Physical examination in a psychiatric patient Flashcards
Sign associated with neurosyphilis and diabetes
Argyll-Robertson pupil
Bilaterally small pupils which accommodate but do not react to bright light
Argyll-Robertson pupil
Sign where there are multiple surgical scars due to factitious disorder
Checker-board abdomen
Drug intoxication associated with constricted pupils
Opiates
Conditions associated with dilated pupils
Stimulant abuse
Anxiety
Opiate withdrawal
Eye sign associated with Wilson’s Disease
Kayser Fleischer ring
Neck sign associated with thyroid disease or rarely with lithium use
Goitre
Medical causes of gynaecomastia
Hyperprolactinaemia Cirrhosis Normal male puberty Hypogonadism Tumours including adrenal or testicular Renal failure
Medication associated causes of gynaecomastia
Oestrogen containing drugs e.g. goserelin Spironolactone Finasteride Ketoconazole Methadone
Recreational drugs causing gynaecomastia
Marijuana
Amphetamines
Heroin
Body hair seen in anorexia nervosa
Lanugo
Disease causing lemon stick appearance
Cushing’s syndrome
Eye signs seen in hyperthyroidism
Exophthalmos
Lid retraction
Lid lag
Orbital fat prolapse
Disease classically associated with a mask-like face
Parkinson’s disease
Diseases associated with parotid swelling
Bulimia nervosa
Mumps
Sign seen in bulimia nervosa where there are callouses at the knuckles
Russell’s sign
Medication causing Sialorrhoea (hypersalivation)
Clozapine
Signs in infective endocarditis
Splinter haemorrhages
Osler nodes
Janeway lesions
Tender, red, raised lumps typically found on the fingers and toes in infective endocarditis
Osler nodes
Non-tender red lesions seen on the palms and soles of the feet in infective endocarditis
Janeway lesions
More common side for a unilateral paraesthesia caused by hyperventilation
Left
Usual distribution for paraesthesia caused by hyperventilation in a panic attack
Bilateral, upper limbs
Minor physical anomaly associated with developmental disorders where there is a skin tag in front of the ear
Preauricular skin tag
Syndrome occurring where there are lip pits and cleft lip/palate
Van der Woude syndrome
Minor physical anomaly associated with developmental disorders where there are small white/grey spots in a ring around the pupil
Brushfield spots
Cranial nerve number I
Olfactory
Cranial nerve number II
Optic
Cranial nerve number III
Occulomotor
Cranial nerve number IV
Trochlear
Cranial nerve number V
Trigeminal
Cranial nerve number VI
Abducens
Cranial nerve number VII
Facial
Cranial nerve number VIII
Vestibulocochlear
Cranial nerve number IX
Glossopharyngeal
Cranial nerve number X
Vagus
Cranial nerve number XI
Accessory
Cranial nerve number XII
Hypoglossal
Main clinical examination technique for the olfactory nerve
Check sense of smell
Main clinical examination technique for the optic nerve
Visual acuity using Snellen charts
Colour sight using Ishihara charts
Visual fields
Pupillary reflexes
Main clinical examination technique for the oculomotor nerve
Eye movements - elevation, adduction, depression in abduction
Eyelid elevation
Pupillary reflex
Main clinical examination technique for the oculomotor nerve
Eye movements - elevation, adduction, depression in abduction
Eyelid elevation
Pupillary reflex
Eye abnormality seen with a third cranial nerve lesion
Down and out
Main clinical examination technique for the trochlear nerve
Eye movements - depression in inversion
Eye abnormality seen in a fourth cranial nerve lesion
Upwards
Main clinical examination technique for the facial nerve
Facial movement
Taste for front 2/3 of the tongue
Main clinical examination technique for the trigeminal nerve
Sensation to the face
Chewing
Three branches of the trigeminal nerve
Ophthalmic
Maxillary
Mandibular
Main clinical examination technique for the abducens nerve
Eye movements - abduction
Eye abnormality seen in a sixth cranial nerve lesion
Eye turned inwards
Main clinical examination technique for the vestibulocochlear nerve
