Clinical skills quizzes

The JVP height is measured from the manubriosternal angle. (link)

Calcification of aortic valve and aortic regurgitation cause a soft second heart sound. RBBB causes splitting of the first heart sound. (link)

The normal JVP height at 45 degrees is 1 – 3 cm (link).

In the sitting position with the head turned slightly away from the examiner, the normal JVP is best visualised medial to the clavicular head of the sternocleidomastoid. (link)

The accuracy of clinical examination when measuring the JVP within 2cm of its actual value is about 50% (link)

The specificity of the presence of a visible venous column above the clavicle in a patient sitting upright is approximately 85% and about 65% sensitive. (link)

Feature of the JVP that help to differentiate it from carotid pulsation includes;the venous pulse is not usually palpable; pressure over the base of the vein or over the liver (hepatojugular reflex) makes the vein more prominent; the venous pulse alters with changes in posture; the venous pulse usually decreases with inspiration; the venous pulse has a double impulse for each arterial pulsation; the venous pulsation is prominent during diastole and the vein fills from above. (link)

SVC obstruction usually has an absent venous waveform.(link)

Tricuspid regurgitation causes a combined c-v wave as the R atrial pressure is elevated throughout ventricular systole and is visible during all of systole. (link)

Pure concentric LV hypertrophy (as occurs in pure aortic stenosis) does not cause an increase in the external LV diameter until the AS becomes severe, so does not displace the apex beat in most cases. Displacement of the apex beat is 75% sensitive and 70% specific for cardiomegaly. (link)

VSD produces a murmur in 90% of cases, mitral regurgitation and aortic stenosis in 70% and aortic regurgitation in only 30%. (link)

A prolonged diastolic filling time (e.g.,1st degree HB), delayed ventricular systole (e.g., LBBB) or mitral regurgitation cause a soft first heart sound.

A 3rd heart sound is low pitched, early to mid diastolic and is caused by tautening of the mitral and tricuspid papillary muscles at the end of rapid diastolic filling. It is best heard with the bell of the stethoscope and a RVH H2 is best heard over the left sternal edge. I has a cadence similar to ‘Kentucky’ and may be physiological in children and young adults. (link)

The 3rd heart sound is only about 25% sensitive, but 95% specific, for LVF. It has a cadence like ‘Kentucky’ (Tennessee is the cadence of the 4th heart sound) and is caused by tautening of the mitral and tricuspid papillary muscles. Apart from LVF it is caused by aortic regurgitation, mitral regurgitation, VSD or patent ductus arteriosus. Hypertension causes a 4th heart sound. (link)

The 4th heart sound is higher pitched than a 3rd heart sound, but still best heard with the bell of the stethoscope. It occurs in late diastole and has a cadence similar to ‘Tennessee’ . It is caused by a reflected high pressure atrial wave from a poorly compliant ventricle and is never physiological. It is absent in atrial fibrillation, as there is no atrial contraction. (link)

If originating from the LV, the 4th heart sound is best heard over apex with patient in the left lateral position and is softer during inspiration. When originating from the RV it is best heard over left lower sternal border and is louder during inspiration. Although higher pitched than a 3rd heart sound, it is still best heard with the bell of the stethoscope. (link)

A VSD causes a 3rd heart sound. Acute mitral regurgitation can cause a 4th heart sound, but chronic MR causes a 3rd heart sound, Aortic stenosis, pulmonary stenosis and pulmonary hypertension can also cause a 4th heart sound.(link)

Ejection clicks are the most common early systolic sounds and are due to abrupt halting of the semilunar valves. An aortic ejection click is a loud high frequency sound associated with aortic stenosis due to a bicuspid aortic valve, but not usually with calcific aortic stenosis. It does not vary with respiration and is best heard at the apex. An opening snap is a high pitched early diastolic sound associated with mitral stenosis. It is best heard between the apex and the left lower sternal border with the patient in the left lateral position and is softer in inspiration. (link)

