O --Onycholysis Thyrotoxicosis, psoriasis,
C-- Clubbing Lung cancer, lung abscess , infective endocarditis,
cyanotic heart disease, IBD
K-- Koilonychia spoon-shaped nails
Iron deficiency, fungal infection, Raynaud’s disease
M --Mees’ Single transverse white band
found in Arsenic poisoning, renal failure or severe illness
Y --Yellow nails Yellow nail syndrome
R --Red nails Polycythaemia (reddish-blue),
carbon monoxide poisoning (cherry-red)
I—infarction in nail Infective endocarditis, vasculitis 233
B --Blue nails Cyanosis, Wilson’s disease
234
235
236
INFORMATION FORM HAND
nail finger palp
clubbing janeway lision
koilonychias oslar node
leuconychia
splinter haemorhagge
capillary refilling –dehydration
nail infarction
palmer dorsum
palmer erythema dorsal guttering
Dupuytren’s contracture swan neck
claw hand boutonniere
wrist drop Z from
wasting of thenear and ulnar deviation
hypothenaer swell finger
Myotonic dystrophy grotron papule
finger Anxiety
rheumatoid nodule Hyperthyroidism
calcinosis Raynaud’s phenomenon
tophi Acromegaly
trigger finger

237
what is palmer erytema
Palmar erythema is a reddening of the skin on the palmar aspect of the hands,
usually over the hypothenar eminence. It may also involve the thenar eminence
and fingers. It can also be found on the soles of the feet, when it is termed
plantar erythema.
pathogenisis
increase circulating levels of estrogen in both cirrhosis and pregnancy,
estrogen was thought to be the cause for the increased vascularity
Causes of palmar erythema
C--TROPP
 C--Cirrhosis
 T--Thyrotoxicosis
 R--Rheumatoid arthritis
 O—Oral contraceptic pill
 P--Pregnancy
 P--Polycythaemia

238
what is Spider telangiectasia?
Spider telangiectasia is a central arteriole from which small vessels radiate
What is the site ?
o along the distribution of superior vena cava circulation
o usually above the nipple
o Normally found: 1or 2 in 2 % people
what is the causes ?
Cause due to: hyper dynamic circulation. In case of CLD due to access
oestrogen as metabolism of oestrogen decreased by diseased liver.
C--PHOT
 C-CLD
 P-pregnancy
 H-viral hepatitis
 O-OCP
 T-thrytoxicosis ,
How will u see it?
With the help of pin head or glass slide
How will differentiate between purpura and spider nevi ?
Purpura does not blanch on pressure (as it extravascular )
Spider nevi : Blanch on pressure and when release the pressure it will reappear

239
What is gynaecomastia?
Enlargement of male breast tissue due to proliferation of glandular component.
causes 0f gynaecomastia ?
To remember --- BLAST3
B—Bronchogenic carcinoma
L—chronic liver disease
A—Adrenal carcinoma
S—spirolactone
T1--Testicular tumour (leydig cell),
T2-- Testicular failure (trauma, orchitis, radiation)
T3---Thrytoxicosis
What is the mechanism of gynaecomastia ?
Mechanism: Either due to increase activity of oestrogen or decrease activity of
testosterone
How to differentiate gynaecomastia from lipomastia
Lipomastia is due to deposition of fat in the breast. Therefore, it is soft.
Gynaecomastia is the enlargement of male breast due to glandular tissue proliferation.
Hence, it is firm, hard or rubbery
Name some drug responsible gynaecomastia ?
Spirolactone , cemitidine , digoxin
Cause of gynaecomastia is in CLD?
Due CLD it self @ drugs spirolactone
differentiate between two -- Painful gynaecomastia found in Spirolactone

240
where and how bony tenderness is seen
Test bony tenderness by pressing over the manubium sternum with
right thumb but look at the face of the patient while pressing.
where bony tender ness is positive ?
acute leukaemia
other sites ?
over clavicle
scapula
spine
how many pressure is given ?
4 dyne or until nail become white

241
 Dupuytren contracture ?
Dupuytren disease is a fibrosing disorder characterized by is a fixed flexion
contracture of the hand due to slowly progressive thickening and shorting of
the palmar fascia
 it causes flexor deformity of metacarpophalangeal (MCP) joints or the
proximal interphalangeal (PIP) joints
 usually affects the fourth and fifth digits (the ring and small fingers)
causes
DM
CLD
Alcoholism
idiopathic