Balance - Romberg test
Hearing - Rinne/Weber tests
Main clinical examination technique for the glossopharyngeal nerve
Taste to the back 1/3 of the tongue
Sensation to the soft palate
Main clinical examination technique for the vagus nerve
Cough
Vocal cord movements
Main clinical examination technique for the accessory cranial nerve
Head turning
Shoulder shrugging
Main clinical examination technique for the hypoglossal cranial nerve
Tongue movements
Cranial nerve test where a vibrating tuning fork is held against the forehead in the middle of the face
Weber test
Cranial nerve test where a vibrating tuning fork is held at the mastoid bone, and then in front of the ear
Rinne test
Weber test result in normal hearing
Sound heard equally loudly bilaterally
Weber test result in conductive hearing loss
Sound louder in the abnormal ear
Weber test result in sensorineural hearing loss
Sound louder in the normal ear
Positive (normal) Rinne hearing test
Sound continues when the fork is moved from the bone to the air
Negative (abnormal) Rinne test
Sound does not continue when the tuning fork is moved from the mastoid to the air
Type of hearing loss associated with an abnormal Rinne test
Conductive hearing loss
Direction in which patients with poor vestibular function fall in a Romberg’s test
Forwards to the side of the poor vestibular function
Testing for poor vestibular function in which cold or warm water is poured into an ear to elicit nystagmus
Caloric testing
Normal results in caloric testing in unilateral poor vestibular function
Cold water - nystagmus to the opposite side
Warm water - nystagmus to the same side
Test used to elicit ataxia
Heel toe walking
Cerebellar signs
Ataxia Hypotonia Intention tremor Past pointing Dysdiadokokinesis Dysarthria
Sign of meningism where flexion of the neck causes flexion of the knees and hips
Brudzinski sign
Sign of meningism where there is spasm if the knee is extended while the hip is flexed
Kernig sign
Sign suggestive of lower lumber nerve root irritation where the passive flexing of the hip while in the supine position causes pain
Straight-leg raising sign/Lasègue sign
Sign suggestive of upper lumbar nerve root irritation where there is pain on the passive hyper-extension of the hip while in the prone position
Reverse straight leg raise sign
Neurological signs which do not point to a lesion in a specific area
Soft neurological signs
Neurological sign where there are small quivering of the muscles
Fasciculations
Neurological sign where there are brief, jerky movements of the wrists on holding the arms out with the palms facing outwards
Asterixis
Slow, writhing spasms along the long axis of the limbs or the whole body
Athetosis
Semi-purposeful movements of the limbs affecting multiple joints; more peripheral than central
Chorea
Violent flinging movements of half of the body
Hemiballismus
Area of brain generally affected when primitive reflexes are seen in an adult
Diffuse cerebral damage, particularly in the frontal lobes
Primitive reflex where the arms jerk out and the head and legs extend on a sudden change of position
Moro reflex
Primitive reflex where the baby’s head is turned to one side, and the arm on the side the head is turned straightens while the other arm bends at the elbow
Asymmetrical tonic neck reflex
Normal abdominal reflex
A line is drawn away from the umbilicus along a diagonal line, and the umbilicus is drawn towards the direction the line is drawn
Normal cremasteric reflex
Scratching the medial thigh in males causes elevation of the ipsilateral testis
Normal plantar reflex
Plantar flexion of the great toe on drawling a line up the sole of the foot
Positive Babinski sign
Dorsiflexion of the great toe on drawing a line up the sole of the foot
Spinal root of the biceps reflex
C5, C6
Spinal root of the brachioradialis reflex
C6
Spinal root of the triceps reflex
C7
Spinal root of the patellar reflex