A Grade 1 murmur is just audible with a good stethoscope in a quiet room. Grade 2 is soft but readily audible with a stethoscope. Grade 3 is easily heard with a stethoscope. Grade 4 is an obvious murmur with a palpable thrill. Grade 5 is very loud, heard not only over the precordium but elsewhere in the body. Grade 6 can be heard with the stethoscope off the chest ( i.e. just possibly audible with a stethoscope in a busy ED!). (link)

Papillary muscle dysfunction usually causes a late systolic murmur. (link)

The murmur of a PDA is usually continuous, not just systolic. (link)

Isometric exercise reduces the murmur of aortic stenosis, HOCM and mitral valve prolapse. (link)

AS is the most common isolated valve lesion. (link)

The most common cause of isolated aortic valve disease in younger people in Australia is aortic stenosis. The most common cause of AS in this population is a congenital bicuspid valve, which accounts for about 60% of cases. It has a 1 – 2% prevalence in the general population, is more common in males and is associated with aortic dissection. Degenerative calcific aortic tricuspid valve is the next most common in this age group (and most common in people > 70 years of age, and increasing in frequency as the population ages). Rheumatic heart disease is the third most common cause (and decreasing in frequency), is associated with AR and nearly all cases also have mitral valve disease. Coarctation of the aorta is the least likely cause. (link)

A slow upstroke or plateau pulse has a LR + of 8.
BP changes are unreliable in the elderly so the pulse pressure may be normal or minimally reduced even in severe AS.
a prominent a wave and RVF due to septal hypertrophy (Berheim effect) can be caused by AS, however other causes of a prominent a wave (e.g. TR) make this a less specific sign. A soft H2 has a LR+ for AS of 3.1 and is less specific than a slow upstroke or plateau. (link)

The murmur of AS may be soft in severe disease due to LV dysfunction. Radiation of the murmur to the neck is not considered a sign of more severe AS. (link)

Aortic sclerosis is at least as common as aortic stenosis in older patients and has a systolic murmur similar to aortic stenosis, except that it peaks in early, rather than late, systole. There is no reduction in pulse pressure, the pulse volume and form is normal and there is no single or reversely split H2 as can occur in aortic stenosis. Radiation to the neck can occur in either aortic sclerosis or stenosis.(link)

Duroziez’s sign is systolic and diastolic murmurs over the partly occluded femorals. A water hammer pulse is another peripheral sign of AR. (link)

Another common cause is a bicuspid aortic valve and hypertension in older people. Other uncommon causes include aortic dissection, Marfan’s syndrome, VSD and tertiary syphilis. (link)

Examination is about 75% sensitive and 90% specific – so if you hear the typical murmur, the patient very likely has AR. Examination is only 25% sensitive for mild AR as the early diastolic murmur may not be heard unless the patient is sat up and auscultation occurs in full expiration.(link)

The first heart sound is usually loud in MS and is not considered as a sign of severity. More severe disease also has pulmonary hypertension, and atrial fibrillation is common in many cases of even mild-moderate disease. (link)

Rheumatic heart disease is by far the most common cause of MS in Australia. Congenital MS is rare, as is aortic regurgitation severe enough to impair mitral valve function and cause an Austin-Flint murmur. Calcific, degenerative disease affects the aortic valve, but not the mitral valve significantly. (link)

Other chronic causes include LVF, congenital endocardial cushion defects and radiotherapy. Acute causes are less common but include infective endocarditis, papillary muscle rupture and (very rarely) trauma. (link)

The sensitivity of clinical examination for at least moderate severity MR is approximately 65%. (link)

MVP (and papillary muscle dysfunction) usually has a normal first heart sound, whereas other causes usually cause a soft H1.
Both murmurs are loudest at the apex, but the murmur of MVP tends to be more late systolic than pansystolic (as for cardiomyopathy), and MVP more commonly radiates to the sternum or aortic area as the posterior leaflet of the MV is more commonly affected than the anterior one. MVP may also have a mid systolic click. (link)

There is a prominent v wave in the JVP in TR, not a prominent a wave (as might be expected in TS). Other features such as a pulsatile liver, ascites and prominent peripheral oedema are also suggestive of TR. (link)

