A site for medical students - Practical,Theory,Osce Notes

Significance of hand examination in systemic diseases

Examination of hand reveals specific features of systemic diseases.
  • Cold clammy hand with peripheral  cyanosis indicate shock
  • Cold moist hand in anxiety state
  • Cold dry hand is a feature of myxedema
  • Warm moist hand seen in thyrotoxicosis
  • Pallor of palmar crease observed in anemia
  • Wasting and fasciculation of hand muscles- is seen MND, syringomyelia
  • Myotonic disorders can be associated with slow relaxation on shaking hand
  • Cyanosis and clubbing together-Cyanotic CHD, ILD
  • Nail-fold infarct and telangiectasia are seen in vasculitis. SLE, PAN, PSS
  • Osier's node, splinter hemorrhage, Janeway suggestive of infective endocarditis
  • Pigmentation is a feature of Addison's disease, megaloblastic anemia
  • Arachnodactyly is a feature of Marfan's syndrome
  • Deformed hand diagnostic of rheumatoid arthritis 
  • Sclerodactyly in PSS, MCTD
  • Heberden's node are characteristic of osteoarthritis
  • Clawing of hand  in ulnar and median nerve lesion
  • Dupyutren's contracture a feature of alcoholic liver disease, trauma
  • Gottron's papule is seen in dermatomyositis
  • Large spade hand in acromegaly
  • Short 4th metacarpal- pseuda-hypopara thyroidismdism, reverse Marfan's syndrome (Weil-Marchesani syndrome)  and Turner's syndrome
  • Long thumb-fingerization-Holt-Oram syndrome.

Ataxic Gait (Cerebellar Lesion)

  • This gait is also called as reeling. staggering. drunken gait
  • This type of gait is seen in patients with cerebellar lesion and alcohol intoxication
  • The patient is ataxic and reels in any direction, including backwards and walks on a broad base.
  • The unsteady feet are planted widely apart and placed irregularly.
  • The steps are uncertain, some are shorter and some are longer than Intended, and the patient tends to fall or deviate to the side of cerebellar lesion.
  • The ataxia is equally severe whether the eyes are open or closed
  • The patient finds difficulty in executing tandem walking.
  • Gait ataxia is seen in lesion of upper vermis and anterior lobe of cerebellum
  • Titubant ataxia - ataxic gait with vertical oscillation of head and trunk. 

How to examine for Dorsalis pedis pulse:an OSCE guide

Dorsalis pedis pulse is  located on top of the foot, immediately lateral to the extensor of hallucis longus (dorsalis pedis artery).
The dorsalis pedis pulse is palpated in the groove between the first and second toes slightly medial on the dorsum of the foot (i.e., dorsolateral to the extensor hallucis longus tendon and distal to the dorsal prominence of the navicular bone) with the middle and/or index fingers

Feel the pulse lateral to the extensor hallucis longus tendon and proximal to the first metatarsal space.

Comment on the following
  • Rate, rhythm, character, volume.
  • Character of the vessel wall.
  • Palpability of all vessels.
Clinical significance

Dorsalis pedis pulse is absent in condition of proximal vessel occlusion  such as embolism to popliteal artery or in peripheral vascular disease.

Physiology of Ocular Movement

There are 3 planes of movement of eyeball
Vertical plane 
  • Adduction - Medial rectus 
  • Abduction - Lateral rectus
Horizontal plane 
  • Elevation - Superior Rectus and inf. oblique
  • Depression - Inferior Rectus and Superior oblique
Diagonal plane 
  • Intorsion - Superior rectus and Superior oblique
  • Extorsion - Inferior rectus and Inferior oblique

Normal range of eye movement
  • Abduction - 60°
  • Adduction - 50°
  • Depression - 50°
  • Elevation - 30°
Types of  ocular movement
  • Saccadic movement-jerky voluntary movement from an object to another
  • Pursuit movement-smooth follow movement
  • Fixation movement-move the head while the gaze is fixed
  • Reflex movement-oculocephalic, oculovestibular movement.
Symptoms of ocular motor system
Diplopia, squint, ptosis, defective vision,dizziness (ocular vertigo).