L2-4
Spinal root of the Achilles reflex
S4
Lesions causing exaggerated tendon reflexes
UMN lesions
Lesions causing lack of tendon reflexes
LMN reflexes
Condition associated with frontal baldness
Myotonic dystrophy
Condition associated with ash leaf spots
Tuberous sclerosis
Condition associated with moles and dimples along the spine
Spina bifida occulta
Condition associated with Coast of Maine hyperpigmented skin lesions
McCune-Albright syndrome
Conditions associated with Café-au-lait spots
Neurofibromatosis, tuberous sclerosis
Condition associated with axillary freckling
Neurofibromatosis
Type of dysarthria characterised by a strained and hoarse voice with hypernasality, often with swallowing and drooling difficulties
Spastic dysarthria
Type of dysarthria characterised by a small tongue
Hypotonic dysarthria
Type of dysarthria characterised by loudness, tremor and irregularity
Ataxic dysarthria
Lesions associated with spastic dysarthria
UMN lesions
Lesions associated with hypotonic dysarthria
LMN lesions
Lesions associated with ataxic dysarthria
Cerebellar lesions
Type of dysarthria characterised by a quiet, breathy, monotone voice
Hypokinetic dysarthria
Type of dysarthria characterised by strained hoarseness and speech arrests
Hyperkinetic dysarthria
Lesions associated with hyperkinetic dysarthria
Basal ganglia lesions
Type of dysarthria characterised by sudden loss of voice, normal vocal cord movement and normal examination
Hysterical aphonia
Type of gait characterised by a paralysed leg which appears longer due to an extended knee, associated with a clenched hand on the ipsilateral side
Hemiparetic gait
Condition associated with a hemiparetic gait
Stroke
Type of gait characterised by a staggering, wide based gait
Ataxic gait
Area of lesion associated with an ataxic gait
Cerebellar
Type of gait characterised by very short steps
Shuffling gait
Type of gait characterised by progressively shorter steps due to acceleration while walking
Festinating gait
Condition associated with festinating gait
Parkinson’s disease
Type of gait characterised by exaggerated steps, as if climbing stairs while walking on the flat
High stepping gait/neuropathic gait/equine gait
Condition associated with a high stepping gait
Chronic peripheral neuropathies
Type of gait characterised by a broad base, and the dropping of the pelvis on the side of the leg being raised, leading to a compensatory body swing forward
Waddling gait
Conditions associated with waddling gait
Proximal myopathy
Congenital hip dislocation
Pregnancy at near term
Type of gait characterised by over adduction and rigidity in the legs, causing the knees to rub together, as well as plantar flexion of the ankle causing forced tip toe walking
Scissoring gait
Condition associated with a scissoring gait
Spastic paraplegia
Type of gait characterised by the inability to lift the feet off the floor
Magnetic gait
Condition associated with magnetic gait
Normal pressure hydrocephalus
Conditions associated with absent ankle jerks and upgoing plantars
Subacute combined degeneration of the cord
Neurosyphilis
Friedrich’s ataxia
Term for pupillary asymmetry
Anisocoria
Term for the denial of illness
Anosognosia
Lesion associated with anosognosia
Right frontoparietal lesion
Sign characterised by the upward deviation of the umbilicus when an attempt is made to sit up from the supine position due to lower abdominal paralysis
Beevor sign
Condition characterised by ipsilateral spastic paralysis and loss of position sense below the level of the lesion, hyperreflexia, and contralateral loss of pain and temperature sensation
Brown Sequard syndrome
Electrolyte abnormality causing Chvostek sign
Hypocalcaemia
Electrolyte abnormality causing Trousseau’s sign
Hypocalcaemia
Sign characterised by facial spasm on the ipsilateral side when the cheekbone is tapped
Chvostek sign
Sign characterised by carpal spasm when a blood pressure cuff is tightened
Trousseau sign
