‫بسم هللا الرحمن الرحيم‬

This book is a result of a lot of exerted effort from a group

of students hoping for nothing but to help their colleagues. We
hope you get as much benefits as possible.
Best wishes
 The OSCE exam:
5 stations each 25 marks
Each station is 2 parts, the first is to do some points in the local
examination or general examination. And the second part is a
discussion about the case so you must have a good clinical
background and to know some topics in your curriculum well
for the discussion part then this book will tell you what you do
in the part of examination in less than 15min.

 1st station is cardiology

 2nd station is chest
 3rd station is abdomen
 4th station is neuro OR Psychiatry
 5th station is one of three: endocrine, rheumatology and
Hematology

Revised by Dr. Walaa ElSalakawy 

The participants “MO, AHM, MOA, SHAI, ASM, MAN, MAY, NOR.”
 CARDIOLOGY

General Examination
1. ABCD :
 General
 Body
 Appearance “good, bad, fair, cachectic”
 Built “over built, under built, average”
 Consciousness “usually conscious”
 Decubitus
 No special decubitus for medical importance
 Orthopnoea :
 Lt sided Hrt failure
 Status athmaticus
 Tense ascitis
 Squatting position in Fallot
 Praying Muslim position for Pericardial effusion or Medistinal syndrome
2. Facies:
 Malar flush : Mitral stenosis
 Elfin facies : Supra valvular Aortic stenosis
3. Complexion
 Pallor : we examine Mucous membrane , skin , Lips , Nails
 Low COP
 Anemia  Toxemia
 Joundice :
 Sclera and lower fornix
 Soft palate
 Lunula of tongue
 Skin
 Cyanosis :
 Central : decrease O2 Saturation in Arterial blood below 80:85%
 Congenital cyanotic Hrt diseases as Fallot
 Eisenmenger Syndrome
 Ebstein anomaly
 Transposition of great vessels

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 This type is characterized by:

 Affects Skin, nails, lips, MM, tongue

 Warm hands
 CLUBBING
 Peripheral : Normal O2 saturation but there is VC or stagnant circulation
 Low COP eg Ht Failure
 Peripheral vascular disease

This type is characterized by: Hands are cold

 Affect skin with nails, tip of nose, ear – NO clubbing

 Pallor and jaundice “Artificial Valves which make mechanical hemolysis of RBCs ,
Hemolytic anemia eg Thalassemia .
 Cyanoicterus “cyanosis and jaundice” in Tricusped incompetence

 NB : Tongue is Free ( Not cyanosed )

 NB : Venous obstruction as in superior vena caval obstruction >> associated with
tongue cyanosis .

4. Vital sign:
 Pulse : comment on
 Rate
 Rhythm
 Vessel wall condition
 Volume
 Equality on both sides
 Special characters:
 Watter hummer pulse: Aortic Incompetense or PDA
 Plateau pulse in Aortic stenosis
 Pulsus bisferiens in Aortic Incompetence
 Pulsus alternans in Lt ventricular failure
 Pulsus paradoxicus in Rt ventricular failure or in constrictive
pericarditis or in cardiac tamponade
 Peripheral pulsations : dorsalis pedis and posterior tibial artery and
Carotid pulsation .
 BP
 Temperature

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5. Neck :
 Arterial pulsation
 Venous pulsation
 Thyroid swelling

 Difference between Arterial and venous pulsation:

Venous Arterial
Better seen than felt Better felt than seen
Wavy Jerky”one wave”
Can be obliterated by pressure Can not
Got on upper level No upper level
Change by changing position No
Engorged with blood on straining No

6. Hands:
 Temperature
 Tremors
 Cap.pulsation : Aortic Incompetence
 Splinter hmg in Infective endocarditis
 Osler nodules in Infective endocarditis
 Jane way spot in Infective endocarditis
 Cyanosis
 Clubbing in Infective endocarditis or congenital cyanotic heart disease
Degrees: 1st obliteration of the angle, 2nd parrot peak, 3rd drumstick, 4th
thichening of distal ends of long bones at wrist and ankle
 Spooning of the nails

7. Lower limbs:
 Oedema “over bony prominence posterior to malleoli, dorsum of foot, chin of
tibia” write in your comment
a) Uni or Bi
b) Pitting or non
c) Level of edema
 Cyanosis
 Clubbing
 Pulsations

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 8. Any other +ve data

9. Examine for the bilateral fine basal crepetations for pulmonary venous congestion as
in Lt ventricular failure

10. Abdominal Ex for enlarged tender liver in Rt sided Hrt failure or enlarged
splenomegally for Infective endocarditis

11. Neurological Ex for Lateralizing signs

Lateralizing signs
a. One hand drops rapidly and passively than the other hand
b. Conjugate deviation of the eye movement to one side
c. The cheeks moves in and out during inspiration
d. The limb which is not affected is painful on moving
e. +ve Babinski sign on the affected side

Local Examination

INSPECTION PALPATION “at the same time” ,,, percussion is obsolete .

1. Inspection: inspect 5
Pericordial bulge, apex, scars, dilated veins, pulsations
 Pericordial bulge:
Look tangentially next to the pnt and on foot bed side
Causes:
 Congenital
 Rheumatic
 Pericardial effusion
 Apex: site and extent
 Site:
Lower most, outer most , palpable and visible pulsation
Lt 5th intercostals space mid clavicular line , 3.5 inch from mid line, 1
inch in diameter ( Normal Apex site )

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 Abnormalities:
 Rt ventricular enlargement
Shifted outwards
 Lt ventricular enlargement
Shifted down and out:
 Extent:
Normally it is localized and it may be due to Lt ventricular failure
But it may be diffuse = more than 1 inch and more than 1 space in Rt
ventricular enlargement or failure

 Other pulsations:
 Suprasternal pulsations in : Hyperdynamic circulation, aortic aneurism,
atherosclerosis which make kinking of carotid
 Epigastric pulsations either from above in Rt ventricular enlargement,
from inside “Aortic pulsations” or from Rt “Liver pulsations”
 Rt 2nd space pulsations: Ascending Aorta dilatation in Aortic aneurism ,
sys HTN , Post stenotic dilatation
 Lt 2nd space dilatation Pulmonary artery dilatation in pulmonary HTN
 Lt 3rd and 4th parasternal area: Rt ventricular enlargement or dilated Lt
atrium which push Rt ventricle forward
 Dilated veins
 Scars of previous operations
 Midline sternotomy " valve replacement, coronary bipass, open Hrt
surgery
 Inframammary transeverse scare in mitral valvotomy

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2. Palpation
 Apex:
 Confirm site
 Character of apex:”amplitude and
duration”
1) Normal:
2) Hyperdynamic apex as in
AI,MI,VSD,PDA‫زقة‬
3) Heaving sustained as in AS ,
sys HTN‫زقة بتعلق‬
4) Slapping apex : palpable 1st
Hrt sound with weak apex in
MS
 Thrill: ‫زنة‬
MI make sys thrill
MS make diastolic thrill

 Palpable sounds:‫نقرة‬
1st Hrt sounds palpable in MS
 Lt parasternal area:
1) Pulsation :

Rt ventricular enlargement or dilated Lt atrium which push Rt

ventricle forward

2) Heave “ pressure load” in pulmonary HTN and PS ( by base of

metacarpals )

3) Thrill of VSD

 Epigastric pulsation:
either from above in Rt ventricular enlargement, from inside “Aortic
pulsations” or from Rt “Liver pulsations”
 Base
3. Percussion 

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 4. AUSCULTATION comment
1. Heart sounds :
S1 “over apex or mitral area” is normal or increased or
decreased

S2 “A1& P” is normal or increased at pulmonary area more than

Aortic area which indicates pulmonary HTN”
2. Murmur
3. No added sounds “gallop , rub ,S3,S4”
4. Type of lesion

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 Cardio Auscultation Scheme
1. Heart sounds

S1 : Loud is known by experience or by comparison

S2: Listen to aortic and pulmonary areas by comparison

 In pulmonary HTN: 2nd sound will be more louder on pulmonary area than
Aortic area
 In systemic HTN: 2nd sound loud all over