TR is caused by tricuspid annular dilation in 75% of cases. This can be due to left or right ventricular failure or pulmonary hypertension.
Other causes include infective endocarditis (especially IV drug users), rheumatic heart disease (usually associated with mitral valve disease), Epstein’s anomaly, papillary muscle dysfunction, transvenous pacemaker insertion and trauma (rarely). It is commonly physiological with 75% of normal people having trivial – mild TR on echocardiography, however this is not clinically significant. (link)

Clinical examination for at least moderate TR is approximately 50%. (link)

TS is very rare, and nearly always rheumatic in origin with the aortic and mitral valves also involved. The JVP typically shows a slow y descent and a prominent a wave (if still in sinus rhythm). The diastolic murmur is similar to MS but louder on inspiration. There may be a pre-systolic pulsation of the liver. (link)

Pulmonary stenosis is uncommon, and is congenital in the vast majority of cases in children, often associated with other congenital abnormalities. In adult, carcinoid syndrome is a cause. The clinical features include peripheral cyanosis, a reduced pulse pressure , giant a waves in elevated JVP, a right ventricular heave / pulmonary thrill , an ejection click then ejection systolic murmur greatest in inspiration, H4 and pre-systolic hepatic pulsation. An ejection click can also occur in congenital forms of aortic stenosis, so is the least helpful of the features listed in differentiating PS from AS.(link)

The presence of a 3rd heart sound is the least useful differentiating feature as it can be present in either MR or a VSD. The murmur of a VSD is louder on inspiration and loudest at the left sternal border (or apex) whereas the murmur of MR is loudest at the apex and unchanged (or reduced) by inspiration. A VSD does not usually cause pulmonary oedema, whereas MR commonly does (right sided > L due to the direction of the regurgitant jet). (link)

Approximately 95% of soft murmurs in patients < 50 years of age are benign. Approximately 65% of murrmurs in asymptomatic ED patients are benign. (link)

Murmurs are present in nearly all women during pregnancy. They are usually soft, mid systolic, are heard along the left sternal border and increase in intensity during pregnancy. Pregnant women may also have continuous murmurs from cervical venous hums or increased mammary blood flow.(link)

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The murmur of mitral stenosis has virtually no radiation and is only heard at the apex. Pulmonary regurgitation and tricuspid stenosis murmurs also have very little radiation.
The murmur of aortic regurgitation radiates down the left sternal border, that of aortic stenosis to the neck (right carotid artery especially), and tricuspid regurgitation murmurs radiate to the lower right sternal border, epigastrium and/or the 5th ICS in the mid left hemithorax. (link)

Acyanotic lesions with left to right shunt are much more common (at least 40% of all congenital heart defects) than cyanotic heart disease (<10%) and are rarely detected soon after birth as pulmonary vascular resistance usually needs to drop (minimum at 3 months) before the clinical features of right to left shunts become obvious. An enlarged heart (or either ventricle) indicates a clinically significant shunt. They consist of ASD, VSD and patent ductus arteriosus. Truncus ateriosus is a single vessel arising from both ventricles and does not have a left to right shunt. (link)

The murmur of a PDA is best heard over the left first intercostal space.  (link)

The apex beat is not usually displaced in an ASD. (link)

The brain is the most commonly affected organ from thromboembolism from left sided native valve endocarditis. The lung is the most commonly affected organ from right sided native valve endocarditis. (link)

Infective endocarditis due to IVDU is usually right sided and does not usually have the peripheral features of left sided endocarditis (Osler’s nodes. Splinter haemorrhages, Roth’s spots, Janeway lesions), unless there is a patent foramen ovale or left sided valve involvement as well. Other common non cardiac features are fever (80%), anaemia (40%), hepatomegaly (30%) and microscopic haematuria (50%). (link)

Osler’s nodes are tender nodules. (link)

Splinter haemorrhages are red for the first 72 hours then become brown. (link)

Osler’s nodes are sterile lesions due to immune complex deposition and usually only last for a few days. More acute forms of endocarditis (eg Staph aureus) usually present early so Osler’s nodes are uncommon. (link)

