Examination Medicine: A Guide to Physician Training (102 page)

Note:
Flapping (asterixis) is not strictly a tremor but rather a sudden brief loss of tone in hepatic failure, cardiac failure, respiratory failure or renal failure.

4. 
On finger–nose testing, a resting tremor diminishes, but an action tremor may appear. Test wrist tone, feeling for cogwheel or lead pipe rigidity. Reinforce this by asking her to turn her head from side to side.

5. 
Test for abnormal rapid alternating movements. Look also for involuntary movements produced by medication use.

6. 
Go to the face. Note tremor, absence of blinking, dribbling of saliva and lack of expression. Test the glabellar tap: the sign is positive (Wilson’s sign) when the patient continues to blink after the middle finger taps several times over the glabella from behind – it is important that your finger is out of her line of vision.

7. 
Test speech, which is typically monotonous, soft, poorly articulated and faint.

8. 
Look at the ocular movements for supranuclear gaze palsies. Feel for a greasy or sweaty brow (owing to autonomic dysfunction).

9. 
Ask the patient to write (looking for micrographia) and test the frontal lobe reflexes and higher centres (looking for evidence of dementia).

10. 
Ask to test for postural hypotension.

11. 
Present your assessment of the degree of disability and whether the main problem is rigidity or tremor. Is there evidence or autonomic dysfunction or gaze palsy?

Causes of Parkinsonism

1. 
Idiopathic (Parkinson’s disease).

2. 
Drugs (e.g. phenothiazines, methyldopa).

3. 
Postencephalitis.

4. 
Other – toxins (carbon monoxide, manganese), Wilson’s disease, Steele-Richardson syndrome, Shy-Drager syndrome, syphilis, tumour.
Note:
Atherosclerosis is controversial as a cause of Parkinsonism.

Chorea

‘Please examine this man’s arms.’

Method

Happily you notice an extrapyramidal choreiform movement disorder. Choreiform movements are non-repetitive, abrupt, involuntary, more distal jerky movements, which the patient often attempts to disguise by completing the involuntary movement with a voluntary one. The condition is caused by a lesion of the corpus striatum.

• 
Hemiballismus
is unilateral and usually involves rotary movements of proximal joints. It is caused by a subthalamic nucleus lesion on the opposite side.

• 
Athetosis
means slow, sinuous distal writhing movements at rest. It is caused by a lesion of the outer segment of the putamen.

If the patient has chorea, proceed as follows.

1. 
First shake the patient’s hand, for a lack of sustained grip (‘milkmaid grip’).

2. 
Ask the patient to hold his hands out and look for a choreic posture (finger and thumb hyperextension and wrist flexion as a result of hypotonia). Note any signs of vasculitis.

3. 
Go to the face and look at the eyes for exophthalmos, Kayser-Fleischer rings and conjunctival injection (ataxia-telangiectasia). Ask the patient to poke his tongue out and note a serpentine tongue (moving in and out). Notice any rash (e.g. SLE).

4. 
If the patient is young, examine the heart for signs of rheumatic fever.

5. 
Test the knee jerks (pendular) and the higher centres (for Huntington’s disease). The causes of chorea are summarised in
Table 16.64
.

Table 16.64

Causes of chorea

¹
Ludwig Traube described a space defined superiorly by the sixth rib, laterally by the mid-axillary line and inferiorly by the left costal margin, which is normally resonant to percussion. It becomes dull if the spleen is enlarged or there is a left-sided pleural effusion. If this area is resonant it is very unlikely the spleen will be palpable by any other manoeuvre.

Index

A

abdominal examination,
358–64

abdominal masses,
361

abducens nerve,
409–10
,
422–4

acanthosis nigricans,
238

accommodation reflex,
416

ACE
See
angiotensin-converting enzyme

acetylcholine receptor antibodies (anti-AChR),
266

acidosis,
255

acoustic nerve,
411
,
426–7

acromegaly,
233–6
,
338
,
378–82

ACTH-secreting pituitary adenoma,
376

acute disseminated encephalomyelitis,
261

acute lymphatic leukaemia (ALL),
190

acute myeloid leukaemia (AML),
190

Addison’s disease,
382–4

Adie’s syndrome,
417

Adult Medicine Self-Assessment Programme (AMSAP),
10

Advanced Life Support,
2

advanced training,
2

AF
See
atrial fibrillation

AICDs
See
automatic implantable cardioverter-defibrillators

AIDS
See
HIV/AIDS

AIDS dementia,
278
,
282

ALL
See
acute lymphatic leukaemia

alopecia,
205

alveolitis,
102

American College of Physicians,
10
,
11

American Heart Association,
45

American Journal of Medicine
,
10

American Rheumatism Association criteria, for SLE,
202

AML
See
acute myeloid leukaemia

AMSAP
See
Adult Medicine Self-Assessment Programme

anaemia

aplastic,
190

in CKD,
255

haemolytic,
158–64

hypothyroidism and,
373

analgesic nephropathy,
249
,
295
,
297

aneurysm, aortic,
355

angina,
33

angioid streaks,
230
,
381

angioplasty,
38–9

angiotensin-converting enzyme (ACE),
33
,
51–2

ankylosing spondylitis,
405–8

Ann Arbor classification,
176

Annals of Internal Medicine
,
10

anosmia,
415–16
,
430

anti-AChR
See
acetylcholine receptor antibodies

antibody deficiency,
300
,
301

anticoagulation,
293

antihypertensive drugs

classes of,
62

factors in choice of,
63

antiphospholipid antibody syndrome,
213–15

anti-platelet treatment,
38
,
272

antiretroviral drugs,
281
,
286

aortic aneurysm,
355

aortic regurgitation,
324–5

aortic stenosis,
325–8

apex beat,
315

aphasia,
432

aphthous ulcers,
134

aplastic anaemia,
190

arcus cornea,
56–7

Argyll Robertson pupil,
417
,
418

Arnold-Chiari malformation,
428

arterial pulse,
313
,
314

arthritis

feet,
401–4

gouty,
398
,
404

hands,
389–93
,
399

knees,
399–401

osteo-,
395
,
396
,
399

psoriatic,
279
,
282
,
391
,
393
,
394
,
398
,
403

 
See
rheumatoid arthritis

asbestos,
99

ascites,
142
,
144
,
146

ASD
See
atrial septal defect

asthma,
294
,
297–9

ataxic gait,
438

atrial fibrillation (AF),
68–70
,
290

management problems,
78–80

atrial septal defect (ASD),
332

A-type questions,
8

Audio Digest Internal Medicine,
11

Australian Heart Foundation,
45