S3: on Apex in case of ht failure “as if splitted from the S2”

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 S4: on apex: Systemic Hypertension , AS

Additional Sounds Ejection clicks , Opening snap

MURMURS

STEP 1: Auscultate A1

You should look for “vooooo” - systolic murmur- If present A.S

A.S Organic A.S functional

Harsh – loud – Thrill not harsh-not loud- no thrill

N.B: Organic A.S usually propagates to the Apex so we might think its M.I

If murmur intensity towards Apex decrease THEN It’s A.S

If murmur intensity towards the Apex decrease AND starts to be loud propagating to
axilla and characte changes into soft blowing and pan systolic THEN its M.I

STEP 2: Auscaltate A2 for ‫تحححح‬

If present = A.I

In this step you must cancel breath sound

STEP 3: Auscultate Pulmonary Area

If Pulmonary HTN present Suspect Mitral valve ds

P.S which is organic … Always congenital either isolated or part from fallots

STEP 4: Auscultate the Apex

By DIAPHRAM For Vooooo If present and propagating to the axilla MI By

CONE For “RRRR” If present M.S

STEP 5: Auscultate Tricuspid area

For T.I Which is Soft blowing vooooo and increase by inspiration

STEP 6: Auscultate Left Parasternal Area

Harsh , Loud With Thrill = VSD

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 Summary For Cardio Auscultation

‫ تح‬is only present on A2 A.I

RRRR Is only Present on Apex M.S

VOOOOOOO On A1 = A.S

On apex propagating to Axilla = M.I

On tricuspid Area = T.I

On pulmonary area = P.S

On left parasternal area = VSD

Some examples of cases

1. Mitral stenosis
2. Mitral incompetence
3. Aortic stenosis
4. Aortic incompetence
5. Fallot
6. Click of an artificial valve

1st case “ Aortic stenosis” “just an example”

1. GENERAL EXAMINATION +VE SIGNS
 Plateau pulse: small volume with slow rising

2. LOCAL EXAMINATION:
 Inspection and palpation:
 Localized apex”due to concentric LV++”
 Heavy sustained “pressure load”
 In 5th IS midclavicular line not shifted but may be shifted in late cases
 Thrill at base A1 and neck
 Palpable S1” Heavy sustained “pressure load” muscular component
 Auscultation:
 Hrt sounds:
S1 is accentuated
S2 is muffeled
 You can hear S4 before S1 due to increasing end diastolic
volume so the ventricular pressure increase so the atrium
makes vigerous contraction

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  You can hear S3 after S2 in Lt ventricular failure then the
Hrt will be flappy so S3 can be heared
 But please you are not an expert , so it is not pereferable to
concentrate more to hear S3 and S4 otherwise you will
forget your important points to comment on.
 Murmur:
Harsh,ejection systolic,low pitched, max intensity over 1st Aortic
Area and propagate to Neck and grade it
 Also you can hear ejection systolic click due to valve
sclerosis on long standing HTN
 But you are not expert so do not concentrate on this point

Another way to know how to palpate

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Another way to know how to auscultate

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Then the check list as it is directly from the departement

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 Don’t assess the type of murmur of the patient with an artificial valve by the heart sounds as
you can hear loud S2 in a patient with mitral rugurge so if you hear a metalic click of an
artificial valve externally even without the stethoscope, don’t depend on the heart sounds
 How to assess the type of the artificial valve?
If you hear the metalic click with ‫طلعة‬carotid it is mirtal
But if it is with ‫نزلة‬carotid it is aortic
And you can ask the patient easily about the artificial valve
Or you can detect this by the site of the scar “but you may not found any scar of
this patient as it healed completely

This chapter is written by “MO”

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 CHEST
Local Examination
Inspection
1. Technique
Look tangentially beside the patient and infront of him at the
level of his legs “foot bed side”
2. Comment
11 points must be fulfilled

4S 3P MDRL
 Shape: normal shape or hyperinflated chest
look for AP diameter and subcostal angle (↑diameter, obtuse angle in
hyperinflated)
 Symmetry (normal chest is symmetrical or the abnormal is bulged or retracted
in a localized area)
 Scars and swelling
 Subcostal angle (normally is acute but in hyperinflated chest it is obtuse)
 Pulsations (apical and epigastric) either visible or not visible
 Pigmentations
 Pattern of breathing (abdominothoracic in males and thoracoabdominal in
females)
 Movement (normally it is equal movement on both sides but it is may be
diminushed in a localized area)
 Dilated veins
 Respiratory rate (in a minute) “the time is sufficient”
 Litten’s sign (+ve in COPD in Respiratory Distress ) indrawing of intercostal
muscles during inspiration with fixed ribs

Palpation

1. Technique
1. To confirm the movement, put your palms and the 2 thumbs
infraclavicularly, at mammary area and inframammary
And during the movement confirmation, try to detect the tenderness and any
palpable ronchi
2. To detect the TVF put your palm in the infraclavicular area, mammary area
and inframammary area . your palm is in the direction of bronchial tree and
away from midline. Ask the patient to say 4 4
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 3. Then palpate the apical and epigastric pulsations. Ask the patient to change
his position from flat position to his left to detect the apex of heart the ask
him to return flat again as he was. Some patients has emphysema so you
can’t detect the apex of heart
4. Then ask the patient to sit and put your left hand on his head to be semi
flexed , put your right index at suprasternal notch then enter the 2 recesses
between the trachea and the 2 sternomastoid heads . detect the trachea either
central or shifter to the right or to the left

2. Comment

6 points must be fulfilled

3T 2P 1M
1. Trachea (central or shfted to lt or rt) (the last thing to be done)
2. Tenderness
3. TVF (equal TVF on both sides or decreased or increased in a localized
area and confirm it in your comment)
4. Pulsations(apical and epigastric) visible or not
5. Palpable ronchi
6. Movement (the 1st thing to be done) (equal or diminushed in a localized
area and confirm the site in your comment)

Percussion

 Use your middle finger middle phalanx

 The role of percussion is from 2nd space then to other spaces in percussion of upper
border of liver and bare area of heart
 Start with upper border of liver (heavy percussion) MCL
 Then bare area of heart 4th and 5th IS parasternally
 Then start comparative percussion lightly
Start with clavicle directly then infraclavicular area MCL then from 2nd
to 6th IS MCL then from 4th and 8th IS midaxillary line
 Traub’s area : “LEFT” 6th midclavicular to 8th costochondral to 9th to 11th
midaxillary line and percuss lightly for 1 percussion or 2
 Kronig’s isthmus (dull to resonant to dull)
 Then write your comment either resonant or dull or hyperresonant
or tympany ”traub’s area on empty stomach’’ in all areas you
percussed.

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 Auscultation

1. Method:
TOTALLY 10 AREAS ANTERIORLY

1. Infraclavicular on both sides

2. Mammary area on both sides
3. Inframammary area on both sides
4. 2 araes midaxillary on both sides

2. Comment:
1. Intensity of breath sounds “(normal or decreased)
2. Equality
3. Type of breathing: normal vesicular, harsh vesicular, bronchial “hollow in
character”
4. Adventitious sounds:
either rhonchi or crepitation
asses the site “ex. Infra mammary”
 The rhonchi may be inspiratory and expiratory
 It may be sibelent and sonorous
 The crepitations may be fine or coarse

You must know that you must do broncophony test and whispering if the patient
has bronchial breathing “ask him to say 4 4 and you auscultate his chest”

+ The Back 

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 General Examination
Write your scheme then add the positive signs
1. General condition
2. Mental state
3. Built
4. Decubitus
5. Facial expression
6. Complexion
7. Vital signs
8. Head and neck
9. Upper limbs
10. Lower limbs
11. Lymph nodes
12. Skin
13. Other systems in relation to the case
……………………………………………………………
The POSITIVE signs which you may find
1. General condition: the patient may have respiratory failure so
check his orientation “disturbed conscious level ”
2. Decubitus :
 lateral position in lung diseases like lung fibrosis or lung
abscess or pleural effusion the patient lies on the diseased
side
 orthopnic as in acute sever asthma
3. vital data :
 respiratory rate
 pulsus paradoxicus : inspiratory decline of sys Bp more than 20
mmhg as in cases of constrictive pericarditis, svever bronchial
asthmatic attack,cardiac tamponade and Rt ventricular failure.

