Contents Contents by Condition ...... ix Thomas' test ...... 54 Foreword ...... xv Tinel's sign ...... 55 Preface ...... xvi... Trendelenburg's sign ...... 56 Acknowledgements...... XVIII ... True leg length discrepancy (anatomic Authors ...... xv111 leg length discrepancy) ...... 57 Expert Reviewers ...... xix Ulnar deviation ...... 58 Reviewers ...... xix V-sign ...... 59 Abbreviations ...... xx Valgus deformity ...... 60 Varus deformity ...... 63 Chapter 1 Yergason's sign ...... 65 Musculoskeletal Signs .... Anterior drawer test ...... 2 Chapter 2 Apley's grind test ...... 3 Respiratory Signs ...... 71 Apley's scratch test ...... 4 Apparent leg length inequality (functional Accessory muscle ...... 73 leg length) ...... 5 Agonal respiration ...... 74 Apprehension test (crank test) ...... 6 Apneustic breathing (also apneusis) ...... 75 Apprehension-relocation test (Fowler's Apnoea ...... 76 agn) ...... 7 Asterixis ...... 78 Bouchard's and Heberden's nodes ...... 8 Asymmetrical chest expansion ...... 79 Boutonniere deformity ...... 9 Asynchronous respiration...... 81 Bulge/wipe/stroke test ...... 11 Ataxic (Biot's) breathing...... 82 Butterfly rash (malar rash) ...... 12 Barrel chest ...... 83 Calcinosis/calcinosis cutis ...... 14 Bradypnoea ...... 84 Charcot's foot ...... 16 Bronchial breath sounds ...... 85 Crepiis ...... 18 reflex ...... 86 Dropped arm test ...... 19 (rales) ...... 88 Finkelstein's test ...... 20 Dyspnoea ...... 89 Gottron's papules ...... 21 Funnel chest (pectus excavatum) ...... 92 Hawkins' impingement sign ...... 22 Grunting ...... 93 Heliotrope rash ...... 24 Haemoptysis ...... 94 Kyphosis ...... 25 Harrison's sulcus (also Harrison's Lachman's tesvsign ...... 26 groove) ...... 95 Livedo reticularis ...... 27 Hoover's sign ...... 96 McMurray's test ...... 29 Hypertrophic pulmonary osteoarthropathy Neer's impingement sign ...... 30 (H POA) ...... 97 Patellar apprehension test ...... 31 ...... 98 Patellar tap ...... 32 Intercostal recession ...... 100 Patrick's test (FABER test) ...... 33 Kussmaul's breathing...... 101 Phalen's sign ...... 34 Orthopnoea ...... 102 Proximal myopathy...... 35 Paradoxical abdominal movements (also Psoriatic nails/psoriatic nail dystrophy ...... 36 abdominal paradox) ...... 104 Raynaud's syndromejphenomenon ...... 38 Paradoxical respirationlbreathing...... 105 Saddle nose deformity ...... 40 Paroxysmal nocturnal dyspnoea (PND) ...... 106 Sausage-shaped digits (dactylitis) ...... 41 ...... 107 Sderodactyly ...... 43 Percussion: dullness ...... 108 Shawl sign ...... 44 Percussion: resonancelhyper-resonance ...... 109 Simmonds-Thompson test ...... 45 Periodic breathing ...... 110 Speed's test ...... 46 Pigeon chest (pedus carinatum) ...... 111 Subcutaneous nodules (rheumatoid Platypnoea...... 112 nodules) ...... 47 ...... 114 Sulcus sign ...... 48 Pursed lips breathing...... 115 Supraspinatus test (empty can test) ...... 49 ...... 116 Swan-neck deformity ...... 50 ...... 117 Telangiectasia ...... 52 ...... 118 Contents