Janeway lesions are painless lesions that contain bacteria and are more common in acute (esp. Staph Aureus) endocarditis. They may be haemorrhagic and last for days to weeks, but usually have an acral distribution, not an extensor distribution. (link)

Up to 4 splinter haemorrhages are considered normal, as they can occur due to trauma (especially in those that work with their hands). (link)

Bioprosthetic valves are more likely to become stenotic than mechanical valves, but are less prone to ring abscesses that cause valve dehiscence, perivalvular leaks and purulent pericarditis. (link)

An ASD is the most common defect as it includes those people who only have a patent foramen ovale (25% of the population) without significant right to left shunting. The frequency of PFO in the general population has only recently been acknowleged, so many references markedly underestimate the frequency of ASDs as a group. MVP is the most common valve lesion (2-3%) (although you could argue it is a genetically acquired rather than a congenital defect) with bicuspid aortic valves not far behind (2%). VSD is the second most common congenital heart defect (or the most common if you don’t consider a PFO as a defect). (link)

Patients with ASD are usually in sinus rhythm until 30-40 years of age but atrial fibrillation / SVT is common in older patients. There is usually a normal first heart sound but wide and fixed splitting of the second sound due to delayed emptying of the right ventricle. A soft pulmonary systolic murmur with a mid systolic peak due to increased flow over normal pulmonary valve can also occur. A mid diastolic tricuspid flow murmur may be present if the shunt is large but the flow across the atrial septal defect itself does not produce a murmur. (link)

Approximately 25% of patients with a VSD have other cardiac defects.
In about 5% of cases the VSD is just below the aortic valve and may undermine the valve annulus to cause aortic regurgitation. In 5% of cases it is near the junction of the mitral and tricuspid valves, causing regurgitation of these valves. (link)

The liver rarely extends > 6 cm across the midline into the left upper quadrant, It has a convex upper surface and usually extends to level of 5th – 6th rib anteriorly in quiet respiration. The lower surface tends to be concave, with the gall bladder in it and descends 2-3 cm in inspiration with the anterior surface rotating slightly to the right. The Falciform ligament is a fold of peritoneum that joins the mid anterior surface of the liver to the diaphragm and anterior abdominal wall and divides the liver into right and left lobes. (Link)

The upper limit of normal in an average sized adult in the right mid clavicular line is 13 cm (Link)

Friction rubs of the liver are always abnormal, but are rare and nonspecific. They can be due to primary and metastatic malignancies (in < 10%), following liver biopsy or with infective and inflammatory conditions. (Link)

Venous hums occur in portal venous hypertension and are a low-pitched murmur with systolic and diastolic components. They arise from communication between the umbilical/paraumbilical and abdominal wall veins and have inconsistent responses to Valsalva, splenic pressure. They can be distinguished from arterial bruits as aterial bruits are rarely continuous. (Link)

A continous murmur can occur with splanchnic circulation AVM or hepatic haemangioma. Many types of liver tumours can cause bruits, however < 3% of hepatic tumours cause bruits. Only 1% of unselected general medical patients have some kind of abdominal bruit and venous hums are usually lower pitched than arterial bruits. (Link)

The measurement of liver span is more important than palpability of its lower border. There is only moderate inter observer agreement for the presence of a palpable liver edge.About 80% of people have some palpable infracostal extension of the liver so a palpable liver has < 50% chance of being enlarged.. Extension > 2 cm below the costal margin (i.e. more than just palpable) is usually due to hepatomegaly (LR+ 2.5, LR- 0.45). (Link)

Amyloidosis usually only causes mild hepatomegaly. (Link)

Sarcoidosis usually only causes mild hepatomegaly. (Link)

Jaundice is difficult to detect clinically unless bilirubin > 40 µmol/L, although it may still be visible at < 40 µmol/L if it is resolving. The sensitivity of the clinical detection of jaundice is 70% for bilirubin levels  > 50 µmol/L, 85% for > 170 µmol/L and 95% for > 250 µmol/L. (Link)