4. Complexion :
 Cyanosis
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5. Jaundice
6. Head:
 Upper eye lid : puffiness in Ch. Cough
 Parotid enlagrment as in sarcoidosis
 Jaundice
 TB and sarcoidosis uveitis
 Fundus examination in TB lesion in the fundus or papillioedema
 Conjunctival hmg in chronic cough
7. Neck:
 Congested neck veins: due to :
 Emphysema with expiratory filling due to increasing
intrathoracic pr.
 Core pulmonale
 Massive pulmonary effusion
 Pneuomothorax
 Copd
 Mediastinal syndrome : SVC obstruction
 Enlarged lymph nodes: due to :
 Bronchogenic carcinoma “mainly at scalene LND” between 2 heads
of sternomastoid
 TB and sarcoidosis
8. Hands:
 Clubbing of fingers :
 Toxic: chronic lung abscess, broncheiactasis
 Hypoxic: interstitial lung diseases
 Para malignant : bronchogenic carcinoma and mesothelioma
 COPD may make clubbing if
bronchogenic carcinoma is developed
on top
 Flabbing tremors : in respiratory failure “co2 retention”

9. LL: EDEOMA IN A CHEST CASE IS DUE TO 1 OF 3 CAUSES:

 Rt ventricular failure due to core pulmonale
 Renal amyloidosis due suppurative lung diseases which makes Nephrotic
syndrome
 Hypoproteinemia due to loss of proteins in the sputum

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10. Abdomen : examine LIVER, SPLEEN AND ASCITES, abdominal hernia for
chronic cough
 LIVER : hepatomegaly due to:
 Rt sided heart Faliure
 Secondaries from bronchogenic carcinoma
 Amoebic liver abscess
 Miliary TB
 Alpha 1 anti trypsen dif. Which makes liver cirrhosis
 Associated liver diseases

 SPLEEN: splenomegaly due to

 Amyloidosis
 Military TB
 Sarcoidosis
 Bilharzial cor pulmonale
 Ascites : due to
 Cirrhotic ascites which leads to Rt sided pleural effusion
 TB peritonitis and right sided Heart failure

11. Skin :
 Erythema nodosum in TB or sarcoidosis or hairy cell leukemia or
inflammatory bowel disease or post streptococcal infection
 Herpetic vesicles causes unilateral chest pain
12. Neurological examination:
 Myopathy “paramalignant syndrome”
 Neuropathy
 Myasthenia gravis
 Meningeal irritation in TB
 Pott’s disease
 Bronchogenic carcinoma

Check lists as it is directly from the department

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This chapter is written by “MO, MAN, MAY”

32
 ABDOMEN
Local examination

1. Inspection:
12 points must be fulfilled

2 starting 2 above Umbilicus 3 below 4 general

points umbilicus umbilicus
-general -subcostal -hernial -dilated veins
form and angle orifices -visible
contour -epigastric -hair peristalsis
-movement pulsations distribution -scars of
-- operations
divarication -striae and
of recti pigmentations

33
  General form and contour:
 Bulging :
 Localized: organ swelling “ detect which region is bulged”
 diffuse
 Retraction : sunken or scaphoid
Ex. In ascites : diffuse bulging and increase abdominal contour mainly in
flanks
 Movement:
 Normally the abdomen moves freely with respiration
 May be one side moves only as in unilateral paralysis of diaphragm
peritonitis : no movement
 May be paradoxical movement as in bilateral paralysis of diaphragm
 Sub costal angle :
 Wide “ obtuse” as in hepatosplenomegaly and ascites
 May be normal”90”
 Epigastric pulsations:
 Absent
 May be visible as in right ventricular enlargement or hepatic congestion in
tricuspid incompetence or in thin persons

Divarication of recti: ask the patient to raise his head "‫ "يهم براسه‬if there is bulge due to
increase intra abdominal pressure (HSM) or loss of muscle tone
 Umbilicus
 Central in position
 Shifted downward as in upper abdominal swelling in hepato
splenomegaly and ascites
 Shifted upward as in lower abdominal swelling in ovarian cyst or any
pelviabdominal swelling
 Everted in ascites
 Nodules in umbilicus as in 2ries from abdominal malignancies”
 Bluish “Cullen sign” as in haemoperitoneum”
 Inflammatory reddish swelling in diverticulitis
 Discharge
 Adenoma
 Herniation ask him to cough and notice umbilical and inguinal hernia “the
patient examined while standing”
Hair distribution either masculine or feminine “male or female” In liver cirrhosis , the
male
distribution change to female distribution.

34
 Dilated veins
 Peristaltic waves
 Striae (stretch marks ) © don’t forget to inspect the back ”for the same
items”
 Scars of previous operations “cholecystectomy, nephrectomy, splenectomy”

2. Palpation
The pnt lies flat and flex his legs then ask him if there is any
tendreness or not
1) SUPERFICIAL PALPATION
Palpate the 9 areas of the abdomen
Detect 3:
1. Tenderness
2. Abdominal guarding or rigidity
1) Localized + rerbound tenderness = focal area of peritonitis
2) Generalized + never to be relaxed=generalized peritonitis
3. Superficial mass comment on 7
“site, shape ,size ,surface ,edge, consistency and movement with
respiration

2) DEEP PALPATION
35
 Liver
1) start from right iliac fossa and ask the patient to take quite breathing from
his mouth ,searching for lower lobe of the liver
2) detect the upper border by heavy percussion when the dullness found
Ask the patient to take deep breathing to make sure that is upper border of
the liver not the lower border of the lung . then measure the span of the
liver “tidal percussion”
3) start from midline above the umilicus searching for lower border of left
lobe then measure the distance between it and the sub costal margin.

Then comment on 6

Size (span) - consistency - border - surface - pulsation- tenderness

N.Bs:

- Palpable left lobe only = shrunken cirrhotic liver

- cirrhosis : not tender ,pulsating or not , sharp edge ,smooth or
nodular surface , firm in consistency and its size = ....cm below
costal margin.
- hepatitis or congested liver : soft and tender

36
 Dipping method is used in presence
of massive
ascitis to detect hepatic or splenic
swelling, pressing by tips of fingers
giving tapping sensations as the
organs are dipped in the ascitic liquids

Normal method

37
 Bimanual ex. To detect expansile pulsation of liver ,kidney and
spleen

Spleen

1) Start from right iliac fossa with the tip of the hand directing toward the
left axilla followed the roles of palpation moving toward the left
hypochondrium until the spleen was felt
2) bi manual examination if not palpable
3) If negative put the patient in right lateral position with flexion of left knee
&hip
4) Splenic percussion sign: percuss on the traub's area( the last intercostal
space anterior axillary line) if not palpable : start to percuss after the
patient hold a deep inspiration ,normally this area is tympanic if become
dullness >> slightly enlarged spleen
 Also bimanual, hooking and dipping method can be used in spleen
examination

Comment on : 5

size ( tip of the spleen felt ....cm below the costal margin along its long
axis ,notch felt or not ,surface(smooth or nodular ) ,consistency (soft,firm
or hard) ,border(rounded or sharp)

38
 Ascites
1. Shifting dullness for moderate ascitis
 Ask the patient to undress from symphsis pupis to above the xiphoid

process allowing the patient to cover with a clean sheet

 Put your hand above the umbilicus transversely and percuss downward
toward symphisis pupis till detecting dullness (urinary bladder)
 Choose a resonant point directly above the urinary bladder
 Change the direction of finger >> longitudinally
 Heavy percussion progress laterally toward the flanks (between ribs&hip)
 On detecting dullness >>hold finger at point and ask the patient to sleep on
opposite side
 wait 10 sec and percuss again if resonant, do the same on opposite side
2. Fluid thrill for tense ascites
Place a detecting hand on pnt’s flank, flick the skin over flank
using thumb with pnt’s hand placed on the abdomen along the
midline to prevent any possible thrill transmitted via the
abdominal wall
3. Knee elbow position for mild ascites
4. Puddle sign for minimal ascites

39
Check lists as it is directly from the departement

40
41
42
43
Percussion “there are another signs to be percussed but it is to your knowledge
or if you are asked about in the discussion part of the osce exam , you can read
it from any other source”

This chapter is written by “MO, ASM”

44
 ENDOCRINE
1. Acromegaly
2. Thyroid
3. Cushing
……………………………………………….
You must know the technique, comment and
NAZARY related.

