OSCE

myoedema 

It is a phenomenon of mounding of muscle tissue occurring after a light pressure stimuli 

method of eliciting : 

 It is produced by flicking across along the contours of bulk of arm involving biceps belly with the thumb and index fingers. This causes a visible and palpable non-tender, firm, localized ridge in the muscle immediately under the point of tactile stimulus. The swelling reaches its maximal size after 1-2 seconds and gradually subsides over some 5-10 seconds, following which the muscle resumes its normal smooth contour with no palpable localized hardening. The swelling does not spread elsewhere along the muscle. The magnitude as well as the duration of this phenomenon is quite variable, depending upon the thickness of the muscle and the overlying soft tissues and the intensity of the blow delivered. Myoedema is entirely reversible by thyroid hormone replacement, and it does not have any harmful effects 

Myoedema is due to prolonged muscle contraction caused by delayed calcium reuptake by sarcoplasmic reticulum, following local calcium ion release brought out by percussion or pressure. The muscle involvement in hypothyroidism is caused by alterations in muscle fibers from fast twitching type II to slow twitching type I fibers, deposition of glycosaminoglycans, poor contractility of actin–myosin units, low myosin ATPase activity, and low ATP turnover in skeletal muscle 





reference 

g vignesh et . al Indian J Endocrinol Metab. 2013 Mar-Apr; 17(2): 352.

doi: 10.4103/2230-8210.109672


The Walker–Murdoch sign (the wrist sign )

method eliciting 

elicited by asking the patient to grip his wrist with his opposite hand. If the thumb and fifth finger of the hand overlap with each other, the sign is positive 

discussion 

seen in marfans syndrome 

The wrist sign indicates hypermobility and arachnodactyly, which is suggestive of Marfan syndrome, when accompanied by other signs and symptoms 

reference 

Gupta S, Gupta N. Wrist (Walker–Murdoch) and Thumb (Steinberg) Signs. MAMC J Med Sci 2017;3:111-2. 

Steinberg (the thumb sign ) 

Steinberg or the thumb sign is elicited by asking the patient to fold his thumb into the closed fist. If the thumb tip extends from the palm ofthe hand,the test is positive 

discussion 

seen in marfans syndrome, ehler danlos syndrome and in some percentage of normal children (part of ghent criteria 1 and 2)


reference 

Gupta S, Gupta N. Wrist (Walker–Murdoch) and Thumb (Steinberg) Signs. MAMC J Med Sci 2017;3:111-2. 

icterus 

method of elicitation 

examine in adequate natural day light (slight degree of icterus cannot be seen in artificial light so day light is prefered ) 

examine posterior sclera when patient looks down (bulbar conjuctiva is not preferred because mud or dust will cause yellowish discolration --> muddy conjuctiva) 

examine soft palate , under the tongue palms and index 

comment as icterus present or absent 

discussion 

sclera is rich in elastin which has a high affinity for bilirubin

perilimbal sclera is more thinner than posterior part of sclera (so posterior sclera is rich in elastin tissue). hence posterior part of  sclera appears more yellowish than anterior perilimbal sclera and this two areas can be easily compared .

icterus appears initially  on under surface of  the tongue  followed by soft palate 

icterus appears when bilirubin is more than 2-3mg/dl 

based on severity 

kramer's rule is used for pediatric patients 

reference : 

objective structured clinical examination by Dr K R Sethuraman 2nd edition 



high arched palate 

method oef eliciting 

a scale is placed between upper incisor and tip of uvula 

the maximum distance between the scale and arch of palate should be less than 3 cm 

if its is more than 3 cm it is called high arched palate 

discussion 

classically seen in marfan syndrome 

but can also occur in ehler danlos syndrome, down syndrome, treacher collins syndrome and crouzon syndrome 


rhombergs test 

The Romberg sign is an easily administered, no-equipment, bedside physical exam maneuver used since its description in the 19th century to help diagnose tabes dorsalis and dorsal column and proprioceptive dysfunction. A positive test is an inability to maintain an erect posture over 60 seconds with eyes closed. 


steps of exmination 

discussion 

causes of positive rhombergs sign 


False positive romberg’s test



birds index for short neck 

ratio of height to distance between external occipital protuberance and cervical spine (C7)

normal <12.8 

abnormal if >13.6 

short neck is seen