Shifting dullness to percussion is about 75% sensitive and specific for collections of > 500 mL. Bulging flanks is about 80% sensitive and 50% specific. A fluid thrill is about 60% sensitive and 90% specific for ascites. A succussion splash is a sign of gastric outlet obstruction, not of ascites. (Link)

More than 5 is considered abnormal. (Link)

Campbell de Morgan spots are also known as cherry angioma and are due to proliferation of blood vessels. They are the main differential diagnosis of spider naevi, but are are non blanching, are usually 1-2mm in diameter and rarely > 6mm diameter whereas spider naevi can be up to 1cm in diameter. They appear commonly in middle to late age on the chest and usually have no underlying cause. (Link)

Gynaecomastia is considered present if the amount of subareolar breast tissue in a male is > 2mm in diameter. (Link)

Palmar erythema is predominently on the hypothenar eminence, it blotchy (not uniform), blanches and bilateral. (Link)

Palmar erythema is a non specific finding with multiple causes.
It is most commonly idiopathic but 25% of patients with cirrhosis will have it. It occurs in 30% of pregnant women, 60% of patients with Rheumatoid arthritis and is less common in sarcoidosis, SLE, and polyarthritis. It occurs in 20% of patients with thyrotoxicosis, 5% of patients with diabetes mellitus and can be caused by polycythaemia, leukaemia, eczema, psoriasis, cerebral tumours, amiodarone, gemfibrozil, cholestyramine, topiramate and salbutamol. (Link)

Inflammatory bowel disease and hepatic cirrhosis are the only abdominal diseases that cause clubbing. (Link)

The sensitivity and specificity of percussion for splenomegaly is approximately 80%, with the sensitivity reduced in obesity and the specificity reduced following recent food intake. Palpation is only approximately 25% sensitive but > 95% specific. (Link)

A kidney usually moves downward a little with respiration and is unable to be palpated above it. Due to overlying colon, it is usually resonant to percussion, It is usually balottable from the loin.

Both kidneys may be palpable in the first 48 hours of the neonatal period, but only the lower pole of the right kidney is usually palpable in about 10% of normal people. This is because it is lower than the left, not due to any maldistribution of peri-renal fat. (Link)

The urinary bladder usually becomes palpable when it contains 125mL of urine. (Link)

The normal prostate is usually 4 cm wide, 2.5 to 3 cm high, 4.5 cm long and has a volume of 20 mL. It is normally non tender, smooth, slightly movable, and of rubbery consistency. Two distinct lobes should be felt separated by a median sulcus with distinct lateral sulci. (Link)

A normal transplanted kidney usually lies beneath an arcuate LIF (or RIF scar), is a 8-12 cm ovoid mass that is superficial (extraperitoneal), relatively mobile and able to be palpated around. It is normally non-tender and has no movement on respiration.(Link)

The Normal dimensionsof the adult spleen are: length < 12 cm; width < 7 cm; cephalocaudad diameter < 13 cm; and weight < 250 g. Dullness > 8 cm above the costal margin indicates splenomegaly. (Link)

The correct answer is 3% (Link)

The examination features of the spleen are: unable to get above it; palpable notch; moves towards RIF on inspiration; ballotable from laterally; dull to percussion. (Link)

Subacute bacterial endocarditis usually only causes mild splenomegaly. (Link)

Haemolytic anaemia usually only causes mild splenomegaly. (Link)

SLE usually only causes mild splenomegaly. (Link)

Apart from RHF, the other options usually only cause mild splenomegaly. (Link)

The features of Dupuytren’s contracture include thickening of the palmar fascia (usually the ring or little finger) that starts as a nodule and may develop into a fibrous band leading to fixed flexion at the MCP and PIP joints. It is associated with Garrod’s knuckle pads in 50%, plantar fibromatosis in 20% and penile fibromatosis (Peyronie’s disease) in 5%. It has a variety of causes including alcohol
ism, anticonvulsants, smoking, diabetes and may be idiopathic.(Link)

Flatness is a short sound found on percussion over muscles. Dullness is a longer sound found over fluid filled cavities. Hyperresonance is found over emphysematous lung and tympany is a longer sound typical of a large single gas filled structure such as bowel. (link)

Breath sounds are normally longer in inspiration than expiration, usually reduced by endobronchial obstruction, are harsher in bronchial breathing and have a dry,early – mid inspiratory, crackling nature in pulmonary fibrosis. Crepitations of pulmonary oedema are wet sounding.  (link)

The normal forced expiratory time is < 3 seconds. Values higher than this indicate airway obstruction (link).