(1) ACROMEGALY

 FACE

1) Frontal skull bossing

2) prominent supra orbital ridge
3) Enlargement of the nose

45
4) Thick lips
5) thick nasolabial fold
6) infra orbital puffiness
7) prognathism
“downward and
forward growth of the
mandible”
- Ask the patient to press on his teeth to
check for jaw
malocclusion in the form of “under bite”
8) teeth separation
9) macroglossia “ ask the pnt to protrude his
tongue”
 HAND and FEET
1) Check for carpal tunnel $ as GH makes flexor
retinacula enlarged so pressures on median
nerve by tapping on lateral side of hand ( if he
feels tingling or pain ) this is tinel sign , other
test may the examiner ask about 1 min phalen
test by flexion of both wrists for 1 min it causes
more compression to nerve and more tingling.
2) Atrophied thenar muscles from nerve
compression.
3) Peripheral neuropathy as growth hormone is
diabetogenic.
4) Bulky, large
5) Blunt, spade like
46
 6) Sausage fingers
7) Thickening of the skin
8) Increased sweatiness and oiliness
 Large feet , crepitus in knee joint due to
osteoarthritis ( felt as vibration on knee when you
put your hand on patient’s knee while moving knee
joint).

 N.B :
1. Examination of the abdomen :
hepatomegaly due to fatty liver
2. Eye: visual field examination for bi temporal
hemianopia.
3. Neck : thyroid ( simple goiter due to ↑size
by growth hormone), acanthosis negricans (
pigmentation in flexural areas also present in
axilla)
4. Built : overbuilt due to muscle hypertrophy.
5. Blood pressure : hypertension is expected
due to↑insulin.

 NAZARY RELATED:
 Main etiology is pituitary adenoma leads to excess
GH
 in this case, prolactin is high so FSH and LH are
low…hypogonadism

47
 high GH levels leads to DM leads to hyperinsulinemia “insulin
resistance” leads to Na and water retention, stimulation of
sympatahtic, insulin is atherogenic so HTN is developed
 thyroid is enlarged but no hyperfunction
 all organomegaly except splenomegaly
 laryngeal hypertrophy leads to deep voice
 1.25 dihydroxy vit D hyprecalcuria and renal stones
 Proximal myopathy with ms hypertrophy
 Complicated with carcinogenic colonic polyps
 Complicated with congestive hrt failure and
cardiomyopathy
 Complicated with sleep apnea
 Complicated with DM and HTN
 Dx are : myxedema and pachy dermo peri osteitis
“clinical manifestations of acromegaly but normal
GH and IGF1 levels in blood
 How to manage?

 Investigations :
 Lab : (1) high GH levels after glucose
infusion <10ng/ml
(2)high Somatomedin C
(3)high blood sugar
(4)increase phosphorus due to
high reabsorption by GH
 Imaging : (1) CT/MRI on pituitary
(2)X ray: 1.skull : wide
sella turcica and wide paranasal sinuse
2.hands: tufting of terminal phalanges
“mashroom shape)
48
 3.heel pads:
increase thickness
4. visual field:
bitemporal hemianopia
 TTT :
 1st line of choice is SURGERY
“transsphenoidal” radiotherapy by
gamma knife for recurrence
 MEDICAL : somatostatin
“octereotide”, GH Rc antagonist “given
till surgery

(2) THYROID “local examination”

Inspection
1. Stand infront of the pnt “ with the pnt sitting at
the same plane with you”
2. Ask him to swallow
3. Ask him to protrode his tongue
4. Comment on :
1) Shape: : butterfly shaped or irregular
2) Size: measure the swelling size L x W
3) Site : : swelling in the front lower part of neck
4) Skin overlying
 Normal , stretched or pigmented
 Signs of inflammation ( red , hot ,edema and
tenderness )
 Scar of previous operations
49
 5) Pulsations: look Tangentially
6) Special character :
 Moves up with deglutition
 Moves up with protrusion of the tongue 
Thyroglossal Cyst

Palpation
1. Stand behind the pnt “lahey’s method”
2. Ask the pnt to slightly flex his neck ant. And relax
3. Fix the tracheal wall by your left hand and palpate by
your right hand his right lobe and repeat the palpation
for the other lobe
4. Ask the patient to swallow and palpate the isthmus,
palpate the symmetrical enlargement, detect the
retrosternal extension
5. Examine the carotid pulsation unilaterally
6. Examine the LNDs of the neck “for thyroid malignancy”
7. Examine surrounding structures as Skin or
sternomastoid
8. Check for Thrill

- Comment :
 Warmth (compare skin overlying with another area of
patients skin), Tenderness ( look for pain facial
expression)
 size
 Edges (rounded borders or irregular)
 Surface (smooth or nodular)

50
  Consistency (soft or firm or stony hard or fleshy as
muscle)
 Lower border detection by placing both index fingers at
neck route and asking the patient to swallow if lower
border is felt no retrosternal extension.
 Feel Thrill on gland by metacarpals only in
hyperthyroidism
 Mobility ( mobile or non mobile in malignant infiltration
of surrounding) as follows:
1- Skin (fixed or not) ( pinch the skin over the gland)
2- Sternomastoid muscle : 1st you find the muscle by
making it’s action:
- If Bilateral : ask Pt. to flex the neck against resistance
- If Unilateral : ask Pt. to rotate his head against
resistance to the opposite side of the examined
muscle.

pinch the muscle ask the Pt. to swallow  if doesn’t move with
swallowing  not fixed

3- Trachea: Hyperextension of the head  fixing the

Trachea  If the Thyroid moves freely Across the
Trachea Not fixed
4- Carotid artery :
1) if felt pulsations at neck  no infiltration
2) if not felt : try to feel temporal artery at lateral
aspect of forehead during closing mandible , if
temporal artery is felt : no infiltration also but if
not felt  infiltration
 absent carotid pulsation called berry’s sign

51
  detect relation of the gland with skin and
sternomastoid
 Percussion
Tapping by 2 fingers on manubrium normally ( it is
resonant area ) , but if you found it dull that may mean :
retrosternal extension from gland
 Auscultation
Auscultate the thyroid. A bruit, a sign of increased
blood flow, may be heard in
hyperthyroidism.(machinery bruit over the apex of
lobes )
 Pemberton’s sign:
Congestion and cyanosis of the head on lifting
both upper limbs due to retrosternal extension of
the thyroid goiter in the thoracic inlet

Eye Examination in thyrotoxicosis

1. Inspection

Comment on:
 Eye look “staring look or stellwag
look”
 Presence of rim of sclera above the
cornea “ dalrymple”
 Lid retraction
 Lid lag “von graef” ‫الجفن بيتأخر شوية‬
‫عند النزول مش زي الطبيعي‬
 Conjunctiva “chemossis or injection”
 Eye puffiness

52
  Tremors in the eye lids on gentle eye closure
“rosenbach”
 Free eye ball so on looking up no forehead
corrugation of frontalis , on confrontation wider
field.