Sign to test for brainstem integrity in a comatose patient where the head is moved quickly from side to side while the eyes are held open
Doll’s eye manoeuver
Sign elicited in the doll’s eye manoeuver if the brainstem is intact
Both eyes deviate to the opposite side to the direction the head is being turned
Condition associated with high foot arches, kyphoscoliosis, cerebellar signs, impaired joint position, cardiomyopathy and optic atrophy
Friedrich’s ataxia
Sign associated with Duchenne’s muscular dystrophy, where someone attempts to stand up by climbing up their own legs with their arms
Gower sign
Condition associated with a dilated pupil that reacts poorly to light, and absent patellar and Achilles reflexes
Holmes-Adie syndrome
Signs of horner’s syndrome
Ptosis Anhydrosis Miosis Enophthalmos Loss of ciliospinal reflex
Tumour causing horner’s syndrome
Pancoast tumour
Sign where the abnormal pupil dilates as a swinging light moves towards it from the normal side
Marcus Gunn pupil
Condition associated with a Marcus Gunn pupil
Afferent pupillary defect
Painful, asymmetric peripheral neuropathy with damage to at least two separate nerve areas
Mononeuritis multiplex
Causes of mononeuritis multiplex
Diabetes Vasculitis Amyloidosis Tumours Autoimmune disorders Paraneoplastic syndromes
Sign associated with chorea where someone cannot sustain a grip
Milkmaid’s grip
Sign characterised by continued blinking with repeated glabellar taps (normally there is extinction of the reflex)
Myerson’s sign
Condition associated with Myerson’s sign
Parkinson’s disease
Triad of optic neuritis
Loss of vision
Eye pain
Dyschromatopsia (decrease in the perception of colours)
Heat or exercise induced vision loss
Uhthoff sign
Sign characterised by an unsteady tongue when it is protruded out of the mouth, associated with chorea
Trombone tongue
Signs associated with an UMN lesion
Rigidity
Hypertonia
Hyperreflexia
Mild atrophy from disuse
Signs associated with a LMN lesion
Atonia or hypotonia
Loss of tendon reflexes
Atrophy
Fasciculations
Lesion causing a bulbar palsy
LMN lesion of cranial nerves IX - XII
Lesion causing a pseudobulbar palsy
Bilateral UMN lesions of the lower cranial nerves
Signs of a bulbar palsy
Wasted, fasciculating tongue
Nasal speech
Lack of jaw jerk
Lack of gag reflex
Signs of a pseudobulbar palsy
Stiff tongue
Donald-duck speech
Exaggerated jaw jerk
Emotional lability
Causes of a bulbar palsy
MND Polio Botulism Myasthenia Gravis Muscular dystrophy
Causes of a pseudobulbar palsy
MND
MS
Multi-infarct dementia
Severe head injury
Area of brain lesion suggested by anomic dysphasia
Dominant temporo-parietal lesion
Failure to recognise an object despite normal visual input
Visual agnosia
First sign to improve when thiamine is given to a patient with Wernicke’s encephalopathy
Ophthalmoplegia
Area of brain lesion suggested by poor visuospatial ability
Parietal lobe
Inability to read
Alexia
Area of brain lesion suggested in alexia without agraphia
Posterior cerebral territory (usually dominant)
Test used to identify patients with conversion disorder, where the patient is unable to lift their affect limb, but when lifting their unaffected limb against resistance is able to push down with their affected limb
Hoover’s test
Area of brain lesion suggested by poor categorisation
Frontal lobe
Area of brain lesion suggested by poor error correction
Frontal lobe
Area of brain lesion suggested by a spastic hemiparesis
Contralateral frontal lobe
Hemisphere of brain lesion suggested by constructional apraxia
Right
Signs seen in a senile pupil
Sluggish light and accommodation reflex
Reductions in cognitive abilities seen in healthy aging
Motor speed
Visuospatial skills
Attention span
New learning ability
Most common type of tremor
Benign essential tremor
Type of tremor which can be improved by alcohol and beta blockers
Benign essential tremor
Type of tremor which is not associated with pathology, which mostly affects the hands and which slowly progresses
