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
seen in
overt hypothyroidism (hypothyroid myopathy)
malnutrition, hypovitaminosis, and hypoalbuminemia
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.
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
Reddish shade (Rubin jaundice): Hepatitis
Lemon yellow with a reddish hue (Flavin jaundice): Hemolysis
Greenish yellow (Verdin jaundice): Obstructive jaundice
Grayish or blackish green (Melas jaundice): Prolonged obstructive jaundice
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
explain the procedure to the patient
It is important to reassure the patient that he will be supported in case of severe imbalance. The physician should be facing the patient; his arms should be extended on either side of the patient to support him (without touching the patient)
The patient is then made to stand with his feet close together, arms by the side and eyes open. Any significant swaying or tendency to fall is noted. The patient is then asked to close his eyes.
Romberg’s test is considered positive if there is significant imbalance with the eyes closed or the imbalance significantly worsens on closing the eyes (if imbalance was present with the eyes open--> consider cerebellar etiology).
Normal individuals also tend to sway to some extent on closing their eyes
discussion
causes of positive rhombergs sign
positive Romberg’s test is a hallmark of sensory ataxia. However, a positive Romberg’s test can result from:
Inherited causes
Autosomal dominant sensory ataxic neuropathy
Autosomal dominant sensory neuropathy with scoliosis and deafness
Autosomal dominant posterior column ataxia
Posterior column ataxia and Retinitis pigmentosa
Friedrich’s ataxia
Ataxia associated with Progressive External Ophthalmoplegia
Cerebellar atrophy of late onset
Biemond syndrome (posterior column ataxia)
Metabolic and toxic
Vitamin B12 deficiency - Subacute combined degeneration of the cord (SACD)
Diabetic peripheral large fibre neuropathy
Vitamin E deficiency
Pyridoxine excess
Thiamine deficiency
Drugs: Semi-synthetic penicillins, cisplatin, taxol
Immunological and others
Paraneoplastic sensory neuropathy
Guillain-Barré Syndrome (Miller Fischer variant)
Idiopathic Sensory Neuronopathy
Tabes dorsalis (classical cause)
Compressive lesion involving dorsal columns
Multiple hamartoma and neoplasia syndrome (Cowden syndrome)
False positive romberg’s test
Labyrinthine disease
Hysteria
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
klippel Feil syndrome
morquios syndrome (MPS IV)