2. Examination of proptosis “ask the patient to tilt his

head backward”
proptosis by looking from behind the patient
the pushed eye prevent seeing zygoma
3. Examination of extraoccular ms movements
4. Examination of eye convergence movement
inability to maintain convergence ( mobius)

5. Confrontation test method “ H method” wider field

+ve signs

 Skin :
in hyperthyroidism:
1) hot and sweaty
2) palmar erythema

in hypothyroidism:
1) cold and dry
2) Coarse, brittle, straw-like hair
3) jaundice and pallor in hypo

53
 In hypothyroidism:
1) Dull facial expression
2) Coarse facial features
3) Periorbital puffiness
 Built :
1) weight gain in hypo , weight loss in hyper
 Upper and lower limbs :

In hyperthyroidism
1) Tremors of hands (placing a piece of paper on the
backs of the patient’s outstretched hands may show
this.)
2) Check the nails for any thyroid acropachy – similar to
clubbing, or onycholysis – where the nail comes away
from the nail bed.
3) Next you should feel the pulse. It is tachycardic
4) isolated systolic HTN +/- AF

in hypothyroid
1) increased diastolic blood pressure
2) Nonpitting edema (myxedema)
 Nazary related
Revise this topic from your book because it’s too long to be
written here and it is very important for the discussion in your
practical exam

54
 CUSHING

(1) Skin: in general

 thin, transparent, exposure of subcutaneous
vascular tissue
 rupture of collagen fibers in the dermis “ stria
rubra in lateral abdomen and axillary sites”
 delayed wound healing
 scars with localized hyperpigmentation “if high
ACTH”
 skin bruises
check for mucocutaneous fungal infections : oral
candidiasis ( a cheesy layer on tongue with easy
removal )
 Acne : due to androgenic receptors stimulation

ant acne may also be found on chest and back

 hirsutism in female :
on face , abdomen, breast, chest and thigh

polycythemia
(2) Face :
 plethora : red flushing face “thinning of the skin
combined to loss of facial subcutaneous fat”
 Moon face : due to deposition of fat in temporal
and buccal region you may not see his lobules of
ear
 Acne :face, chest and back
 Hursitism: face , abdomen, breast, chest and
thigh

55
(3) Wrinkling of the skin on the dorsum of the hand
“cigarette paper app.”
(4) Red purple stria rubra
 Wide “ 0.5×2 cm” depressed
 Abdomen, breast, hip, buttocks, thigh and axilla

(5) Built :
 Abnormal fat distribution “central obesity”
1. Moon face
2. Neck
3. Trunk "truncal obesity"
4. Abdomen
 Fat accumulation :
1. Buffalo hump :dorso cervical fat pad
“intrascapular”
2. Supraclavicular no groove behind clavicle due
to fat accumulation
 Don’t forget symptoms of Dm

56
 Nazary related
 The main etiology is hyperfunction of zona fasciculata of adrenal
cortex
 It may be ACTH dependent due to pituitary adenoma or
paramalignant $ because of SCC of bronchogenic carcinoma which
secretes ectopic ACTH
 It may be ACTH independent due to adrenal tumor which may be
unilateral adrenal carcinoma or bilateral adrenal hyperplasia or
exogenous steroids make cushinoid picture
 The pnt is usualy female, diabetic, HTN and obese
 The increased cortisol level makes:
 Lypolisis of fat so it makes redistribution of fat
 Catabolism of ptn
 Catabolism of CHO so it is diabetogenic
 Proximal ms myopathy “it is a sign not a symptom”
 Osteoporosis
 Decreasing linear growth , short stature
 Depression
 Cataract and 2ry glaucoma
 Peptic ulcer and pancreatitis
 Hypokalemia hypernatremia hypertension
 Weak immunity so recurrent infections with low virulent organisms
 Permissive action on CA by increasing receptors sensitivity to CA so
it will make 2ry HTN and Na water retention “another mech. of
HTN”
 Skin manifestations
 Most common sign of redistributuin of the fat is truncal obesity
 How to manage?
 Dexamethasone sup.test to inhibit the pituitary gland “low
dose of dexa 0.6mg/6h for 48h
If suppressed……simple obesity or syndrome X or OCP
If not suppressed…it is cushing
Then you need to know it is pituitary or adrenal
Give high dose steroids 2mg/6h for48h
If suppressed it is pituitary basophil microadenoma
If not suppressed it is either due to adrenal tumor or
paramalignant syndrome → Do CT/MRI abdomen
57
  TTT: Diet
Insulin
Medical adrenalectomy “ketoconazole or metyrapone”
-if the tumor is operable do the surgical removal

This chapter is written by “MO, SHAI”

LNDS EXAMINATION
 Axillary

58
Ex.
lateral, 1×2cm, 2 nodes, not tender, attached to each
other “or discrete” matted” or discrete”, attached to
the surrounding structure”or not”, attached to skin
“or not”, drain the upper limb

The technique and the lymphatic drainage of axilla

59
60
 Cervical

61
Superficial cervical is ant. and post.
Deep cervical is ant. and post. It is beneath sternomastoid

62
 Tilt the patient’s head to the right so his left side of
neck will be extended so you can palpate the
superficial ant. and post. While his right side is
relaxed so you can palpate the deep ant. and post.
LNDs
 Do the opposite on examining the opposite side of
LNDs
 Lymph drainage

63
 Epitrochlear and inguinal

64
65
 The positioning of the leg to examine the inguinal lymph nodes is
like that on doing the ankle jerk
 Superficial inguinal

66
 The Vertical LNDs drain the lower limb. It is over the
great saphenous v.
 The horizontal LNDs drain the “above in the picture”
 The deep inguinal LNDs are deep to the fascia and drain
the “above in the picture”

This chapter is written by “MO”

67
 NEPHROLOGY
1. End stage renal disease “ESRD”
1) General appearance: “good, bad, fair, cachectic,
infantile”
2) Mental status:
1) Consciousness
2) Orientation to time, place, person
3) Intelligence
4) Memory
5) Mood
6) Attention

3) Decubitus:
1) Prayer’s position in pericardial effusion and
pericarditis
2) Orthopnic
4) Vital data:
1) Bp: hyper or hypo
2) Type of respiration: Kussmaul breathing
a. deep rapid in metabolic acidosis “Kussmaul
breathing”
5) complexion: pallor “mucosa, nail bed, palmar
creases”
6) face: earthy look, urea frost, ammonical smell “the
face is pale and pigmented”

68
7) neck: JVP, central venous catheter, “Mahurker
catheter” and comment :
a. Lt or Rt “hand”
Ex. Lt distal functioning A-V fistula

“insererd in IJV, subclavian V., FEMORAL V.,

congested neck veins
8) hand:
1) scratch marks
2) AV fistula ‫اسمعها وحسها بإيدك وعلق عليها كاألتى‬
“arterialization to the vein”
a. Lt or Rt “hand”
b. Distal or proximal
c. Functioning or not”
d. Ex. Lt distal functioning A-V fistula
3) Lindsay’s nails " the white which is lunula
occupying more than 50% of the nail bed –
Brown outer ½ of the Nail .
4) Flapping tremors

69
 9) LL edema “and comment” and peripheral pulsations
10) Chest: bilateral fine basal crepitations .
11) Cardiac: pericardial rub, hemic murmur on the
base.
12) Abdomen: renal swelling “bimanual examination”
for polycystic kidney and ant.abd.wall edema "by
diaphragm of the stethoscope”.
For u;
a. Catheter "permi cath" 1:1.5 years but normal catheter
lasts for 30 or 40 days.
b. Puffiness of eye lids and proteinuria.

70
71
 Leukonychia totalis

 Muehrcke’s lines

72
  Terry’s nails

For u;
a. Mahorker’s lines for "acute assessment of dialysis".
b. Permicath for "chronic assessment of dialysis".