Subcutaneous emphysema/surgical JVP waveform variations: a-waves . emphysema ...... 119 prominent or giant ...... 173 Tachypnoea ...... 120 JVP waveform variations: v-waves .large ...... 174 Tracheal tug ...... 121 JVP waveform variations: x-descent . Trepopnoea ...... 122 absent ...... 175 Vesicular breath sounds ...... 123 JVP waveform variations: x-descent . Vocal fremitusltactile ...... 124 prominent ...... 176 Vocal resonance ...... 125 JVP waveform variations: y-descent . ...... 126 absent ...... 177 JVP waveform variations: y-descent . Chapter 3 prominent (Friedrich's sign) ...... 179 Mid-systolic click ...... 180 Cardiovascular Signs ...... 131 Mitral facies ...... 181 Apex beat (also cardiac impulse) ...... 132 Murmurs ...... 182 Apex beat: displaced...... 133 Murmurs .systolic: aortic stenotic Apex beat: hyperdynamic apical murmur ...... 183 impulse/volumeloaded ...... 134 Murmurs .systolic: mitral regurgitation Apex beat: left ventricular heavelsustained murmur ...... 185 apical irnpulse/pressureloaded apex ...... 135 Murmurs .systolic: pulmonary stenotic Arterial pulse ...... 136 murmur ...... 187 Arterial pulse: anacrotic ...... 138 Murmurs .systolic: tricuspid regurgitation Arterial pulse: bigeminal ...... 139 murmur (also Ca~ello'ssign) ...... 188 Arterial pulse: dicrotic ...... 140 Murmurs .systolic: ventricular septa1 Arterial pulse: pulsus alternans...... 141 defect murmur ...... 190 Arterial pulse: pulsus bisferiens ...... 142 Murmurs .diastolic: aortic regurgitation Arterial pulse: pulsus paws ...... 143 murmur ...... 191 Arterial pulse: pulsus tardus ...... 144 Murmurs .diastolic: eponymous signs of Arterial pulse: sinus arrhythmia ...... 145 aortic regurgitation ...... 192 Bradycardia ...... 146 Murmurs .diastolic: Graham Steel1 Buerger's sign ...... 147 murmur ...... 195 Cardiac cachexia ...... 148 Murmurs .diastolic: mitral stenotic Carotid bruit ...... 149 murmur ...... 196 Cheyne-Stokes breathing...... 150 Murmurs .diastolic: opening snap (0s) ...... 197 Clubbing ...... 152 Murmurs .diastolic: pulmonary Crackles (also rales) ...... 154 regurgitation murmur ...... 198 ...... 155 Murmurs .diastolic: tricuspid stenotic Cyanosis: central ...... 156 murmur ...... 199 Cyanosis: peripheral ...... 157 Murmurs .continuous: patent ductus Ewart's sign ...... 158 arteriosus murmur...... 200 Hepatojugular reflux (also Osler's nodes ...... 201 abdominojugular reflux) ...... 159 Pericardial knock ...... 202 Hepatomegaly ...... 160 Pericardial rub ...... 203 Hypertensive retinopathy ...... 161 Peripheral oedema ...... 204 Hypertensive retinopathy: arteriovenous Pulse pressure...... 207 (AV) nipping (or AV nicking) ...... 162 Pulse pressure: narrow ...... 208 Hypertensive retinopathy: copper and Pulse pressure: widened ...... 209 silver wiring ...... 163 Pulsus paradoxus ...... 212 Hypertensive retinopathy: cotton wool Radial-radial delay ...... 215 spots ...... 164 Radio-femoral delay ...... 216 Hypertensive retinopathy: Retinal haemorrhage ...... 166 miaoaneurysms ...... 165 Right ventricular heave ...... 217 Hypertensive retinopathy: retinal Roth's spots ...... 218 haemorrhage ...... 166 51 (first heart sound): accentuated ...... 220 Janeway lesions ...... 167 51 (first heart sound): diminished...... 221 Jugular venous pressure (JVP) ...... 168 53 (third heart sound) ...... 222 JVP: Kussmaul's sign ...... 169 54 (fourth heart sound) ...... 223 NP: raised ...... 170 Splinter haemorrhages ...... 224 JVP: the normal waveform ...... in Splitting heart sounds ...... 225 JVP waveform variations: a-waves . Splitting heart sounds: paradoxical cannon ...... 172 (reverse) splitting ...... 226 Contents