•Grade 1 - Thickened nodule and

band in the palmar aponeurosis; may
have associated skin abnormalities
•Grade 2 - Development of
pretendinous and digital cords with
limitation of finger extension
•Grade 3 - Presence of flexion
contracture
242
243
 information u got form the tongue
size macro glossia
microglossia
dry tongue dehydration , sjogren’s syndrome
color pale tongue anemia (pale and smooth and loss of papillae
–iron def anaemia)
yellow jaundice
blue tongue cyanosis
Magenta riboflavin deficiency
pigmentation Addison
surface Raw beef tongue red swollen and painful tongue ---Vit—B12
change strawberry tongue scarlet fever
leucoplakia HIV
angry looking tongue central coating with red tip and margin —
enteric fever
geographic
ulcer in tongue –apthous ulcer , malignant ulcer , bechet
disease , celiac disease , SLE
neurologic spastic tongue pseudo bulbar palsy
tongue flaccid tongue with fasciculation bulbarpalsy
loss of taste sensation --- ant 1/3 – facial nerve
post 2/3 –gloss pharyngeal nerve
244
Hereditary haemorrhagic
telangiectasia (HHT)

245
246
what are the causes of macroglossia and microglossia ?
macroglossia to remember ADAM Microglossia
 Acromegaly  cerebral diplegia
 Down syndrome  MND
 Amyloidosis (primary )  wasting of tongue due to LMN of XII
 Myxoedema (hypothyroid ) nerve
 Bulbar and pseudo bulbar palsy
what is the site of test sensation ?
sweet –tip
sour –at margin
bitter –at posterior
salt –any where
What do u mean by halitosis ?
mal odorous breath …or foul-smelling breath is called Halitosis
causes
 poor oral hygiene
 lung abscess
 bronchiectasis
 hepatic and renal failure
 intestinal obstruction

247
 What information u can get from eye
from eye  anaemia
 jaundice
 subconjuntival haemorrhage
 blue sclera –
 KF-ring –willson
 Arcus senilis
eye lid  xanthelasema –hypercholesterolemia Causes of blue sclera--
 unilateral complete ptosis –3rd nerve palsy , HOME
 unilateral partial ptosis—Horners syndrome m-Marfans
 bilateral ptosis ----myasthenia graves H--Homocystinuria
 exophthalmas ---graves disease E--Ehlers-Danlos
 lid leg and lid retraction –graves disease syndrome
pupil  dilated ---3rd nerve O--Osteogenesis
 constricted pupil – OPC poisoning /horner imperfecta
 pin point –pontine haemorrhage
 irregular pupil --- Argyl Robertson pupil
fundoscopy  DM and HTN retinopathy
 optic atrophy
 papillaedema
 roth spots --- SLE, infective endocarditis ,
aplastic anaemia

248
Temperature

249
VITAL SIGNS
Certain important measurements must be made during the assessment of the patient. These relate
primarily to cardiac and respiratory function and
comprise:
● pulse (page 63)
● blood pressure (page 67)
● respiratory rate (page 138)
● temperature (page 36).

250
What is the normal temperature ?
Normal temperature is 370 C or 98.40 F
Site where temperature seen?
in oral cavity-- under surface of the tongue
in the axilla
in rectum or internal ear
Where core temperature is seen?
in rectum or the external auditory meatus
What is the difference of temperature in different site?
temperature in mouth is 0.5°C or 1 0 F higher than the axilla
temperature in rectum is 0.5°C or 1 0 F higher than the mouth
When temp is highest n lowest? What Is the diurnal variation of temp?
body temperature is lowest in the morning and reaches a peak between 6 pm and
10 pm
this diurnal difference is not more than 0.50 C
What do you mean by fever?
Fever is an elevation of body temperature that exceeds the normal daily variation
and occurs in conjunction with an increase in the hypothalamic set point (e.g., from
37°C to 39°C).
What do you mean by hyperthermia ?
Hyperthermia is characterized by an uncontrolled increase in body temperature that
exceeds the body's ability to lose heat. The setting of the hypothalamic
thermoregulatory center is unchanged 251
What is hyperpyrexia?
when body temperature increases hyperpyrexia defined as above 41.6°C
causes
cerebral malaria
garm negative septicaemia
heat stroke
malignant hyperthermia-drug
 anaesthetic agents [e.g. halothane] or
 muscle relaxants [e.g. suxamethonium]),
 the neuroleptic malignant syndrome (a reaction to antipsychotic medication)
intracranial haemorrhage or head injury

Deference between hyperthermia and fever

FEVER HYPERTHERMIA
causes /pathology Involve pyrogenic Failure in thermoregulatory
cytokines homeostasis
Change in occur remain unchanged
hypothalamic set
point
temp Rarely exceed 41 0 C Can exceed 41 0 C
Complications rare common
Diurnal variation present Absence
252
Classify fever with definition and example?
Type of fever
 Continued
 Remittent
 Intermittent -
o a.Quotidian
o b.Tetrtian
o C.Quartan
1. Continued fever : When fever does not fluctuate more than about 1` C (1.5' F) during
24 hours but never touches the base line is called continued fever.
 Causes :-
I. I .Typhoid fever
II. 2- Millar,y tuberculosis
III. Lobar pneumonia
2. Remmittent fever
 When daily fluctuations exceed 20C called remittent fever.
 Causes
I. Amoebic liver abscess
II. Lung abscess
III. Collection of pus in the tissues

253
3. Intermittent fever
When the fever is present only, for several hours during the day it is called
intermittent-fever.
a) Quotidian:
When a paroxysm of intermittent fever occurs daily. the type is quotidian.
Cause - Kala-azar (double quotidian)
b) Tertian
When fever comes on alternate days, it is tertian.
Causes: P. Vivax and P .Ovale Malaria.
C) Quartan
When there is Two days interval between two consecutive attacks. Then it is call
quartan.
Cause- P. Malariae infection.

