Sriram Bhat - SRB’s Clinical Methods in Surgery-Jaypee Brothers (2010)

Atrial fibrillation.

Constipation.

Figs 1.13A to D.

Dehydration or shock.

Bacterial endocarditis and bleeding disorders.

Cellulitis, lymphatic causes, venous diseases, pretibial myxoedema of thyrotoxicosis.

0: none; 1: needs diet modification; 2: needs laxatives; 3: needs manual evacuation or enema; 4: due to obstruction.

Irregular edge of the nail growing beneath the lateral nail fold due to improper trimming.

Moon face.

Hypo-albuminaemia, causing whitening of the nailbed.

A whitish opaque thickened epithelium often associated with superficial glossitis.

Dyspnea, basal crepitations, and cough.

Spasmodic contraction of the diaphragm, commonly idiopathic or post-operative due to increased abdominal pressure.

Pain of acute appendicitis starts at the umbilicus and shifts to the right iliac fossa.

Pallor and koilonychia.

Pseudoclubbing is seen in hyperparathyroidism due to undue bone resorption.

In the lower limbs and is more pronounced in the evening.

Ankyloglossia (tongue tie) or advanced carcinoma infiltrating the genioglossus muscle.

Heaping up of the nail and curling over the end of the toe due to trauma or old age.

An anacrotic wave pulse is a small wave in the upstroke felt in severe aortic stenosis.

Weight loss is graded as: < 5% (0), 5-10% (1), 10-20% (2), > 20% (3).

Disappearance of the diamond-shaped gap between nails when fingers are apposed.

Obstructive jaundice.

A vegetarian diet with high consumption of raw carrots.

Height that is in excess of normal for age, typically more than 6.5 feet in adults.

Yellowish discoloration of skin and mucous membranes due to excess bilirubin.

The sphygmomanometer, invented by Riva Rocci, is used to measure BP by exerting lateral pressure on the artery walls.

Frequent belching more than normal.

36.7°C to 37.5°C (98°F to 99°F).

More than 180 degrees.

Anasarca.

The collection of fluid in the interstitial spaces or soft tissues.

Weight gain is graded as: < 5% (0), 5-10% (1), 10-20% (2), > 20% (3).

Obesity, pregnancy, myxoedema, water retention, and Cushing’s syndrome.

Increased capillary permeability, increased capillary pressure, decreased osmotic pressure, and lymphatic block.

100-200 mg/day.

Carotid artery impact into the jugular vein and right ventricular systole.

Fall in right atrial pressure and atrial relaxation.

Tricuspid regurgitation.

Paradoxical increase in jugular venous pressure during inspiration in constrictive pericarditis.

0 (none), 1 (fatigue over baseline), 2 (moderate fatigue), 3 (severe), 4 (bedridden).

Phase I: Tapping sound; Phase II: Softening sounds; Phase III: Sharper sounds; Phase IV: Muffling sounds; Phase V: Disappearance of sounds.

Epidermal elevations containing pus, often due to bacterial infections.

Superior vena caval obstruction.

Bulbous enlargement of the soft parts of the terminal phalanges with transverse and longitudinal curving of the nails.

Onychia.

Hemoglobin should be present in the circulation; in severe anemia (Hb% below 5 gm%), cyanosis is not seen.

Peripheral and central cyanosis.

1: increase < 4 times/day; 2: increase 4-6/day; 3: increase > 7/day or with incontinence; 4: needs intensive care with hemodynamic collapse.

A condition that occurs after esophageal rupture, leading to mediastinal emphysema, subcutaneous emphysema, shock, and toxicity.

A dicrotic pulse is a twice beating pulse with an initial normal percussion wave of systole and a prominent dicrotic wave in diastole, seen in conditions like CCF and cardiac tamponade.

Reduced oxygen saturation of arterial blood due to poor oxygenation in the lungs.

Starvation, severe gastroenteritis, tuberculosis, anorexia nervosa, diabetes mellitus, advanced carcinomas, and gastrointestinal malignancies.