Splitting heart sounds: physiological Grasp reflex ...... 324 splitting...... , ., . 227 Hand dominance...... 325 Splitting heart sounds: widened splitting ...... 228 Hearing impairment ...... 326 Spling heart sounds: widened splitting . Hemineglect syndrome ...... 328 fuced ...... 229 High stepping gait (steppage gait) ...... 330 Tachycardia (sinus) ...... 230 Hoarseness ...... 332 Xanthelasmata ...... 231 Hoffman's sign ...... 335 Horner's syndrome ...... 336 Chapter 4 Hutchinson's pupil ...... 339 Haematological/Oncological Sis...... 237 Hutchinson's sign ...... 340 Hyperreflexia ...... 341 Angular stomatitis...... 238 Hyporeflexia and areflexia...... 343 Atrophic gloss~hs...... 239 Hypotonia ...... 347 Bone tenderness/bone pain ...... 240 Intention tremor ...... 349 Chipmunk facies ...... 242 lnternudear ophthalmoplegia (INO) ...... 351 Conjunctival pallor ...... 243 Jaw jerk reflex ...... 353 Ecchymoses. purpura and petechiae ...... 244 Light-near dissociation ...... 354 Gum hypertrophy (gingival hyperplasia) ...... 246 Myotonia - percussion, grip ...... 356 Haemolytrc/pre-hepaticjaundice ...... 247 Oculomotor nerve (CNIII) palsy ...... 358 Koilonychia ...... 249 Optic atrophy ...... 364 Leser-Trelat sign ...... 250 Orbital apex syndrome ...... 365 Leucoplakia ...... 251 Palmomental reflex ...... 367 Lymphadenopathy...... 252 Papilloedema...... 368 Neoplastic fever ...... 255 Parkinsonian gait ...... 370 Peau d'orange ...... 256 Parkinsonian tremor ...... 371 Prostate (abnormal) ...... 258 Photophobia ...... 372 Rectal mass ...... 259 Physiological tremor ...... 373 Trousseau's sign of malignancy ...... 260 Pinpoint pupils ...... 374 Pronator drift ...... 378 Chapter 5 Ptosis ...... 380 Neurological Signs . Relative afferent pupillary defed (RAPD) (Marcus Gunn pupil) ...... 383 Abducens nerve (CNVI) palsy ...... 267 Rigidity ...... 385 Anisocoria ...... 27l Romberg's test ...... 387 Anosmia ...... 276 Sensory level ...... 388 Argyll Robertson pupils and light-near Sensory loss...... 389 dissociation ...... 278 Spasticity ...... 397 Ataxic gait ...... 280 Sternocleidomastoid and trapezius weakness Atrophy (muscle wasting) ...... 282 (accessory nerve [CNXI] palsy) ...... 399 Babinski response ...... 285 Tongue deviation (hypoglossal nerve [CNXII] Bradykinesia ...... 287 palsy) ...... 400 Broca's aphasia (expressive aphasia) ...... 289 Trochlear nerve (CNIV) palsy ...... 402 Brown-Skquard syndrome ...... 291 Truncal ataxia ...... 406 Cavernous sinus syndrome ...... 293 Uvular deviation ...... 408 Clasp-knife phenomenon ...... 296 Vertical gaze palsy ...... 410 Clonus ...... 297 Visual acuity ...... 412 Cogwheel rigidity ...... 298 Visual field defects ...... 415 Corneal reflex ...... 