Pel-Ebstein fever
A specific kind of fever associated with Hodgkin's lymphoma, being high temp for one
week and low temp for the next week and so on

Stepladder pattern
Typhoid fever may show a specific fever pattern, with a slow stepwise increase and a high
plateau
254
255
Fever with relative bradycardia Fever with relative tachycardia
in this condition increase pulse rate less increase pulse rate more than 10 / min for
than 10 / min for per degree F increase of per degree F increase of temperature is
temperature – called relative tachycardia
example : Example :
1. viral fever --dengue 1. acute rheumatic fever
2. first week of enteric fever, 2. polyarteritis nodosa
other
1. pyogenic meningitis
2. leptospirosis
3. brucellosis
Causes fever with rash according to day of appearance?
very sick person must take double eggs
1. 1st day -> very --varicella (chicken pox )
2. second day  sick --scarntlet fever
3. third day  person -- pox (small pox)
4. fourth day  must --measles , rubella /german measles
5. fifth day  take --typhus
6. six day  double --dengue
7. seven day  eggs ---enteric fever
256
 a patient with three days more than 7 day fever
fever fever with
unconsciousness
viral fever enteric fever
 cerebral malaria
malaria Malaria
 encephalitis
UTI pneumonia  meningo-
pneumonia TB (>2week) encephalitis
kala-azar (>2week)
liver absecess
PUO?
PUO is defined as a temperature persistently above 38.0
°C for more than 3 weeks, without diagnosis despite
initial investigation
during 3 days of inpatient care or
after more than two outpatient visits
Causes of PUO : MIC
Malignancy----
 Heamatological malignancy :lymphoma, leukamia,
myeloma
 Solid tumour : renal,liver,colon carcinoma
Infection-------Abscess, infective endocarditis , TB 257
Connective tissue disease—SLE , vasculitis , adult still
What is hypothermia ?
Hypothermia is defined as a temperature of less than 35°C.
Usually measure in core temperature
 Prolong water immersion
 exposure to cold weather (elderly immobile patients)
 severe hypothyroidism/maxedema coma
 drug overdosage
 alcohol intoxication
 stroke or head injury
What is Fictitious fever? Clue of Fictitious fever ?
Fictitious fever is produced artificially by the patient or an attendant
A—appearancc—Patient looks well
B— Bizarre temperature chart with temperatures >41°C
C— No correlation between temperature and pulse rate
D--- absence of diurnal variation
E— ESR and C-reactive protein is normal
F—fall of temp—No sweating during when temp fall or subsided
g—X
H— Evidence of self-harm ,injection
I—independent observer—Temperature is normal when taken by an independent
supervised observer
258
causes of immune-compromise 3 D
D---due to disease
1. DM
2. HIV
3. Malignancy –lymphoma , leukemia
4. Disease of different organ
a. Renal failure
b. Liver cirrhosis
D—drug
1. Corticosteroids
2. Chemotherapy
3. immunosuppressants drug
D—deficiency
1. Malnutrition
2. Splenectomy

259
260
Machine needed to measure BP
•BP machine
•stethoscope
name of BP machine is
sphygmomanometer
part are :

1. inflatable bladder with cuff

2. Meter
3. Pump
The standard cuff is 12 ×23 cm appropriate  , If the cuff is too small(narrow), the
for arm circumferences . blood pressure will read high
the inflatable bladder of the cuff
 Width of should be about 40% of upper  if the cuff is too large(wide), the blood
arm circumference (about 12–14 cm in pressure will read
the average adult). o low on a small arm and
 Length should be about 80% of upper o high on a large arm
arm circumference (almost long
enough to encircle the arm).
261
how measure BP pressure?
pre-requisite
Use a machine that has been validated, well maintained and properly calibrated
Measure sitting BP routinely, with additional standing BP in elderly and diabetic patients and
those with possible postural hypotension
Remove tight clothing from the arm
Support the patient's arm comfortably at about heart level.
Two method
 plapatory and
 auscultatory
1. Apply the cuff to the upper arm with the centre of the bladder over the brachial artery
2. Use a cuff of appropriate size (the bladder must encompass > two-thirds of the arm)
3. Palpate the brachial pulse.
4. Inflate the cuff until the pulse is impalpable. Note the pressure on the manometer. This is a
rough estimate of systolic pressure
5. now inflate the cuff another 10 mmHg and listen through the stethoscope over the brachial
artery.
6. Deflate the cuff slowly (2 mmHg per second) until regular sounds are first heard. Note the
reading to the nearest 2 mmHg. This is the systolic pressure.
7. Use phase V (disappearance of sounds) to measure diastolic BP
8. Take two measurements at each visit