BP in the right arm is higher by up to 10 mm Hg.

A grating sensation elicited over fracture segments when two bone fragments are moved against each other.

Loss of appetite, which can be seen in conditions like anorexia nervosa and gastrointestinal cancers.

Small blisters containing clear or milk-like fluid, seen in chickenpox and herpes.

Fever more than 101°F lasting more than 3 weeks with no diagnosis after one week of investigation.

From above downwards towards the lower abdomen and to the inferior vena cava.

Dilatation of arteriovenous anastomosis stimulated by systemic circulation.

By asking the patient to look down while the examiner pulls the upper eyelids upwards, and also checking the nasal tip, ear lobule, fingertips, and under surface of the tongue.

Greater than 180°.

Carcinoma bronchus, lung abscess, bronchiectasis, tuberculosis with secondary infection.

Bile pigment (bilirubin) is seen in the urine.

Change in color, splinter hemorrhage, clubbing, pallor, koilonychia, and other features.

Crepitus felt at the junction of extensor pollicis brevis and abductor pollicis longus when the hand is opened and closed.

Pulsus alternans indicates alternate strong and weak beats due to alternate contractions of the cardiac muscle, seen in left ventricular failure and toxic myocarditis.

It will elevate the diastolic BP by 10%.

Fine crepitations in chronic diseases, coarse irregular crepitations in osteoarthritis, and clicks due to loose bodies.

The proportion of soft tissue structures in relation to bony structure.

A typical pale look.

Diminished BP with systolic pressure less than 90 mm Hg.

Brittle, flat nails (platynychia) or spoon-shaped nails (koilonychia).

Tissue hypertrophy beneath the nailbed.

Broad flat face, wide apart eyes, protruded tongue.

It conjugates bilirubin to bilirubin glucuronide, making it water-soluble for excretion.

Right atrial contraction.

It is a rapid rising, twice beating wave in the systole of the pulse, felt in idiopathic hypertrophic subaortic stenosis and severe aortic incompetence with mitral stenosis.

Weight loss more than 5% in 30 days; more than 7.5% in 60 days; more than 10% in 180 days.

Pregnancy, travel sickness, gastritis, peptic ulcer, and intracranial tumors.

Upper GI bleed due to blood coming in contact with gastric juice.

0 (none), 1 (one episode in 24 hours), 2 (2-5 episodes), 3 (>6 episodes), 4 (needs parenteral fluid/nutrition).

It can indicate their condition; for example, a comatose patient is silent and immobile, while a patient with ureteric stones may be restless.

Cardiac tamponade, right ventricular failure, tricuspid stenosis, increased blood volume, asthma, emphysema, SVC obstruction.

Persistent raised systolic (above 140 mm Hg) or diastolic (above 90 mm Hg) BP.

A temperature of 39.4°C to 40.5°C (103°F to 105°F).

Increased growth hormone due to pituitary acidophilic adenoma.

Weakness of all muscles, particularly eyelids.

Altered bilirubin transport leading to an increase in unconjugated bilirubin.

Extra chromosome 21, totaling 47 chromosomes.

More than 3 stools per day.

Initially in the eyelids and face, then generalizes to legs and ascites.

Anaemia, massive bleeding, shock, and anxiety.

Traumatic injuries like rib fractures, laryngeal injury, or surgical procedures that trap air in the subcutaneous plane.

It is seen in fungal infections.

It is seen in smokers, stomatitis, and poor oral hygiene.

Excess of circulating red blood cells, giving a purple-red florid appearance.

BP provides insight into the general condition of the patient and varies with factors like emotion, exercise, and age.

A flat alteration in skin color that is not raised; examples include capillary naevi and purpuric macules.

Stature is the total height from vertex to soles.

Coffee brown colored patches on the skin, typically more than 5 in number.

130 to 170 degrees.

Progressively thickened, pale, waxy skin with reduced facial expressions.

