Clinical Signs

Question 1

Frank’s Sign

Answer 1

A diagonal crease in the lobule of the ear, grade 3 is deep crease across whole ear lobe. Associated with coronary artery disease in most people.

Question 2

Corrigan’s Sign

Answer 2

Forced carotid artery pulsations in aortic incompetence.
Dancing carotids.
Also with collapsing radial pulse.

Question 3

Lupus pernio

Answer 3

Lupus pernio (LP; Besnier-Tenneson syndrome)2 is a form of cutaneous manifestation which is expressed as blue red to violet smooth shiny nodules and plaques on the head and neck, predominantly on the nose, ears, lips, and cheeks. 3. LP is an indicator of chronic sarcoidosis.

Question 4

Inspiratory Crackle, causes @ timing

Answer 4

Early Inspiratory: chronic bronchitis, asthma

Early + Mid inspiratory: Bronchiectasis (recurs in expiration, quality changes after coughing)

Mid/Late inspiratory: fibrosis alveolitis, pulmonary edema (restrictive)

Question 5

Forced Expiratory Time( FET)

Answer 5

Time to expire all air from lungs after prior deep inspiration. Normally it is 1 second per decade means 30 year old should empty lungs in 3 seconds.
More than >6 seconds implies airway obstruction (as in COPD)

Question 6

Troisier’s sign

Answer 6

Enlarged left supra clavicular lymph node(Virchow’s node) behind left sterno-clavicular joint can be a sign of gastric cancer/abdominal cancer or ca bronchus
and needs further evaluation.

Question 7

Chadwick maneuver

Answer 7

Striking lateral sole of foot from down to up and below toes towards great toe - in pyramidal lesions great to goes up and other toes fans out, known as Babinaski reflex or sign or extensor plantar. In mild lesions it is + with this maneuver.

Question 8

Oppenheim’s sign

Answer 8

Babinaski that is extensor plantar response when tibial shin is heavily pressed - occurs in extensive pyramidal lesions/damage.

Question 9

Gordon reflex

Answer 9

Babinaski or extensor plantar response on pinching the Achilles tendon and also indicates extensive pyramidal tract lesion/damage as with oppenheim sign.

Question 10

Facial Signs to Look for:

Answer 10

1.Eye lids = ptosis, Heliotrophic rash on upper eye lid with dermatomyositis, xanthelasma
2. Eye lashes -sparse in Alopecia (autoimmune association, DM etc)
3. Pupil Anisocoria: small with Horners, large with 3rd nerve palsy, large and tonic with Holme-Adie syndrome (also check limb DTR)
4. Cornea: Arcus senilis, Hazy in congenital syphilis, Lisch nodules of NF, KF rings of wilsons
5. Iris - muddy in Iritis
6. Face itself:
Lupus pernio - sarcoidosis
Lupus vulgaris - painful cutaneous TB
Malar flush - SLE, Mitral stenosis
Perioral tight skin - systemic sclerosis
Angular cheilosis - IDA
Pigmented Lip macules - Peutz Jegher
Oral telangiectasis - Osler-Weber-Rendu
Facial telangiectasis - HHT
Cyanosis or pigmentation - Addison’s
Lemon Yellow Look - Vit B12 deficiency
Facial weakness - 7th palsy, ?ear zoster
Alopecia areata - auto-immune
Parotid swelling, both - Alcoholism
Adenoma sebaceoum- Tuberous sclerosis

Question 11

Thomas Test

Answer 11

to assess fixed flexion deformity of hip
Fully flex one hip and knee, ask patient to hold it to his abdomen and observe the opposite leg.
Normally it should lie flat - If it lifts off the couch, then there is a fixed flexion deformity in that hip.
(As the pelvis is forced to tilt a normal hip would extend allowing the leg to remain on the couch.) This is masked by excessive lordosis of LS spine (forward flexion which is unmasked by flexing other hip fully)

The likely causes of hip flexion contracture can be one or more of the following: shortening of the iliopsoas muscle, shortening of the rectus femoris muscle, shortening of the TFL muscle, or contracture of the anterior hip capsule.

Question 12

McMurray’s Test for knee
for menisci assessment

Answer 12

fully flex patient’s knee and then internally rotate by holding leg - and extend knee with knee in internal rotation - pain at knee suggest medial meniscus injury.
Repeat same way but in external rotation of knee - pain while extending indicates lateral meniscal tear.