262
Write down the phases of Korotkoff sounds ?
five phases of Korotkoff sounds as the cuff is deflated:
Phase 1: the first appearance of the sounds marking systolic pressure
Phase 2 and 3: increasingly loud sounds
Phase 4: abrupt muffling of the sounds
Phase 5: disappearance of the sounds
phase 1 is systolic BP and phase : 5 is diastolic BP
SN : in those conditions where Korotkoff sounds remain audible despite complete
deflation of the cuff (aortic regurgitation, arteriovenous fistula, pregnancy) here
phase 4 must be used for the diastolic measurement
Define BP and classify?
sustained elevation of blood pressure / arterial pressure above the normal level is
called Hypertension
two type
 Essential hypertension ((95%)
 Secondary hypertension (5%)

263
casues of secondary hypertension ?
to mnemonic REDCAP C— Coarctation of the aorta
R—renal disease, , A—Alcohol
 renal Parenchymal disease, P—pregnancy
glomerulonephritis
 renal artery stenosis
 polycystic kidney disease
E-endocrine --2C,2T,2P
 Cushing
 conns syndrome
 hypothyroidism
 hyperthyroidism
 phaeochromocytoma
 hyperparathyroidism
D--Drug
 OCP
 NSAID
 steroid
what is white coat hypertension
When BP measurement by physician show apparent hypertension in the clinic but
show normal BP when it is recorded by automated devices used at home.
264
it occur 20% patient
Could be the blood pressure may differ in both hand?
yes
usually it is 5 to 10 mm of Hg
Pressure difference of more than 10–15 mm Hg occurs in
 subclavian steal syndrome,
 aortic dissection
 Coarctation of the aorta proximal to left subclavian artery
what is isolated systolic blood pressure?
when systolic blood pressure is ≥140 mm Hg, and diastolic blood pressure is <90 mm
Hg.
what is the target BP?
in normal population
 140 /90 mm of Hg
in DM
130 /85 mm of Hg
if proteinuria >1 gm/24 hr (CKD)
125/80 mm of Hg
What are causes of hypotension?
 shock
 hypovolumia
 Addison disease 265
what is postural hypotension
Orthostatic hypotension/ postural hypotension
it is defined as a fall in systolic blood pressure of at least 20mm Hg and diastolic blood pressure of at
least 10 mm Hg when a person assumes a standing position from sitting position
Causes of postural hypotension ?
 hypovolemia
 drug
o Diuretics, vasodilators, antidepressants
 Addison's disease
 DM
 Parkinson's disease
How will measure?
how to measure :
1. first measure BP in supine position
2. now deflate the bladder
3. ask the patient to stand
4. again inflate the bladder and measure the BP after 2 min of standing but within greater within 3
minutes of standing
what is the treatment of postural hypotension
non pharmacological :
 correct hypovolemia
 stop the drug
 Support stockings—compression bandage
pharmacological :
 Non-steroidal anti-inflammatory drugs (NSAIDs)
 Fludrocortisone 266
 α-adrenoceptor agonist (midodrine)
if patient is pulse less how will measure the BP
if patients are pulseless due to from Takayasu arteritis, atherosclerosis
if only in upper limb measure in lower limb keeping the patient on prone position and
wrap cuff on thigh and measure in popliteal atery .
if all limb are pulseless then measure with droppler flow
what is the causes of BP more in leg or arm then corresponding
BP more in leg then arm
Takayasu arteritis
Bp more in arm then leg
coractation of aorta
How will measure BP if patient mid arm circumference is more ?
 If the arm circumference is >50 cm and not amenable to use of a thigh cuff
 wrap an appropriately sized cuff around the forearm,
 hold the forearm at heart level and feel for the radial pulse
 and measure BP on radial artery
What will u do When you cannot hear Korotkoff sounds at all, ?
estimate the systolic pressure by palpation
what is malignant hypertension

what is hypertensive urgency and emergency ?