A normal person should be able to count to 15. If unable to do so, this indicates poor respiratory reserve. (link)

Whispering pectoriloquy and increased tactile fremitus are less reliable signs of collapse than comparative dullness to percussion. The effect of collapse on breath sounds is variable, depending on whether the bronchus is obstructed or not. The trachea will be displaced to the ipsilateral side only if the collapse is large.(link)

Increased tactile fremitus and whispering pectoriloquy may occur, but are less common than crackles on auscultation. Breath sounds are more likely to be bronchial in nature, than absent and hyperinflation would not be expected to occur. (link)

Abnormal comparative percussion is most likely in pleural effusion.Increased tactile fremitus and bronchial breathing may be present if there is collapse above the effusion, but are less reliable findings. A pleural rub would not be expected and tracheal displacement to the contralateral side only occurs with very large effusions. (link)

The right oblique fissure runs slightly posteriorly to the left, which may help to identify it on the lateral CXR. The pleura may protrude slightly inferiorly to the costal margin on the right side, but not on the left (this is why the left xiphisternal region is suitable for pericardiocentesis). The pleural reflection follows the left border of the sternum until the 4th CC then deviates to almost the midclavicular line by the 6th CC.

False ribs articulate with the 7th costal cartilage. The nipple is males is in the 4th ICS in the midclavicular line. Cervical ribs are present in < 1% of the population and lumbar ribs are much less common that cervical ribs. The apex of the pleura extends up to 2cm into the supraclavicular fossa, hence may be damaged with wounds or procedures in this area.

This is why intercostal catheter placement in the supine patient should occur at a high level.

This is why intercostal catheter insertion should occur in the anterior axillary line or posterior to the mid axillary line.

Silicosis predominantly involves the upper lobes. (link)

Asbestosis predominantly involves the lower lobes. (link)

Features of clubbing include; an AP diameter of the finger at the nail bed: at the DIP joint > 1; fluctuation of the nail bed; beaking of the fingernail; rounding of the nail plate; flattening of the angle between the nail plate and proximal nail skin fold; and shiny smooth skin over the cuticle. (Link)

The most common pulmonary cause of clubbing is lung cancer. Less common causes are idiopathic pulmonary fibrosis, sarcoidosis, empyema, lung abscess and bronchiectasis. It is uncommon in COPD and TB. (Link)

Normal chest expansion is > 5 cm. It is generally reduced in chest hyperexpansion and fibrosis and locally reduced due to many underlying causes. (Link)

Inspiration is louder and longer than expiration with normal vesicular breath sounds. Bronchial breath sounds have a tubular quality and a more pronounced expiratory phase. Egophony is the change of the pronounced sound of ‘eee’ to ‘aaye’. Coarse crackles are gurgling in quality and imply fluid in small airways. (Link)

Causes of pulmonary fibrosis that can affect any area of the lung include: radiation, smoke inhalation, ARDS, methotrexate, hydralazine, nitrofurantoin, amiodarone, busulphan, cyclophosphamide, methysergide and paraquat. Coal miners pneumoconiosis usually affects the upper lobes. (Link)

The likelihood ratios for COPD are: Barrel chest and loss of cardiac dullness to percussion – 10; rhonchi – 6; hyperresonance – 4.8; FET > 9 – 4.8; FET < 6 – 0.45; pulsus paradoxus –  3.7; decreased breath sounds – 3.7. (Link)

Pancoast’s syndrome is an apical tumour with local extension and is usually a squamous cell carcinoma. The C8, T1, T2 nerves are often involved with pain along their nerve roots. Destruction of 1st and 2nd ribs may also occur. (Link)