Question 13

Leg-Length Shortening

Answer 13

Measure from ASIS to medial malleolus
Reasons for shorter Leg:
1. Protrusio acetabulum - where head of femur migrates through acetabulum due to local cause as OA, RA,
2. fracture neck femur, missed
3. Hip + knee both replaced prosthesis- bone shortened more than proper
4. Girdlestone procedure done where head and neck of femur resected and not replaced by prosthesis due to fitness issue for major surgery and bone moves into capsule upward
5. apparent, not true leg shortening due to pelvic tilt as in muscle weakness

Question 14

Tinel’s Sign

Answer 14

Tapping on radial side of wrist palm side will cause tingling or electrical sensations along thumb side in CTS.

Question 15

Phalen’s sign

Answer 15

reverse prayer sign, flexing both wrists for a minute induces symptoms of CTS in hand.

Question 16

Froment Sign
Ulnar nerve injury

Answer 16

Hold a paper between index finger and thumb as a currency note. if thumb flexes to hold paper tightly - shows froment sign positive and indicates - weakness or loss of function in adductor pollicis muscle (ulnar nerv injury), where the patient flexes the thumb interphalangeal joint in an attempt to hold on to paper (due to contraction of the flexor pollicis brevis, which is supplied by the median nerve).

Question 17

Finkelstein’s Sign

Answer 17

It is a provocative test for diagnosis of De Quervain’s disease that can easily be performed in an office setting or at the bedside. Finkelstein’s test produces severe tenderness and usually pain on the radial aspect of the wrist when the thumb is flexed into the palm and the wrist is ulnar deviated.

Question 18

Trendlenberg Test/Sign

Answer 18

Test: The provider stands behind the patient at the hip level and places their hands on the iliac crests on either side of the pelvis observing to see if it stays level during the single-leg stance. Repeat the test on the opposite side. A positive Trendelenburg sign is when the pelvis drops on the unaffected side

Indicates damage to Superior gluteal nerve which controls Hip abductors as glutes and piriformis.

Question 19

Tinels Sign of Spine

Answer 19

Tap forcefully parallel to spine along neck and below. Elicitation of parasthesias (tingling, numbness, pins and needles) in the respective dermatome indicates root compression. For example - tapping along C6 causing tingling at thumb.

Question 20

Femoral Stretch Test
Mackiewicz Sign

Answer 20

Femoral nerve stretch test, also known as Mackiewicz sign,[1] is a test for spinal nerve root compression, which is associated with disc protrusion and femoral nerve injury.

To perform a femoral nerve stretch test, a patient lies prone, the knee is passively flexed to the thigh and the hip is passively extended (reverse Lasegues). The test is positive if the patient experiences anterior thigh pain.

It can reliably identify spinal nerve root compression for L2, L3, and L4.[2] It is usually positive for L2-L3 and L3-L4 (high lumbar) disc protrusions, slightly positive or negative in L4–L5 disc protrusions, and negative in cases of lumbosacral disc protrusion

Question 21

Beck’s Triad

Answer 21

Beck’s triad (hypotension, distended neck veins and muffled heart sounds) will be present in patients with pericardial tamponade.

Question 22

Prevost Sign

Answer 22

conjugate eye and head deviation to side of stroke(ie side of lesion and not of weakness) at rest.
Example - in a right MCA/ACA infarct stroke -disrupted signals to left eye with normal signals to right eye causes as imbalance in neural tone that causes RiGHT EYE to move to right at rest due to no counter pull from left and left eye follows RE due to intact MLF mechanism between 3/6 nerve nucleus.
So both eyes deviates to side of stroke.

Question 23

Piano Key Sign

Answer 23

The Piano-Key Sign Test is a test carried out for the clinical assessment of wrist instability. It is used as an indicator for distal radio-ulnar joint instability and tears of the triangular fibrocartilage complex of the wrist.
Examiner hold wrist, palm down with both hands and push ulnar side down to check for instability & hold radial side to stabilize pisiform to up. One can feel subluxation at radio-ulnar joint which spring back to original position when forces released.

Question 24

Forearm Exercise Test

Answer 24

to detect intermittent myopathy with myoglobinuria with glycolysis defect

How to: = put anticubital IV Line, take samples for Lactate and ammonia. Then perform forceful hand opening and closing exercise for one minute while cuff is still applied and then collect blood at 1, 2, 4, 6 and 10 minutes. Lactate and ammonia rises 3-4 times typically in normal people and CPK, k DOESNT RISE.

in Glycolytic defects as with myophosphorylase deficiency in McArdles disease = lactate doesnt rise, NH3 rises normally.

Lack of effort: both doesnt rise

No ammonia rise but lactate rises:
selective myoadenylate deaminase deficiency.

Question 25

Schilling Test for B12 absoprtion

Answer 25

01- give oral radiolabelled B12 and IM unlabelled B12
02- measure urinary excretion of radiolabelled B12

03- Normal Urine radioB12 > 5% -implies normal intestinal absoprtion of B12: cause of low B12 is diet deficient in it cause absoprtion normal.