This chapter is written by “MO”

73
 Rheumatology
Local Examination
1. Hand examination
3 joints *wrist *metacarpophalangeal *interphalangeal
 You will examine each joint movement (active and passive
movement).
INSPECTION PALPATION MOVEMENT
1) Skin: 1) Temperature 1. Regarding the hands the
a. Rash Compare patient will be required
b. Scars proximally to open and spread his
c. Ulceration fingers, close them
d. Texture: shiny, loss 2) For tenderness (power grip) with the
of luster and swelling thumb holded by his
e. Purpuric eruption detection you will other fingers, pinch the
f. Gottren papules in first do metacarpal tip of index finger and
dermatomyositis squeeze in the hand thumb (precision pinch)
g. Palmar erythema or metatarsal to feel its power.
h. Reynould’s squeeze in the foot
phenomenon and if there is 2. Regarding the wrist the
i. Skin tightness in tenderness you will patient will be required
sclerod. examine each joint to put his hands in the
2) Nails: separately, press prayer position keeping
a. Pitting as in every joint slightly palms together while
psoriasis on the joint line lowering his hands
b. Infarcts (with your finger (dorsiflexion of the
c. Ulcerations below the joints at wrist) then he will be
d. Clubbing the interphalangeal required to place the
e. Spooning and dorsum of his hands
f. Brittle metacarpophalange together and raise the
g. Psoriatic changes al joints in the arms upwards (flexion
hands or of the wrist).
interphalangeal and If the patient had
metatarsophalangea limited movement or
l joints in the foot can't do any of these
3) Nodules where you will feel movements tell him to
a. Beuchard “PIP” in a small depression do flexion and
OA this is the joint line dorsiflexion of every
b. Heperden “DIP” in and note that you wrist joint separately.
OA can’t feel it at the To sum up:
74
 c. Rheumatoid nodules distal Flexion and extension
d. others interphalangeal “wrist”
4) Swelling joints because the Abduction, adduction
5) Deformities joint space is very “metacarpophalangeal”
a. Swan neck small so you will Apposition, precision pinch
b. Buttonier apply a pressure for interphalangeal j.
c. Z deformity with your thumb
d. Ulnar deviation and index vertically
on the joint and
horizontally) and as
you do the squeeze
6) Muscle atrophy or examining each
a. Thenar joint separately you
b. Hypothenar have to look at the
c. Interosseous space patient's face for
sings of tenderness.

3) For hand and feet

swelling you can do
the fluctuation
technique in which
you press the
metacarpophalange
al joints or
metatarsophalangea
l joints with your
thumb on one side
of the joint and
receive the bulge
with your other
thumb on the other
side of the joint.

75
76
Another way “simplified”

77
78
79
 Elbow examination

INSPECTION PALPATION MOVEMENT

Ask the pt. to make slight 1) Temperature Do the active and
flexion to elbow and exam Compare passive
from behind “put cubital proximally movement
fossa anteriorly” 1) Tenderness and
1) Skin: swelling
If the pt. has
a. Rash As examination periarticular
b. Scars of hand disease, the
c. Ulceration Start with joint active movement
d. Texture: shiny, line above the will be limited
loss of luster olecranon to get while passive
e. Purpuric the joint space will be intact
eruption then palpate the
f. Skin tightness in medial and
If the pt. has
scleroderma lateral articular disease,
either limited epicondyle both movements
cutaneous or For swelling will be limited
diffuse cutaneous ‫اضغط على نقطه‬
2) Nodules ‫واتلقاها من الناحية‬ Flexion and
a. At cubital fossa ‫التانية‬ extension
b. At olecranon
bursa
3) Swelling
4) Deformities
Ask him to extend
his both hands
 Flexion
deformity
 Carrying
angle is
more than
15 degrees
as the
forearm
pass
laterally
5) Muscle atrophy
6) +/- obliteration of para
olecranon groove

80
Another way “simplified”

81
82
Shoulder examination

 (then repeat on the other side)

83
84
85
2) Ankle and feet “as scheme above”

 Flex and extend the MTP joints.

86
87
Knee examination

88
Movement:
Ask the patient to flex each knee in turn and observe the range of
movement (0-150°) and any signs of pain. Ask the patient straightens
each knee, place a hand on the knee to feel the crepitus.

89
90
Hip examination

91
92
93
Spine examination

94
Lumber spine:
Ask the patient to try to touch the toes without bending the knees patient
flex forward, examines curve of spine from upper thoracic to sacrum by
Schober's Test To tilt sideways from the vertical to try to touch the sides
of the knees

95
96
97
To sum up the examination of all joints

Inspection
1.Technique
1- Hand:

 Swelling,
 deformity,
 nodules,
 muscle wasting (thenar, hypothenar, interossei and
forearm muscles),
 skin abnormality,
 nail abnormality and palmer erythema.

2- Elbow:

 Swelling,
 deformity (valgus in full extension and supination position
of the forearm),
 nodules,
 muscle wasting (in the forearm, biceps and triceps
muscles),
 skin abnormality and dimples.
3- Shoulder:

 Swelling,
 deformity,
 nodules,
 muscle wasting,
 skin abnormality from the front and back.

98
4- Ankles and feet:

 Swelling,
 deformity,
 nodules,
 muscle wasting,
 skin abnormality, nail abnormality and flattening of the
longitudinal arch of
the foot.

5- Knee:

 Swelling,
 deformity (while the patient is standing whether valgus or
varus, flexion or hyperextension deformities),
 nodules,
 muscle wasting (quadriceps, hamstring muscles and calf
muscles),
 skin abnormality and dimples.
6- Hip:

 Pass the hand behind the lumbar spine while the patient is
lying flat on the bed to detect deformities of the spine,
 Inspect for the direction of the patella on both limbs,
 skin abnormalities and muscle wasting.
7- Cervical Spine:

 Abnormal kyphosis or lordosis,

 scoliosis (from the anterior aspect),
 head posture for torticollis,
 skin changes (sinuses, scars redness and dilated veins),
 swellings and muscles of the neck condition.
99
 8- Dorsolumbar spine:
a. Inspect the patient's back while standing
 position of the head,
 level of the shoulders,
 position of the scapulae
 shape of the thoracic cage,
 lateral margin of the flanks,
 relative prominence of the iliac crests and curvatures
of the spine for kyphosis, lordosis or scoliosis),
b. inspection of the skin for any abnormality and the state
of the
paravertebral muscles.

2.Comment
All joints you will have to comment for +/- deformity, swelling,
muscle atrophy (according to the atrophied muscle), nodules, skin
abnormalities and specific items for each joint as follows:

 Hand and wrist:

1. Nail changes (clubbing, spooning, brittle or psoriatic
nails),
2. +/- palmar erythema.
 Elbow:
1. Dimples (preserved or swollen),
2. deformities (valgus or wide carrying angel).
 Shoulder: Nothing specific.
 Ankles and feet:
1. Nail changes (as the hands and wrist),
2. flattening of the longitudinal arch of the foot.
100
  Knee:
1. Dimples (preserved or swollen),
2. deformities (valgus or varus, flexion or
hyperextension).
 Hip: Nothing specific.
 Cervical spine:
1. Deformity (kyphosis, lordosis, scoliosis),
2. head posture (torticollis).
 Dorsolumbar:
1. Position of the scapulae (at the same level or not,
winging of the scapulae),
2. prominence on the iliac crest +/- and curvatures
(scoliosis, kyphosis or lordosis).

Palpation

1. Technique

 For tenderness and swelling detection, firstly do

metacarpal squeeze in the hand or metatarsal squeeze in
the foot
 if there is tenderness, examine each joint separately,
 press every joint slightly on the joint line (with your finger
below the joints at the interphalangeal and
metacarpophalangeal joints in the hands or interphalangeal
and metatarsophalangeal joints in the foot where you
will feel a small depression this is the joint line and
note that you can’t feel it at the distal interphalangeal
joints because the joint space is very small so you will

101
 apply a pressure with your thumb and index vertically on
the joint and horizontally)
 while you do the squeeze or examining each joint, look at
the patient's face for sings of tenderness.
 For tenderness and swelling in large joints, press the
joint line with your both hands (by the thumb from the
front and index from the back of both hands) and keep in
mind looking at the patient's face for signs of tenderness.
 For hand and feet swelling, do the fluctuation technique
in which you press the metacarpophalangeal joints or
metatarsophalangeal joints with your thumb on one side of
the joint and receive the bulge with your other thumb on
the other side of the joint.
 For temperature palpation, apply the dorsum of your
hand on the joint examined and then apply your dorsum of
the hand at a proximal area form that joint to compare the
temperature.
 special test in palpation of the knee joint for detection
of joint effusion, (place one hand on the quadriceps
muscle and move while pressing towards the patella to
force any fluid to be accumulated in the central part of the
joint then push the patella with your finger down and if
there is a joint effusion it will bounce up) or (place one
hand as mentioned before and with your other hand move
it from the medial aspect of the joint to the lateral aspect of
the joint while pressing to force any fluids to move to the
lateral side of the joint only then press on the lateral side
and observe any bulging in the medial side).
 In shoulder joint palpation, do it in a systematic
approach (start with sternoclavicular joint → clavicle bone
→ acromioclavicular joint → glenohumeral joint →

102
 deltoid muscle → spine of the scapula → supraspinatus
and infraspinatus muscles → trapezius muscle).
 In spinal palpation cervical or dorsolumbar, palpate the spine
with your thumb and the paravertebral muscles as well and any
structure surrounding the vertebra.
 In hip joint palpation, palpate greater trochanter and anterior
superior iliac spine.