The positive LRs for CAP are: egophony – 6; bronchial breath sounds – 3.5, dullness to percussion – 3; T > 37.8 C – 3; RR > 25/min. – 2.5; crackles – 2.5, decreased breath sounds – 2.4. (Link)

Decreased breath sounds are about 75% sensitive whilst increased percussion note is only 10% sensitive. Small pneumothoraces (< 15%) may have no obvious clinical signs. Tracheal deviation occurs in < 25% of cases of tension pneumothorax, so is an insensitive feature. (Link)

Hypercalcaemia and hypoglycaemia are most commonly caused by squamous cell tumours. Eaton Lambert syndrome, hyponatraemia, carcinoid and ectopic ACTH are most common in small cell tumours. Hypertrophic pulmonary osteoarthropathy (HPO) is usually due to adenocarcinoma. (Link)

SVC syndrome may have features of voice hoarseness, however true stridor or dysphagia are rare.
Upper body oedema is common, especially of the face, neck, periorbital tissue and tongue. The neck veins are usually distended and there is facial plethora or telangiectasia. Elevation of the arms (Pemberton’s sign) causes worsening facial suffusion. (Link)

The clinical sensitivity of cyanosis is approximately 50% at a paO2 of 80mmHg, 75% at 70mmHg and 100 at 60mmHg. (Link)

The normal anterior-posterior to transverse ratio in and adult is 1:2. (Link)

The normal AP:transverse chest ratio is 1:1 from birth until 2 years of age. It is 1:1.4 by 6 years of age and 1:2 by adulthood. (Link)

The inspiratory crackles of pulmonary fibrosis tend to be later in onset and of longer duration than the crackles of pulmonary oedema. Bronchial breath sounds may be normal over the central region of the chest and the apex of the right lung. Wheezes and rhonchi have a duration of > 250 milliseconds. Wheezes are higher pitched than rhonchi. (Link)

The minimum difference in diameter between the dominant and non dominant leg considered abnormal is 1cm. (link)

The minimum difference in diameter between the dominant and non dominant arm considered abnormal is 0.5cm. (link)

Random generalised twitches are pathological and their presence implies a lower motor neurone lesion. They are of the same rapidity and strength as benign fasciculations, however benign fasciculations are characterised by a repetitive twitch in the same muscle fibre, whereas pathological fasciculations tend to be random and generalised in a muscle. (link)

Fasciculations may be difficult to see in overweight patients and are easiest to see in the first dorsal interosseous muscle of the hand. Strong muscle contraction or percussion may increase the frequency of the fasciculations following relaxation. Fasciculations are rare following peripheral nerve lesions and can be caused by motor neurone disease, motor root compression, motor neuropathies and myopathies. (link)

When tone is normal, rapid passive flexion of the knee usually raises the heel off the bed slightly and transiently. If the heel drags across the bed from the start, this indicates hypotonia. If the heel is jerked upward, this indicates increased tone. Reinforcement techniques are used to increase the strength of weak reflexes, but do not usually increase muscle tone. (link)

Clasp knife rigidity is due to a heightened stretch reflex from an upper motor neuron lesion. Rapid passive flexion and extension of the elbow or knee produces a transient increase in resistance that occurs after a period of normal resistance, and is then overcome. (link)

With lead pipe rigidity the increase in tone is equal in the flexors and extensors and is felt throughout the range of movement. It may be easier to detect with slow movements and may gradually increase in intensity with repeated motion. (link)

Cog wheel rigidity is a rapid, regular series of resistances during passive movement. It may occur in essential or familial tremor in the presence of normal tone and is one of the classical  features of Parkinsonism. (link)

Gegenhalten phenomenon is the resistance by the patient against any passive movement. When present attempted movement is met with an equal and opposing force. It is usually associated with diffuse cerebral disease and advanced dementia. It is derived from the german ‘gegen’ – against, and ‘halten’ – to stop.