130°-170°.

Pain felt at a distant site rather than at the site of the disease.

Pitting on pressure.

Softening and fluctuation of the nailbed.

It should be done in privacy, with limited clothing and in broad daylight.

Ribbing, brittleness, and falling of nails.

Visible dilated veins radiating from the umbilicus, seen in portal hypertension.

From below upwards towards the axillary vein along inguinoaxillary vein.

Height that is far less than normal for age and sex, typically below 4.5 feet.

Posture reflects the positional relationship of different body regions and can indicate specific diseases.

A raised tiny nodule, usually a few mm in size, seen in conditions like measles and chickenpox.

Rapid breathing seen in conditions like fever, shock, and hypoxia.

Both longitudinal and transverse curvatures are increased.

Dry brown tongue.

Specific discolorations.

Short stature, webbed shoulders, and a widened neck.

A crackling or grating sensation felt on palpation of subcutaneous tissue, joint, or bone.

In the sacral region.

It is crucial in specific clinical situations like head injury, hepatic encephalopathy, and septic shock.

Grade I: properly oriented; Grade II: conscious but disoriented; Grade III: drowsy; Grade IV: unconscious but responsive; Grade V: comatose.

Pigmentation around the areola and midline abdomen.

The sensation of wanting to vomit, which may or may not lead to actual vomiting.

Cuff should be inflated rapidly and deflated early and completely.

It is an ideal indicator of severity of many diseases.

An elevated patch on the skin with a paler center, often associated with allergic conditions.

When fluid accumulates more than 5 litres.

3 positive waves (a, c, v) and 2 negative waves (x, y).

Phrenic nerve (C4, C5) and cutaneous supply (C4, C5).

Poor perfusion of peripheral vessels leading to reduced oxyhemoglobin in capillaries.

0: None; 1: Asymptomatic, no drug therapy; 2: Symptomatic, requires drug therapy; 3: Symptomatic, limited function, not responding to therapy; 4: Anasarca.

Blue/purple discoloration in skin and mucous membranes due to increased levels of reduced hemoglobin.

Wasting is observed on the upper half of the body, often with edema in the lower half due to hypoproteinaemia.

Pulsus paradoxus is a decrease in systolic pressure during inspiration by more than 10 mm Hg, seen in SVC obstruction, airway obstruction, asthma, and pericardial effusion.

A waterhammer pulse is a large bounding pulse with a forcible jerk, associated with conditions like thyrotoxicosis, AV fistula, and aortic regurgitation.

3-4 cm of water.

Pre-hepatic (excess hemolysis), hepatic (liver dysfunction), and post-hepatic (obstruction).

Rate, rhythm, tension and force, character, and condition of arterial wall.

Enlargement of the tongue, seen in conditions like lymphangioma and acromegaly.

It is compared to a 10 cm line numbered 0 to 10, where 0 means no pain and 10 is the worst pain.

Myocardial infarction, intravenous fluid infusion, or retrosternal goiter/thoracic outlet obstruction.

It is felt when the lining is rough or contains loose fibrinous particles.

By passively moving the affected joint with one hand while placing the other hand over it.

It is suggestive of systemic illness or stress.

In the upper sclera, nailbed, ear lobule, nasal tip, and under surface of the tongue.

The patient should rest for 5 minutes, avoid exertion or meals 30 minutes prior, and the arm should be positioned correctly.

For a full one minute; counting for a few seconds and multiplying is incorrect.

In the nailbed, palm, toes, and tip of the nose.

Hypoxia leads to opening up of deep arteriovenous fistulas, increasing perfusion of fingers and toes.

By checking the tongue, nailbed, palms, and toes.

Emaciation, shallow pale face, loose wrinkled dry skin, loss of fat, and profound loss of appetite/weight/energy.

It should be analyzed carefully.

Rough skin, brittle hair, and edema in feet.

The usual position is supine with the arm supported at heart level.

Fever that persists throughout the day without fluctuating more than 1°C.