2. Comment

For each joint you will comment on +/- tenderness, swelling,

hotness and :

Range of movement
 examine each joint movement (active and passive movement).
 Active movement is the movement performed by the patient
alone without any assistance while passive movement you will
assist the patient in the movement.
 Regarding the hands the patient will be required to open and
spread his fingers, close them (power grip) with the thumb
holded by his other fingers, pinch the tip of index finger and
thumb (precision pinch) to feel its power.
 Regarding the wrist the patient will be required to put his
hands in the prayer position keeping palms together while
lowering his hands (dorsiflexion of the wrist) then he will be
required to place the dorsum of his hands together and raise the
arms upwards (flexion of the wrist).
If the patient had limited movement or can't do any of these
movements tell him to do flexion and dorsiflexion of every
wrist joint separately.

103
 Regarding elbow joint the patient will be required to flex and
extent both elbow at the same time and then flex his elbows
with 90◦ and do supination and pronation movements.
 Regarding shoulder joints the patient will be required to do
the collective movements (place his hands behind his head
while his elbows are pointing laterally (flexion, abduction and
external rotation) then place his hands over lumbar area from
the back (extension, adduction and internal rotation), if the
patient failed to do any of these movements you have to tell him
to do every movement separately.
 Regarding hip joint the patient will be required to flex his hip
joint by flexing the knees and then flexing the hip as fair as
possible, abduction and adduction by straightening his legs and
then moving it outwards and inwards respectively, external
rotation and internal rotation by flexing both knee and hip and
moving the leg medially and laterally respectively.
 Regarding knee joint only flexion and extension movements.
 Regarding ankle joint the patient will be required to planter
flex and dorsiflex each ankle, flexion and extension of the
metatarsophalangeal joins and passively invert and evert the
subtalar joint.
 Regarding the cervical spines the patient will be required to
look up and down, right and left and tilting his head sideways
aiming to touch each ear on the shoulder without raising the
shoulder.
 Regarding dorsal spines movement will be assessed by
measuring the chest expansion with a tape at the level of the
nipple line by applying the tap around the patient and it should
be 5 cm increase.
 Regarding lumbar spines the patient will be required to bend
forward and trying to touch his toes without flexing his knees
(flexion), bend backwards as fail as possible (extension),

104
 bending to the right and left sides (lateral bending) and finally
sitting on the bed or a chair and asking him to rotate to the right
and the left without moving the hip (rotation).
 If the patient failed to do any of the previous movements
completely or partially you will assist him to complete the
movement (passive movement) and if the movement was a
collective movement you will first, ask him to do each
movement separately and then assist him in the limited
movement.
 If you failed to complete the movement passively skip it as it is
a limited passive and active movement and continue your
examination.
 Completing an active movement with a passive one (assisted)
indicates and extra articular lesion while a limited passive and
active movement indicates an articular lesion.
 Your comment will be on each movement either completed
actively or passively or limited on active and passive
movement.
……………………………………………………………
…………………………………..
Most of these pictures are collected from the guideline and
checklists of the department

“this is a fully detailed description of the examination. You

must watch some videos after reading this description”

This chapter is written by “MO, AHM”

105
 Short case OSCE Only.

 No History Taking, No Long case.

 The Exam will be only one point of 7 of mental state examination (MSE).

 The common is:

1. Examine Attitude, App , Behavior
2. Examine Thinking
3. Examine Perception
4.
1. General Appearance:
 Appearance of cooperation
 (Cooperative, Hostile ‫ عدائي‬, Evasive ‫ مراوغ‬,
Well groomed ‫ لسه منسق‬, Hygiene ‫) نظافة شخصية‬
 Gait and posture: Normal brisk slow , catatonic ‫ثابت علي وضعية و مغيرهاش‬

 Eye to Eye contact:

- poor ( depression , paranoid , autism )
- Darine ( Mania )
- Excessive scanning ( schizophrenia , hallucination )

- Good ^_^

 Grooming ‫ و منسق‬, ‫ هدومه مهندمة‬

 Facial Expression :
o Reactive / Normal
o Blunt / Flat
 Level of Activity :
o hyperactive , agitated ( Mania )
o Restless ( Anxious )
o Retarded ( sever depression )
 Special Marks :
o Abnormal Movements ( tics , Chorea , Tremors )
o Bruising
106
So FULL COMMENT 

Patient is cc g3 n3 :

1. Clam , Cooperative and Reactive .

2. Groomed .
3. Good hygiene .
4. Good eye to eye contact .
5. Normal level of activity
6. No abnormal gait , movements
7. No special posture

2. Examine Thinking :

“ Stream , Form , Control , Abstraction , Content “ ( SF ,CAC )

……………………………………………….
We will start with SF , ask about them by
Open – End Question : ‫و أالحظ طريقة كالمه‬

‫* ممكن تقولي جيت المستشفي هنا ليه ؟‬

‫* فطرت ايه النهاردة ؟؟‬
‫ درست ايه ؟؟‬,, ‫* كلمني عن دراستك‬

(S) ‫ سرعة كالمه‬: Slow , Fast , Average

(F) ‫ طريقة عرضه ألفكاره‬:

 Circumstantial
‫رغاي أوي و بيتكلم كتير و بس بيوصل لألجابة في االخر‬
 Flight of ideas
‫ كله ورا بعضه‬,, ‫مش مالحق علي الكالم‬
 Derailment
‫بيلف و يدور و مش بيوصل لألجابة في االخر‬
 Poverty of thinking
107
 ‫كل األسئلة لها نفس الجواب‬

‫‪ Loosing of association‬‬

‫ملوش عالقة ببعضه‬
‫‪ Off pointing‬‬
‫بسأل سؤال و يرد بعيد عن االجابة تماما ‪ ,‬هو في وادي و انت في وادي تاني خالص‬

‫هنفحصهم ورا بعض بأسئلة خاصة لكل نقطة ‪CAC :‬‬

‫‪ Control :‬‬

‫‪- Thought reading‬‬
‫بتحس ان فيه حد بيقرأ أفكارك ؟‬

‫‪- Thought Broadcasting‬‬

‫بتحس ان التليفزيون بيذيع أفكارك ؟‬

‫‪- Insertion‬‬

‫بتحس ان حد بيزرع في أفكار في دماغك ؟‬

‫‪- Withdrawal‬‬

‫بتحس ان فيه حد بيسحب األفكار منك ؟‬

‫‪ Abstraction‬‬
‫شوف مدي قدرته علي انوا يفهم المقصد من األمثلة الشعبية ‪:‬‬

‫* اللي بيته من ازاز ميحدفش الناس بالطوب‪.‬‬

‫* الدم عمره ما يبقي مية‪.‬‬

‫* علي قد لحافك‪ ،‬مد رجليك ‪.‬‬

‫* العين عمرها ما تعلى عن الحاجب ‪.‬‬

‫* اقلب القدر علي فمها ‪ ,‬تطلع البنت ألمها ‪.‬‬

‫‪*Reference :‬‬
‫بتحس الناس بتتكلم عليك ؟‬
‫‪* Persecution :‬‬
‫) ‪ Content ( Delusions and obsessions‬‬ ‫بتحس الناس مضطهدينك ؟‬
‫‪* Grandiosity :‬‬
‫بتحس انك شخص مهم ؟‬
‫‪*pre-occupation , obsessions‬‬
‫‪108‬‬ ‫بتحس ان فيه فكرة شاغلى بالك و مضايقاك ؟‬
 So FULL COMMENT :

1. Average steam
2. No Formal thought disorders
3. No thought control Disorder
4. Abstraction is intact /Concrete thinking
5. Normal content of Thinking