04- Low Urine B12 levels implies impaired absorption of B12

05- Now give Radiolabelled B12 + Intrinsic factor and measure
Urinary radio-labelled B12
= normal Urine B12: pernicious anemia ie intrinsic factor issue
= Low Urine B12: - malabsoprtion syndrome

Question 26

Pemberton Maneuvre

Answer 26

tell patient to raise both arms above head levels. This closed thoracic outlet. If within a minute, patients face turned red and he feels dizzy, test is positive for Thoracic Outlet Obstruction as in SVC syndrome due to pancoast tumor or Goiter

Question 27

Drop Arm Sign

Answer 27

Patient lowers arm slowly from 160 degrees of initial abduction of shoulder. Inability to control the arm drop which comes down quickly to side indicates rotator cuff tear.

Question 28

Knee Unhappy Triad

Answer 28

an unhappy triad is an injury to 3 structures at knee: ACL + MCL + Medial meniscus

Question 29

Schick Test

Answer 29

involves intradermal injection of a small amount of diphtheria toxin. If positive reaction, a wheel develops and indicates person is susceptible to diphtheria

Question 30

Sacro-iliac Stretch Test

Answer 30

Pain on adduction of hip with hips and knees flexed, positive in sacroliac joint pathology

Question 31

Schober’s Test

Answer 31

mark a point on line joining posterior superior iliac spines on both sides of back and mark a point 10 cm above this.
Ask patient to bend forward - the distance between these two points will increase and shoulder be more than 15 cm normally.
Spinal fusion and stiffness as in ankylosing spondylosis will reduce this distance much.

Question 32

Speed’s Test

Answer 32

Patient starts with arm flexed forward 60 degrees, elbow extended forearm in supination ie palm up - ask to flex shoulder further against resistance. Pain on palpation of long head of biceps tendon during this maneuver indicates biceps tendonitis

Question 33

Apprehension Test

Answer 33

Patient supine on bed - Ask to keep shoulder at 90 degrees abducted and flex elbow at 90 degree, forearm supine ie palm up - then abduct and externally rotate arm to Apprehension60, 90, 120 degrees and apprehension suggests anterior joint instability. It tests superior, medial and inferior Gleno-humeral ligaments as 60, 90, 120 degrees of shoulder external rotation.

Question 34

Scarf Test

Answer 34

forced adduction of one arm and palm going to opposite shoulder or neck.
Pain indicated Acromio-clavicular (AC) joint disease.

Question 35

Jobe’s Test

Answer 35

Empty can Test
Patient internally rotates arm with shoulder at 90 degrees abduction and 30 degrees forward flexion and elbow extended (ie whole upper limb horizontal to side), point thumb down like emptying can and press down by examiner while patient tries to resist this push.
If results in pain at shoulder indicates supraspinatus weakness or injury

Question 36

Head Impulse Test

Answer 36

bedside test for vestibulo-ocular reflex
Examiner turns patients head rapidly to each side while patient fixates his eyes onto a target in distant front. Visual fixation is lost and catch up saccade occurs on side of lesion.
Example -
if Left sided horizontal semicircular canal dysfunctional - when moving head to left side, eyes loose fixation on target - moves to left with head but catch up saccade occurs to re fix on target - proving lesion side.
OR also indicates 8th nerve root entry zone lesion in brainstem on same side.

Question 37

GHRH-Arginine stimulation Test

Answer 37

Used to confirm GH deficiency:
Fasting overnight from midnight (except water)
Arrive by 9 am, At least 1 month off GH treatment if in transition. 7 red top Vacutainers
Steps:
1. Cannulate in both arms, and leave to rest for 45 minutes. 2) Take blood into a plain tube (red top Vacutainer) for baseline GH and IGF-1 measurement (-15 mins), and GH at 0 min.
3) Inject GHRH (Somatorelin, Ferring) 1mcg / kg (maximum dose 100 mcg) as bolus injection.
4) Infuse 0.5 g / kg L-arginine mono-hydrochloride (maximum dose 30 g) as a 10% solution (30 g / 300 mL) in normal saline over 30 min. 5) Take blood for further GH estimation in red top Vacutainer (but not IGF-1) at + 30, 60, 90, 120 and 150 min after start of arginine infusion.
6) Can eat lunch at +150 min after last blood test. 7) Stay in bed until +240 min.
8) Monitor pulse & BP every 15 min until +150 min, and every 30 min from +150 min to +240 min.