Hoover’s sign is as follows: with the patient lying in bed, place the palm of the hand between the bed and the heel of the weak limb and ask the patient to raise their unaffected leg. The presence of downward force in the weak leg and the lack of downward force under the good leg when instructed to raise the weak leg indicates feigned weakness. There is no contromano phenomenon! (link)

Clonus is a repetitive contraction of a muscle or muscle group demonstrated by suddenly stretching a muscle. One to two beats of clonus at the ankle is normal in those with naturally brisk reflexes but is considered pathological if it is present at any site other than the ankle or if more than 2 beats are present at the ankle, except in neonates when it can be normal, if not sustained. Fast beats with slow relaxation on lateral gaze is typical of horizontal nystagmus, not clonus. Clonus does not alter the normal pattern of a rapid contraction and longer relaxation of a deep tendon reflex, although tendon reflexes are usually brisk. (link)

Muscle power is assessed across joints. The joint is isolated by stabilising the part proximal to the joint with one hand whilst applying force to the limb proximal to the next joint with the other hand. The same segment is then assessed in the opposite limb for comparison. The grading of muscle power is: 0 = complete paralysis; 1 = flicker of contraction; 2 = movement with gravity excluded; 3 = movement against gravity but not resistance; 4 = movement against resistance; 5 = normal power. (link)

When testing reflexes, support the limb to ensure the muscle is relaxed and the muscle should be at its resting length or slightly stretched (e.g. slight knee flexion for the patellar reflex). (link)

Reflexes are usually graded using the following scale: 0 – absent with reinforcement; 1 – present but decreased in amplitude and velocity from the normal range and elicited with reinforcement; 2 – normal amplitude and velocity without reinforcement; 3 – increased in amplitude and/or velocity with spread to adjacent site; 4 – increased in amplitude and/or velocity with spread to adjacent site and duplication of the jerk or clonus. (link)

A plantar reflex would normally be present after 1 year of age. (link)

The nerve roots involved in the biceps reflex are C5-6. (link)

The nerve roots involved in the triceps reflex are C 7-8 (link)

The nerve roots involved in the finger reflex are C8. (link)

The nerve roots involved in the knee reflex are L 3-4. (link)

The nerve roots involved in the ankle reflex are L5 – S1. (link)

The nerve root involved in the plantar reflex is S1.

The cranial nerve involved in the jaw reflex is V (Trigeminal). (link)

Typical features of an upper motor neurone lesion include wasting which is usually  absent if acute and only mild when chronic. Tone is increased if chronic and decreased if acute. The weakness is usually greater in extensor and abductor muscles of the upper limb and greater in the flexors of the lower limb. (link)

Lower motor neurone lesions typically have wasting that is often profound when chronic, fasciculations, decreased tone and reflexes that are decreased or absent. (link)

Generalised symmetrical distal weakness is most likely due to a peripheral neuropathy. The weakness is usually mild. (link)

A generalised symmetrical proximal weakness is most likely due to a myopathy. (link)

Ipsilateral cranial nerve lesions and contralateral motor or sensory deficits are most likely due to a unilateral brainstem lesion. (link)

Weakness associated with visual field disturbance is most likely due to a cortical lesion. (link)

Pain and temperature sensation is transmitted via the spinothalamic pathway with the nerve fibres entering the spinal cord and crossing a few segments higher. It is less sensitive than 2 point discrimination in determining sensory loss in sensitive areas of the body (e.g. palm). The vibration and some proprioception pass through the nucleus gracilis and cuneatus in the medulla after ascending in the posterior columns of the spinal cord. (link)

A 256hz tuning fork is used to test hearing and bone conduction and is the same pitch as ‘middle C’ on a piano. (link)

Vibration testing in a limb should be performed from distal to proximal – if there is no distal loss, then proximal loss is highly unlikely and testing for it can usually be omitted.
The start of sensory loss at the same level around a limb suggests peripheral neuropathy.
When testing joint position sense, the joint should be flexed or extended at least 30 degrees – 10 degrees of movement is insufficient to test normal joint position sense. Light touch sensation is transmitted in the ipsilateral posterior columns and contralateral spinothalamic tracts. (link)