267
 hypertensive crisis

Hypertensive
emergency
Hypertensive
urgency 268
Hypertensive what it is Severe elevation of BP > 180 / 120 mm of Hg
emergency complicated by evidence impending or
progressive target organ damage .  They
require immediate reduction of BP reduction
( not necessarily to normal )
example HTN Encephalopathy
 Intracerebral haemorrhage
 Acute MI
 Acute LVF
 Acute pulmonary edema
 Unstable angina
 Eclampsia
place of Rx Treatment in ICU with monitor Parental
administration of Anti- HTN
Goal of therapy ↓ BP not more then 25 % in 1 st hour.
target BP 160/110 mm Hg in next 6 hrs
Then reduction of BP to normal in next 24 -48
hrs
hazard of sudden fall Sudden fall may cause
o Cerebral ischemia
o Renal ischemia
o Coronary ischemia
269
Hypertensive define Hypertensive urgency is Severe elevation
urgency of BP without target organ damage
Upper level of stage ii
Patient is noncompliant or inadequate
treated HTN with little or no Target organ
damage
example Severe head ache
 Epistaxis
 Dyspnea
 Severe anxiety

270
Malignant’ or ‘accelerated’ phase?
Refers to a rapid rise in BP leading to vascular damage (pathological hallmark is fi
brinoid necrosis in the walls of small arteries and arterioles).
The diagnosis is based on evidence of
 high BP Usually (eg systolic >200, diastolic>130mmHg)
 and rapidly progressive end organ damage, such as
o retinopathy (grade 3 or 4),
o renal dysfunction (especially proteinuria) and/or
o hypertensive encephalopathy
o Left ventricular failure may occur

prognosis?
Untreated, 90% die in 1yr; in Davidson –( untreated, death occurs within months)
treated, 70% survive 5yrs.
It is more commo in younger patients and in black patients

271
PULSE

272
what are the vital sign ?
 Pulse
 Bp
 Respiratory rate
 Temperature

Difference between carotid and arterial pulsation

carotid / arterial pulsation venous / JVP
direction Rapid outward movement Rapid inward movement
per heart One peak per heartbeat Two peaks per heartbeat
beat
palpable Palpable Impalpable / only visible
pressure Pulsation unaffected by Obliterated/ diminished by pressure
pressure at the root of the at the root of the neck
neck
position Independent position and varies with respiration and position
respiration
hepato- no change Rises with abdominal pressure
jugular
273
reflux
In examination of pulse what will u see?
Rate
Rhythm
Volume
Character
Radio-radial delay
Radio-femoral delay
Condition of vessel wall

Rate and rhythm seen –radial artery

Volume and character is seen in carotid artery
also in brachial & femoral artery
274
Causes or sinus tachycardia and sinus bradycardia ?
Cause of sinus tachycardia Cause of sinus bradycardia?
Fast heart rate (tachycardia, > 100/min) Slow heart rate (bradycardia, < 60/min
 Physiological  Sinus bradycardia
o Exercise o Sleep
o Pain o Athletic training
o Excitement/anxiety o Hypothyroidism
 Hyper dynamic circulation o Medication:
o Fever  Beta-blockers
o Hyperthyroidism  Digoxin
 Medication:  Verapamil, diltiazem
 sympathomimetics  Pathological
sulbutamol  Carotid sinus hypersensitivity
 vasodilators  Sick sinus syndrome
 Pathological  Second-degree heart block
o Atrial fibrillation  Complete
o Atrial flutter
o Supraventricular tachycardia
Ventricular tachycardia
275
What are causes of irregular pulse? Cause of low volume pulse?
 Irregularly irregular  Shock
o Atrial fibrillation  Aortic stenosis
o Atrial flutter with variable response  Pericardial effusion
o Multiple ectopics  Pulmonary hypertension
 Regularly Irregular
o Sinus arrhythmia
o Second-degree heart block Type –I
o Ventricular extrasystoles
Causes of radio radial delay and radio- Cause of high volume ?
femoral delay?
 Radio-femoral delay  AR
o coarctation of the aorta distal to  Hyperdynamic circulation
left subclavian artery o Fever
 Radio-radial delay o Pregnancy and
o coarctation of aorta proximal o Thyrotoxicosis
o PDA
what are causes of absence of pulse in causes of absence of pulse in lower limb ?
upper limb ?
 takayasu disease  peripheral arterial diseases
 Atherosclerosis  Buerger's disease (thromboangiitis
 thrombo-embolism obliterans)
 aberrant vessel  Vasculitis
276
What are feature of coarctation of aorta ?
 patient have headache
 pulse –radio-femoral delay
 BP—more in upper limb than in lower limb
 Murmur ---systolic murmur at midscapular region
What are feature of takayasu disease ?
it is vasculitis
 patient have HO claudication in upper limb
 pulse ---absent in upper limb
 BP—high
 bruit ---renal , carotid present
 heart –Murmur of aortic regurgitation

277
CHARACTER
OF
PULSE

278
type of different pulse
normal
A Slowly rising & small volume pulse Aortic
Anacrotic stenosis
A Pulsus alternans an alternating strong and weak pulsation LVF

B Pulsus bisferiens Double peak of pulse , combination of slow AS with

rising and collapsing pulse AR
C collapsing Rapid upstroke and descend of pulse. the pulse AR,
which feels as though it suddenly hits your  Hyperdynamic
fingers and falls away just as quickly and seen circulation
by raising the arm above the head .  PDA
 Rupture of sinus of
Valsava
 Large A-V fistula
W waterhammer Collapsing pulse of AR is called water hammer AR
pulse
P Pulsus paradoxus When volume of pulse reduce in inspiration  Pericardial effusion
and increase in expiration then it is called  Chr.constrictive
pulsus paradoxus .it is the exaggeration of pericarditis
normal phenomenon .  Acute severe asthma
 Massive pulmonary
embolism
J Jerky pulse : Hypertrophic
cardiomyopathy 279
280
 Difference between neurogenic and arterial claudication