Benign essential tremor
Type of tremor described as a ‘pill-rolling tremor’
Parkinsonian
Type of tremor which is slow and coarse, and gets worse with intentional movement
Cerebellar/intention tremor
Type of tremor which is variable and improves with distraction
Psychogenic tremor
Type of tremor which is present in all normal people when maintaining a posture
Physiologic
Most coarse type of tremor
Cerebellar/intention tremor
Finest type of tremor
Physiologic
Features common in non-epileptic seizures compared to seizures
Longer duration Gradual onset and fluctuating course Eyes closed Safe fall Recall of the event
Features common in epileptic seizures compared to non-epileptic seizures
Sudden onset Incontinence (can occur in non-epileptic seizures too) Automatisms Biting of tongue or inside of mouth Amnesia for the event
Sustained muscle contractions which cause twisting movements or the maintenance of abnormal postures
Dystonia
Sudden involuntary (and not suppressible) jerks of a muscle or group of muscles
Myoclonus
Loss or absence of voluntary muscle movements
Akinesia
Slowness of movement seen in Parkinson’s disease
Bradykinesia
Subjective feeling of inner restlessness
Akathesia
General term referring to problems with voluntary movements, or the presence of involuntary movements
Dyskinesia
Triad of features present in Parkinsonism
Tremor
Rigidity
Bradykinesia
Involuntary but somewhat suppressible stereotyped motor movement or vocalisation
Tic
Involuntary, rhythmic, alternating movement of one or more body parts
Tremor
Condition in which psychogenic polydipsia most commonly occurs
Schizophrenia
Features of sleep associated with typical depression
Decreased total sleep time Early morning wakening Prolonged sleep onset latency Increased wakening through the night Increased REM time Decreased slow wave sleep
Most typical sleep effect of depression
Early morning wakening
Dilation effect of mydriatic agents on Argyll Robertson pupils
Poor
Sign seen in Wilson’s disease where there is a greenish central disc in the eye with spoke like yellow radiations
Sunflower cataract
Test used to investigate the cause of ataxia
Romberg test
Physical findings in hypothyroidism
Hair loss Bradycardia Periorbital puffiness Dry skin Coarse, brittle hair Myxoedema Hyporeflexia Tremor
Findings in hyperthyroidism
Hair loss
Tachycardia
Tremor
Brisk reflexes
Test used during testing of visual fields where the patient’s visual field is compared with the examiner’s
Confrontation
Clinical features of acute cocaine intoxication
Increased temperature Labile BP and tachycardia Behavioural changes - euphoria, anxiety, agitation, paranoia Teeth grinding Dry mouth Dilated pupils
Clinical features of cocaine overdose
As for intoxication Rigidity and myoclonus Seizures Arrhythmias and ACS Hyperthermia induced rhabdomyolysis, renal failure or cerebral oedema
Clinical features of cocaine withdrawal
Vivid and unpleasant dreams Hypersomnia or insomnia Increased desire for sleep Irritability and anxiety Increased appetite Cravings
Clinical features of opiate overdose
Decreased level of consciousness
Pinprick pupils
Reduced respiratory rate
Clinical features of opiate withdrawal
Nausea, vomiting, diarrhoea Abdominal cramps Restless legs and muscle aches Anxiety Yawning Piloerection Coryzal symptoms and eye watering Pupillary dilation Tachycardia, hypertension
Clinical features of benzodiazepine overdose
Sleepiness
Slurred speech
Impaired balance and motor function
Diplopia
Paradoxical agitation, anxiety, hallucinations
In severe cases coma, respiratory depression, hypotension, hypothermia, bradycardia
Clinical features of benzodiazepine withdrawal
Multiple features including: Anxiety, irritability and panic attacks Confusion Insomnia Weight loss Diarrhoea, nausea and retching Muscle twitching Photophobia Dilated pupils Tachycardia
Clinical features of cannabis intoxication