299 Waddling gait (bilateral Trendelenburg Crossed-addudor reflex ...... 302 gait) ...... 420 Dysarthria ...... 303 Wallenberg's syndrome (lateral medullary Dysdiadochokinesis ...... 305 syndrome) ...... 421 Dysmetria ...... 307 Weakness ...... 423 Dysphonia ...... 309 Wernicke's aphasia (receptive aphasia) ...... 434 Essential tremor ...... 31 1 Facial muscle weakness (unilateral) ...... 312 Chapter 6 Fasciculations ...... 316 Castroenterological Signs ...... 443 Gag reflex, absent ...... 318 Gerstmann's syndrome ...... 320 Ascites ...... 444 Glabellar reflex (Myerson's sign) ...... 321 Asterixis (also hepatic flap) ...... 447 Global aphasia ...... 322 Bowel sounds ...... 448 Contents

Bowel sounds: absent ...... 449 Atrophic testicles ...... 509 Bowel sounds: hyperactive Ballotable kidney ...... 510 (borborygmus) ...... 450 Bruising ...... 511 Bowel sounds: tinkling ...... 451 Chvostek's sign ...... 513 Caput medusae ...... 452 Cushing body habitus ...... 515 Cheilitis granulomatosa ...... 454 Diabetic amyotrophy (lumbar plexopathy) . . 516 Coffee ground vomiting/bloody vomitus/ Diabetic retinopathy ...... 517 haematemesis ...... 455 Frontal bossing...... 520 Counroisier's sign ...... 457 Galadorrhoea ...... 521 Cullen's sign ...... 458 Goitre ...... 523 Erythema nodosum ...... 459 Granuloma annulare ...... 525 Grey Turner's sign ...... 460 Graves' ophthalmopathy (orbitopathy) ..... 526 Guarding ...... 461 Graves' orbitopathy ...... 530 Gynaecomastia...... 462 Hirsutism ...... 531 Hepatic encephalopathy ...... 465 Hypercarotinaemia/carotenoderma ...... 532 Hepatic foetor ...... 467 Hyperpigmentationand bronzing ...... 533 Hepatic venous hum ...... 468 Hyperreflexia ...... 535 Hepatomegaly...... 469 Hyperthyroid tremor ...... 536 Jaundice ...... 470 Hyporeflexia/delayed ankle jerks Kayser-Fleischer rings ...... 473 (VVoltrnan's sign) ...... 537 Leuconychia ...... 475 Hypotension ...... 538 Melaena ...... 476 Macroglossia ...... 539 Mouth ulcers (aphthous ulcer) ...... 477 Necrobiosis lipoidica diabeticorum (NLD) . . 541 Muehrcke's lines ...... 478 Onycholysis (Plummer's nail) ...... 542 Murphy's sign ...... 479 Pemberton's sign ...... 543 Obturator sign ...... 480 Periodic paralysis ...... 544 Palmar erythema ...... 482 Plethora...... 545 Pruritic scratch marks/pruritus ...... 484 Polydipsia ...... 546 PMas sign ...... 487 Polyuria ...... 547 Pyoderma gangrenosum ...... 488 Polyuria: Gushing's syndrome ...... 549 Rebound tenderness ...... 489 Pre-tibia1 myxoedema (thyroid , Rigidity and involuntary guarding ...... 490 dermopathy) ...... 550 Rovsing's sign ...... 491 Prognathism ...... 551 Sderal iderus ...... 492 Proximal myopathy ...... 552 Siladenosii ...... 493 Skin tags (acrochordon) ...... 553 Sister Mary Joseph nodule ...... 494 Steroid acne ...... 554 Spider naevus ...... 495 Trousseau's sign ...... 555 Splenomegaly ...... 496 Uraemic frost ...... 556 Steatorrhoea ...... 498 Vitiligo ...... 557 Striae ...... 499 Webbed neck (pterygium colli deformity) ... 558 Uveitis/iritis ...... 500 Picture Credits ...... 563 Chapter 7 Endocrinological Signs Index ...... 569 Acanthosis nigricans (AN) ...... 506 Angioid streaks ...... 508