Arterial Neurogenic
Pathology Stenosis or occlusion Lumbar nerve root or cauda equina
arteries compression (spinal stenosis)
Site of pain Muscles, usually the calf according to dermatome . May be
associated with numbness and tingling
Onset Gradual after walking Often immediate upon walking or even
the 'claudication standing up
distance'
Relieving On the cessation of Eased by bending forwards and stopping
features walking walking. May have to sit down to obtain
full relief
Colour pale Normal
Temperature cool Normal
Pulses Reduced or absent Normal
Straight leg Normal May be limited
raising
sensory and Normal may absent
jerk 281
What are the sign of acute limb ischaemia ?
Soft signs Hard signs (indicating a threatened
limb)
Pulseless Paraesthesia
Pallor Paralysis
Perishing cold Pain on squeezing muscle
Acute limb ischaemia - embolus vs thrombosis in situ
Clinical features Embolism Thrombosis in situ
Onset Seconds or minutes Hours or days
Embolic source Present (usually AF) Absent
Previous claudication Absent Present
Contralateral leg pulses Present Absent
Diagnosis Clinical Angiography
Treatment Embolectomy, Medical, bypass,
warfarin thrombolysis

282
SKIN

283
Macule A localized area of colour or
textural change in the skin

Papule A solid elevation of skin < 5 mm

diameter

Nodule A solid elevation of skin > 5 mm

diameter

Plaque A palpable elevation of skin > 2

cm diameter and < 5 mm in
height

284
Vesicle A clear, fluid-filled blister < 5mm

Pustule A visible collection of pus in a

blister

Bulla A fluid-filled blister > 5 mm

diameter

Wheal Wheal An area of dermal

oedema

285
Excoriation A superficial abrasion, often
linear, due to scratching

Fissure A linear split in epidermis,

often just extending into
dermis

Erosion A superficial break in the

epidermis, not extending
into dermis, which heals
without scarring

Ulcer A circumscribed area of skin

loss extending into the
dermis
286
 Petechia A haemorrhagic punctate spot 1-2 mm
diameter

Purpura Extravasation of blood resulting in red

discoloration of skin or mucous
membranes

Telangiectasia Dilated dermal blood vessels resulting in a

visible lesion

Ecchymosis A macular red or purple haemorrhage, > 2 mm

diameter, in skin or mucous membrane

Erythema Redness of the skin due to vascular dilatation

287
 Scales An accumulation of excess
keratin( easily detachable )
Sclerosis Induration of subcutaneous
tissues, which may involve the
dermis
Crust Dried serum and exudates
Lichenification Chronic thickening of skin with
increased skin markings,
resulting from rubbing or
scratching
Atrophy Thinning of the epidermis with
loss of normal skin markings
Callus Local hyperplasia of the horny layer, often on palm or sole, due to
pressure
Comedo A plug of sebum and keratin wedged in a dilated pilosebaceous
orifice on the face
Cyst A nodule consisting of an epithelial-lined cavity filled with fluid or
semisolid material
Freckle A macular area showing increased pigment formation by
melanocytes
Wheal A transitory, compressible papule or plaque of dermal oedema, red
or white in colour, and usually indicating urticaria
288
What r skin manifestation of systemic disease ?
Necrobiosis lipoidica DM
Erythema nodosum Sarcoidosis, tuberculosis, IBD
Pyoderma gangrenosum Ulcerative colitis, rheumatoid
arthritis
Dermatitis herpetiformis Gluten enteropathy/ COELIAC
DISEASE
Xanthelasma Hypercholesterolemia
purpura ITP, vasculitis
spider Telangiectasia CLD
Acanthosis nigrican CA-stomach