Euphoria Altered sense of time and mind Poor concentration and short term memory Increased appetite Anxiety, hallucinations, paranoia, psychosis Red eyes and sometimes dilated pupils
Clinical features of cannabis withdrawal
Irritability Anxiety Insomnia Decreased appetite Low mood Abdominal pain Tremors Sweating Headache Fever
Clinical features of alcohol withdrawal
Tremor Insomnia Agitation Seizures Hallucinations Sweating Disorientation Autonomic instability Nausea and vomiting
Clinical features of ecstasy intoxication
Euphoria Dilated pupils Dehydration Hyperthermia Tachycardia and hypertension Nausea, vomiting and diarrhoea Clenching of jaw
Clinical features of ecstasy overdose
Labile BP Hyperreflexia Confusion, paranoia, agitation Muscle rigidity Hyperpyrexia
Sign where the pupils constrict and then widely dilate due to raised intracranial pressure
Hutchinson pupil
Gait seen in hip dysplasia or other strucural abnormalities
Pigeon gait
Gait seen in Friedreich’s ataxia
Stomping gait
Clinical features of amphetamine intoxication
Tachycardia or bradycardia Labile BP Pupillary dilation Sweating or chills Nausea and vomiting Euphoria, anxiety, paranoia (in amphetamine induced psychosis)
Clinical features of amphetamine withdrawal
Cravings Low mood Increased appetite Increased or decreased movement Change in sleep patterns Lucid dreams
Type of lesion which causes pronator drift
Upper motor neurone lesion
Type of gait characterised by a long swing phase and short stance phase on one side
Antalgic gait
Symptom associated with an antalgic gait
Pain on weight bearing
Percentage of patients with autism who also have macrocephaly
20%
Features of a lower motor neurone lesion
Weakness Marked atrophy Fasciculations Decreased tone Decreased reflexes
Features of an upper motor neuron lesion
Weakness Mild atrophy only Increased tone Increased reflexes Upgoing plantars (Babinski) Clonus
Weakness of one side of the body
Hemiparesis
Paralysis of one side of the body
Hemiplegia
Apraxia where there is an inability to plan and complete motor tasks, and to convert an idea into action. May have retained ability to complete the task if not consciously thinking about it or may do the wrong thing e.g. try to brush their hair with a razor.
Ideomotor apraxia
Type of apraxia where someone is unable to brush their teeth when asked to. If handed a toothbrush with toothpaste on they may try to perform the wrong action.
Ideomotor apraxia
Type of apraxia where there is an inability to conceptualise and complete multistep tasks. May complete tasks in the wrong order e.g. putting on shoes before socks
Ideational apraxia
Type of apraxia where someone is unable to make a slice of buttered toast, even though they can repeat each single step when shown by others
Ideational apraxia
Type of apraxia where there is an inability to make fine or delicate movements
Limb kinetic apraxia
Type of apraxia where there is an inability to copy a picture or combine parts of something to form something whole
Constructional apraxia
Type of apraxia where there is an inability to control eye movements properly
Oculomotor apraxia
Psychiatric condition where there is a deficit in smooth eye tracking
Schizophrenia
Percentage of patients with Wernicke’s who have the classic triad of symptoms
10%
Physical signs that can point towards a metabolic or toxic cause of altered mental state
Asterixis
Tremor
Myoclonic jerks
Eye sign which is pathognomic of multiple sclerosis
Bilateral internuclear ophthalmoplegia
Features of internuclear ophthalmoplegia
Impaired adduction
Abducting nystagmus
Length of time post traumatic amnesia should last with a mild head injury
Less than one hour
Length of time post traumatic amnesia should last with a moderate head injury
1 hour to 24 hours
Length of time post traumatic amnesia should last with a severe head injury
More than 24 hours
Level of lesion associated with pronator drift
UMN lesion