In adults (>21y), GH deficiency depends on peak GH and BMI:
BMI <25 kg/m2- Peak GH < 11 mcg/L
BMI 25-30 kg/m2 - Peak GH < 8 mcg/L
BMI > 30 - Peak GH < 4 mcg/L

In transition (adolescence and young adults <21y), peak GH < 19mcg/L confirms GH deficiency if lean.
If overweight or obese, cut-offs in transition are unknown and may be higher than in adults. However while using BMI cut-offs given above from adults may pass some patients with GH deficiency as normal, it should correctly identify transition patients who do have GH deficiency.

Question 38

Neer’s Test

Answer 38

Passive flexion of shoulder lifting it above head with a pronated arm whilst scapula is stabilized. Painful arc between 60 to 120 degrees indicates impingement of rotator cuff.

Question 39

Ortolani Maneuver

Answer 39

This test relocates a subluxated or partially dislocated hip.
With the child’s hips flexed and abducted, place your fingers on the greater trochanter and try to lift up the femoral head and relocate it into acetabulum. Test is POSITIVE when there is palpable clunk as hip relocates.

Question 40

Barlow maneuver

Answer 40

Aims to sublux or disloacate an unstable hip in a child.
Start with hip flexed and adducted slightly. Gently apply axial load to femur and try to dislocate the femoral head with the thumb.
Test is POSITIVE when femoral head is felt to dislocate

Question 41

Galleazzi Test

Answer 41

Looks for apparent shortening of femur caused by dislocation of femoral head.
Make child lie supine on the table with hips flexed and foot flat on table with ankle touching the buttocks. Test if POSITIVE when knees are of different heights.

Question 42

Tests for knee assessment

Answer 42

Varus and Vulgus stress
Anterior drawer Test
Posterior drawer Test
Lachman Test
Pivot shift test
McMurray’s Rotation test

Question 43

Varus/ Vulgus Stress Test

Answer 43

Vulgus Stress:
Knee is flexed 20-30 degrees to relax posterior capsule and cruciate ligaments. One hand lift ankle and other stabilizes knee. Stress the knee by ABDUCTING ANKLE while pushing knee medially (PUSH knee medial) - shows laxity of MCL ie excessive medial movement of knee

Varus Test:
Reverse of vugus stress, knee pushed laterally outside while ankle medially and shows laxity of LCL.

Question 44

Lachman Test for knee

Answer 44

Tests cruciate ligament of knee.
Knee at 20c flexion and patient supine in bed
Place one hand behind tibia & other grasps lower thigh. Examiners thumb should be on tibial tuberosity. Tibia is pulled forward to assess laxity of anterior cruciate ligament.

Question 45

Pivot Shift Test for knee

Answer 45

for ACL assessment
Patient supine, hips flexed to 30 degrees - stand laterally to knee being examined. Grasp Lower leg and ankle maintaining 20 degrees of tibial internal rotation - knee is allowed to sag completely into extension ie gradually extend, grasp at upper tibio-fibular joint with other hand, maintain internal rotation and apply vulgus force while knee is being slowly flexed from initial extension. (extension to flexion)
Positive for ACL instability if around 30-40 degrees, tibia position on femur subluxates.

Question 46

Drawer Test for knee

Answer 46

Anterior and posterior drawer test
Patient in supine position - hips flexed and fix foot flat on bed with knee flexed.
Hold patients knee with both hands behind upper end and front also. Sit on his foot to stabilize it. Pulls out ANTERIORLY for ACL laxity AND push back posteriorly for PCL laxity.

Question 47

McMurray Test for knee Menisci

Answer 47

knee is grasped with one hand and foot with other hand by examiner - flex the knee completely, place hand medially on knee and apply varus LATERAL stress at knee while slowly extending it when other hand rotates it slowly internally same time (Flex knee - internally rotate - apply lateral stress - extend slowly) - this presses lateral meniscus and indicates injury if painful.
For medial meniscus - vulgus, medial pressure to knee is applied while it being externally rotated and extended.

Question 48

Clark’s Test for knee

Answer 48

Pain on patell-femoral compression with hamstrings tensed indicates patello-femoral pain syndrome.

Question 49

Oliver’s Sign

Answer 49

Feeling a downward tracheal pulsation coincident with pulse and not associated with inspiration suggests thoracic outlet aneurysm

Question 50

Ondine’s Curse

Answer 50

more appropriately known as congenital central hypoventilation syndrome, or CCHS—is a rare, severe form of sleep apnea in which an individual completely stops breathing when falling asleep. It is always congenital, meaning that it is present from birth.
This was previously referred to as ‘Ondine’s curse,’ after a German myth in which Ondine curses her unfaithful husband to stop breathing if he falls asleep.

Question 51

Hamman Sign

Answer 51

Left parasternal systolic crunch sound in small left spontaneous pneumothorax