289
What do you mean by Petechia, Purpura, Ecchymosis?
Petechia A haemorrhagic punctate spot 1-2 mm diameter/ Pinhead-sized
Purpura Extravasation of blood resulting in red discoloration of skin or mucous
membranes
Ecchymosis A macular red or purple haemorrhage, > 2 mm diameter, in skin or mucous
membrane
Define purpura ?
extravasation of blood from the capillary in the skin and mucous membrane that not
blanch on pressure is called purpura
Causes of purpuric spot?
haematological –
 acute leukaemia
 aplastic anaemia
 ITP
infective :
 dengue
 meningococcal septicaemia
drugs
vasculitis
 Henoch –schonlein purpura
 Infective endocarditis
others :
senile purpura
SLE, DIC 290
What is the feature of purpura due to vasculitis ?
it is usually painful and palpable
How will differentiate between purpura from spider telangectasia ?
spider telangectasia purpura
it is arteriolar dilatation is extravasation of blood from capillary
it doesn’t blanch on pressure it blanch on pressure
What are the DD of purpura?
 Mosquito bite
 Drug rash
 Spider telangectasia
 Campbell de morgan spots : these are small nodular reddish lesion that do
not blanch on pressure , occure on trunk and upper abdomen resolve
spontaneously . it is benign angioma
What is the bed side test for purpura ?
tourniquet test or Hess test
BP machine cuff is inflate over arm keep 5 min in between systolic and diastolic
pressure and after deflation look for purpuric spot in anticubital fossa
less 5 spots is normal
test is positive if >10 spots
291
Causes of purpura with normal platelet count? (remember first 3 only )
Causes of non-thrombocytopenic purpura
Senile purpura
Henoch-Schönlein purpura
Vasculitis
Factitious purpura
Paraproteinaemias
Purpura fulminans
what investigation u want to do ?
CBC
PBF
Platelet count
BT—bleeding time
CT—clotting time –PT , APTT
how will differentiate bleeding to clotting abnormality and thrombocytopenia
clotting disorder (hameophillla ) thrombocytopenia
deep site ---joint , muscle haematoma superficial—epistaxis , purpura
family history positive not so
platelet count normal decrease
BT—normal BT— increase 292
CT—increase CT— normal
Causes of thicken skin?
 hypothyroid
 systemic sclerosis
 acromegaly
 DM
 amyloidosis
Causes of thin skin
 cushing
hypo pigmentation hyper pigmentation
Albinism Haemochromatosis
Vitiligo Addison
ptyriasis versicolor CLD
leprosy CRF
systemic sclerosis Nelson's syndrome
Drugs

293
Eyes,
upwards subluxation of
lens
blue sclera
mouths
high arch palate
chest
pectus carinutum and
excavatum
spine
scoliosis and
kyphosis
lung
pneumothorax
heart
AR
Mitral prolapsed
dissecting aneurysm
MSK
Joint hypermobility
wrist sign and thumb sign
294
arachnodactyly
pectus arm span > thumb sign wrist sign
excavatum height
thumb sign (Steinberg test):asking the patient to clench his thumb in
his fist; the thumb should not exceed beyond the ulnar side of the
hand in normal subjects but because of hypermobility and laxity
of the joint in Marfan’s disease the entire thumbnail projects beyond
the border of the hand
• wrist sign (Walker–Murdoch sign):when the wrist is grasped by the
contralateral hand, the thumb overlaps the terminal phalanx of the
fifth digit by at least 1 cm in 80% of patients
295
DOWN syndrome

296
297
single palmer crease
short 5th finger
curved inward

flattened nose , upward slanting eye , large

gap between first tongue
and
second toes

298
to remember GOST WALL Narrow
G=Gynaecomastia
O=Osteoporosis
S=Small testis and penis
T=Tallstature
W=Wide hip and female type of
pubic hair
A=Absent of frontal baldness
L=Less hair on chest
L=Less or poor beard growth
Narrow =Narrow shoulder
karyotype 47,XXY,
nondysjunction during meiosis

299
TURNER

300
301
face chest and heart abdomen
to remember short ABCC --NS DISKO
WIFE A--Aortic root D—DM Type 2
short- Short stature dilatation I—IBD
w--webb neck B--Bicuspid aortic valve S-- Streak gonads &
I-less IQ C--Coarctation of aorta Gonadoblastoma
F—fish mouth & high C--Coronary artery K—kidneys Is
arch disease Horseshoe shape
E—low set Ear N-- nipples IS Widely O-- Osteoporosis
spaced amenorrhoea
S--Shield chest infertility

upper limb
SHEL
S— short 4th metacarpal
H— Hypertension
E— elbows is CUBITUS Valgus
L-- Lymphoedema(hands and feet )
302
HYPERTHYROIDISM

303
304
face cvs
ASRAF I CHAPS
A—agitated C= Cardiac failure
S—staring H=HTN (Systolic hypertension)
R—restless A= Atrial fibrillation
A—Anxious P= increased pulse pressure
F—fidgety S= sinus tachycardia
I—irritable GIT
EYE SING (LOL)
O--exophthalmus Diarrhoea,
L- lid lag and normal or increased appetite
L- lid retraction
hand genito urinary
STOP--C ILIAS
S= sweaty and warm hand I= Infertility,
T= Tremor L= Loss of libido
O= Onycholysi I= impotence
P= Palmar erythema A= Amenorrhoea/oligomenorrhoea
C= clubbing S= spontaneous abortion
chest neck
Gynaecomastia &Spider naevi Goitre with bruit(only in grave)
general neuro –
WHAT--P M= myopathy (Proximal)
W-- Weight loss neuro –
H-- Heat intolerance M= myopathy (Proximal)
A-- Anxiety R=Reflex-- Hyper-reflexia
T-- tremor C= Ill-sustained clonus
305
P--Palpitations P= Periodic paralysis
hypothyroidism