Anatomical peculiarity of facialnerve

Facial nerve is a Sensorimotor nerve with the following functions
  • Special visceral efferent (facial muscle)
  • General visceral efferent (submandibular, sublingual and lacrimal glands)
  • Special visceral afferent (taste from anterior two-thirds of tongue)
  • General somatic afferent (sensation from external auditory meatus, mastoid and pinna)
The upper half of the face has a bilateral representation ,whereas the lower half of the face has unilateral representation.
Nuclei of facial nerve are 4 in number
Motor nucleus contains dorsal and ventral group of cells and is situated in ventral pons
Superior Salivatory nucleus control salivation
Nucleus of tractus solitaries carry taste sensation from anterior 2/3 rd of tongue and sensation from external auditory meatus
Lacrimal nucleus. for lacrimation

There is two types of movements voluntary and reflexmovements
Volitional movement
There is supranuclear connection for volitional movement
It is unique for facial nerve
For Volitional movement the fibers start from  lower part of precentral gyrus , corticonuclear fibers descend to pons and cross to opposite facial nucleus. Nucleus  for the superior half of facial muscles receiving ipsilateral and contralateral supranuclear fibers. Nucleus  for the inferior half of facial muscles mainly receive contralateral supranuclear fibers .This explains why the upperhalf is spared in UMN lesion and only lower half is affected.
Occasionally lower half of face also has ipsilateral supranuclear innervation but it is less than contralateral innervation. This will result in only paresis of lower half in UMN lesion, if ipsilateral supranuclear innervation is also equal to contralateral  innervation both upper half and lower half may escape in UMN lesion.
Rarely upper half will have innervation predominantly from contralateral fibers. Thus in UMN lesion there is extension of weakness to upper half of face also.
For reflex movement 
Fibers from premotor area, extrapyramidal center, basal ganglia, through separate pathway, innervate the Nucleus from both sides but predominantly from Right cortex.
Lesion of this pathway produce Mimic facial palsy.
Nervus intermedius
It is the  Sensory counter part of facial nerve,it carry fibers of Superior Salivatory nucleus, lacrimal nucleus, and Nucleus of tractus solitarius.
It subserves the following
Somatic sensation of mastoid region ,part of pinnae, external auditory canal
Secretomotor fibers to lacrimal gland, salivary glands - sublingual and submandibular and
Visceral sensation – taste sensation from ant. 2/3rd of tongue.

Branches facial nerve

Branches at the Geniculate ganglion 
  • Greater superficial Petrosal nerve -supplies secretomotor fibers to lacrimal gland
Braches of Vertical mastoid segment
  • Nerve to stapedius
  • Chorda tympani -arise 5 mm above the stylomastoid foramen, carry taste sensation from anterior 2/3rd of tongue. It supplies secretomotor fibers to submandibular and sublingual gland
Branches at the level of Stylomastoid foramen
  • Posterior auricular braches-supplies occipitalis and auricular muscles
  • Digastric – Posterior belly of digastric
  • Stylohyoid supplies stylohyoid muscle
Branches in the Parotid region 
Temporofacial  branch
  • Temporal
  • Zygomatic
  • Upper buccal
Cervicofacial branch
  • Lower buccal
  • Mandibular
  • Cervical.
They supply muscles of face, scalp, and platysma.

Course of the facial nerve -the 7th cranial nerve

Key anatomical area you should remember in relation to anatomy of the facial nerve are the following
  • Pons
  • CerebelloPontine angle
  • Internal auditory meatus
  • Middle ear 
  • Stylomastoid foramen
Intrapontine segment 
Facial nuclei is situated in the pons
Sensory and parasympathetic fibers are carried by nervus intermedius
It curves around the 6th nerve nucleus to form facial collicullus and form the first genu around the 6th Cranial nucleus
Cerebellopontine  Angle
Nerve emerges at the ventrolateral portion of pontomedullary junction with Nervus intermedius and 8th nerve and lies in the cp angle
Meatal segment
Enters the internal auditory meatus with the 8th nerve with the nervus intermiedius in between
Labyrinthine segment
It  dip into the facial canal in the floor of meatal canal, reaches the medial part of tympanic cavity form the 2nd genu - geniculate ganglion – receives the Nervus intermedius.
It curves posteriorly at the genu giving the Greater superfical petrosal nerve at the genu
Then it travels backwards in the horizontal direction (tympanic segment is above the middle ear)
Mastoid segment
It turns back vertically downwards to emerge through stylomastoid foramen, then turns vertically in the vertical (mastoid) segment
It gives nerve to stapedius and chorda tympani nerve in the vertical part
Parotid region
The facial nerve emerge through the Stylomastoid Foramen and enters the parotid region
It emerges at the stylomastoid foramen
Leaves  the parotid gland by dividing to temperofacial and cervicofacial branches
finally divides into five terminal motor branches