306
307
face genito urinary
Facial features: Galactorrhoea
puffy face Infertility,
Purplish lips Menorrhagia
Malar flush impotence
Periorbital oedema
Loss of lateral eyebrow
hand cvs
dry and rough Cardiac failure
Carpal tunnel syndrome HTN
sinus bradycardia
chest neck
Pericardial and Goitre present or absent
pleural effusions Hoarse voice
general neuro –
Weight gain Psychosis (myxoedema madness)
cold intolerance Cerebellar ataxia
Fatigue, somnolence Carpal tunnel syndrome
Dry skin Aches and pains
Depression Muscle stiffness
Myotonia
Delayed relaxation of ankle reflexes
Deafness
GIT skin
constipation Dermal myxoedema
Ileus, Dry and rough skin 308
ascites Carotenaemia
309
hypothyroid
 puffy face ,
 periorbital edema ,
 baggy eyelids
 loss lateral third of eyelash
 malar flush
 uninterested face

thyrotoxicosis graves diseases

ASRAF exophthalmos
A—agitated diffuse goiter
S—staring lid lag , lid retraction
R—restless
A—Anxious
F—fidgety

310
Cushing

moon face
puffy ,plethoric face
acne ,hirsutism
buffalo hump(supraclavicular fat )

311
Acromegaly
large skull
prominent supraorbital ridge
prognathism (protrusion of lower jaw)
large and coarse facies
large lip, broad nose
malocclusion of teeth
parkinsonism
Mask like face
expressionless face
less blinking face
dribbling of saliva
DOWN
Depress nosal bridge
Low-set ears
Epicanthic fold
Large tongue 312
turner
Low-set ears
Fish-like mouth
High-arched palate
Short stature

Haemolytic anaemia
frontal or parietal bossing
mongoloid face
malar prominence

neprhotic syndrome
puffy face

313
Hepatic face sunken eye ball
prominent zygometric bone
muddy color
jaundice

mytonia dystrophica

anxiety depression

314
SLE
butterfly rash sparing the naso-labial fold
alopecia

systemic sclerosis
pinch up nose
micro-stomia
puckering around the mouth
talengectasia
tightening of the skin
315
DD of puffy face

316
 The patient has puffy face. I have some DD
 Nephrotic syndrome
 Hypothyroid
 CFR
if want more then only say
cushing syndrome –in cushing usually moon face
superior Vana cava obstruction
How will differentiate these three?
one talking if croaky voice / husky of voice –hypothyroid
then sir ask what else will u see --- pulse bradycardia , ankle jerk –delayed
relaxation ankle jerk
if sir ask what 3 we commonly see in hypothyroid –pulse , voice , ankle jerk
next –will see edema –if voice is normal
what is face of cushing ?
usually moon face
plethoric face
acne
if female –hursutism
plus other feature
central or abdominal obesity
striae ---purplish
HTN
skin thin –bruise 317
proximal myopathy
face in hypothyroid
face is puffy and periorbital swelling ,
baggy eye lids &loss lateral 1/3 of eye brows , malar flush
what else u want to see in this patient
talk with the patient for –husky or croaky voice
see pulse –bradycardia
jerk ankle ---delayed relaxation (bed side test for hypothyroid –called hung up reflex )
skin thick and rough and dry
leg –pretibial myxoedema –non pitting edema
which disease u can diagnosis by telephone ?
hypothyroid
how will differentiate primary and secondary hypothyroidism ?
primary –goiter and myxoedema present
secondary (pituitary ) ---goiter and myxoedema absent
What will be the face of in patient with SVO ?
FACE--face is puffy red , plethoric , may cyanoses
EYE--eye congest , red , chemosis (conjuntival edema )
NECK--neck is swellen and engorged nonpulsatile vein
CHEST--visible and engorged vein in chest –direction of flow is downward
UPPER LIMB – edematous , engorged vein
pemberton sign ---if patient elevated hand or upper limb above shoulder level then
cause
 bronchial carcinoma
 lymphoma ,retrosternal goiter ,thymoma 318
Raynaud’

319
What is Raynaud’s phenomenon and Raynaud’s disease? Difference between
them?
Exposure to Cold stimuli may causes vasospasm, leading to the
characteristic sequence of digital pallor due to vasospasm, cyanosis due to
deoxygenated blood, and followed by rubor due to reactive hyperaemia this is
called raynaud .
type Primary Raynaud’s Secondary Raynaud’s
phenomenon (or phenomenon (or
disease) syndrome)
age aged 15–30 years older
sex young women male
ulcer and infarction no yes
family present absent
causes idiopathic systemic sclerosis
SLE
RA
RX prevent exposure surgery
calcium channel blocker prostacycline
prognosis benign bad
320
321