3. Examine Perception :

( Hallucinations , illusions )

 Hallucinations :

NB : ‫ بيؤمروك اسمها‬commanding

‫ يهينوك اسمها‬Insulting

Type ‫سامع‬ ‫شايف‬ ‫شامم‬

‫بتسمع ايه ؟‬
‫كام صوت ؟‬
‫تشوف ايه ؟‬
Content ‫بيقولوا ايه ؟‬ ‫تشم ايه ؟‬
‫خياالت مثال ؟‬
‫بيؤمروك ؟‬
‫بيهيونك ؟‬
‫رد فعلك بيكون ايه ؟‬
Reaction
‫بتتصرف ازاي؟‬
‫امتي ؟‬
Timing
‫ و ال طول اليوم ؟‬,‫و ال بليل بس‬, ‫الصبح بس‬
‫كل يوم ؟‬
Frequency ‫كام مرة في االسبوع ؟‬
‫و في اليوم كام مرة ؟‬

109
  Illusions :

‫بتشوف حاجات الناس شايفاها حاجة تانية ؟ (( بس أكيد مش هنقولها صريحة كدا ) ف مثال‬
: ‫هتقول له‬
‫ بس اللي‬, ‫ و اتخضيت‬, ‫ انت سمعت صوت انفجار‬, ‫مرة و انت قاعد مع اصحابك او اهلك‬
‫ وسألوك اتخضيت ليه ؟؟‬, ‫معاك قالو لك انها موسيقى‬

So FULL COMMENT:

1. The patient has auditory / visual / olfactory hallucinations.

2. Of commanding / insulting content.
3. But he / she ignores / obeys.
4. During day time / at night / all through the day.
5. Everyday / every often day / weekly.
6. The patient has / does not have illusions.

4. Examine cognition

( consciousness , orientation TPP , Memory ,

Attention and concentration )

 Consciousness :
‫ هقوله‬,, ‫من كالمي معاه هعرف‬
‫ حضرتك عامل ايه ؟‬, ‫صباح الخير‬
‫ كويس‬, ‫غالبا هيرد‬
 Orientation :

Time Person Place

‫النهاردة يوم ايه ؟‬
‫تعرف مين دول ؟‬
‫الساعة كام ؟‬
‫و يقربولك ايه ؟‬ ‫احنا فين ؟‬
‫ المغرب ؟‬/ ‫الظهر‬
‫دا طبعا لو حد من االهل موجود‬

110
 ‫‪ Memory :‬‬
‫‪ Immediate‬‬
‫هقولك ‪ 3‬كلمات و قولهم ورايا‬
‫و ميكونش ليهم عالقة ببعض ‪,,‬‬
‫كرسي ‪ ,‬تالجة ‪ ,‬ملعب‬

‫‪ Recent‬‬
‫خليك حافظهم ‪ ,‬عشان كمان شوية هتقولهم تاني‬
‫و اسأله اسئلة تانية بحيث ألهيه ‪ ,‬زي ‪ ,‬ايه اخر‬
‫أكله أكلتها اليوم ‪ ,‬و كانت حلوة ؟ ‪ ,‬و بعدين‬
‫اسأله‬

‫‪ Remote‬‬
‫مين كان رئيس مصر وقت حرب أكتوبر؟‬
‫اتولدت امتي و فين ؟‬
‫اتجوزت سنة كام ؟‬
‫‪ Attention and concentration:‬‬

‫لو بيعرف يحسب ‪ ,,‬يعني تعلميه بعد ‪ 6‬ابتدائي ‪ ,,‬قوله‬

‫اطرح ‪ 7‬من ‪ 100‬خمس مرات وراء بعض‬

‫و لو ملوش في الحساب ‪ ,,‬او مش متعلم ‪ ,,‬او معرفش‬

‫يجاوب ‪ .‬قوله يقول أيام االسبوع بالمعكوس‬

‫‪So FULL COMMENT‬‬

‫( ‪The patient is conscious , Oriented TPP , Intact‬‬

‫‪immediate , recent , remote ) memory , Full attentive‬‬
‫‪and concentrated.‬‬
‫‪ -/+‬لو فيه حاجة متأثرة ‪,,‬‬
‫…………… ‪Cognition is disturbed because‬‬

‫‪111‬‬
 5. Examine Mood and speech :

( Mood , affect , speech ) MAS 

 MOOD :
‫ اخبارك ايه النهاردة ؟‬,, ‫هقوله‬
‫و في الفترة األخيرة كان عامل ازاي ؟‬
, ‫ كان فيه أنشطة كنت بتعملها و بعدين سبتها الفترة األخيرة ؟‬, ‫ فرحان‬, ‫يعني مضايق‬
‫قلقان أو منزعج من حاجة معينة ؟؟‬
‫حاسس انك محتاج تقعد في البيت و متشوفش حد ؟‬

 AFFECT :
 Quality : Appropriate / Incongruent
 Quantity / intensity :
Constricted = flat / blunted
Expanded = Euphoric

 Type :
Sad / Elated / Fear / Anger / Anxious / Flat .

 Speech :
) ‫ عالقة الكالم ببعضه‬, ‫ كمية الكالم‬, ‫السرعة‬ , ‫هفتح أي كالم مع العيان و هالحظ ( علو الصوت‬
* Tone : high , low , vary in pitch
* Speed : slow , fast , average
* Volume : ( increased , decreased )
( circumstantial , poverty )
* Relevance ( coherent , incoherent )

112
So FULL COMMENT :

 The patient`s mood is indifferent / anxious / happy /

Angry
 The patient`s affect is appropriate , constricted , sad .
 The patient`s speech is of
o Low tone / tone of speech varies in pitch .
o Average speed .
o Decreased volume .
o Coherent speech .

This chapter is written by “NOR, MAY ”

113
 Neurology
“This is a fully detailed description of the examination. You must watch some
videos after reading this description”

General Examination Of Neurological Case

 Examination as general examination but stress on the following:

i. Vital signs
 Temperature  Pulse  Blood  Respiratory
pressure rate
See below  Irregular  Hypertension See below
“AF” in in stroke
embolism (thrombotic or
hemorrhagic)

Local Examination Of Neurological Case

1- Mentality 2- Speech
3- Cranial nerves 4- Meningeal irritation
5- Motor system 6- Reflexes 7- Sensory system
8- Others : Cranium , neck , spine& Gait 9- Other systems
 mentality
 Speech
History ‫يتم مالحظته اثناء أخذ ال‬ 
10 ‫ الى‬1 ‫اطلب من المريض يقرأ الفاتحة او يعد من‬ 
‫ن كده‬ah‫ عل‬، ‫ ألنه متعود عليها‬speech defect ‫ممكن يقرأ الفاتحة كويس اوى رغم ان عنده‬ 
)‫الصح انك تخليه يقرأ حاجة مش متعود عليها (بالد بره‬
 Cranial nerve examination
CN 1 : olfactory nerve
:‫طريقة الفحص‬
nostrils ‫ الدكتور يغلق العينين واقفل واحدة من ال‬:‫في نفس الوقت بنفس اليد‬ 
‫واليد الثانية اشممه المادة‬ 
‫ االخرى‬nostril ‫ثم كرر الخطوة السابقة على ال‬ 

:‫ واطلب منه يفتح عين ويغمض التانية‬، ‫ كل عين مرة لوحدها‬،‫ هنفحص عينيه االتنين‬
 Counting finger from 6m to 30 cm , if the patient cannot , do the next step
 Hand movement at 30 cm distance , if the patient cannot , do the next step
 Perception of light:
 No perception of light means blindness
114
 ‫‪ ‬طريقة الفحص‪:‬‬
‫‪ -1‬الدكتور والعيان الزم يكونوا على نفس المستوى‬
‫‪ -2‬المسافة ما بينهم تتراوح ما بين ‪cm 100 – 60‬‬
‫‪ -3‬لو الدكتور او العيان من ذوى النظارات الزم تتشال‪ ،‬لية؟؟؟ ‪rim of glasses may create‬‬
‫‪artificial visual field defect‬‬
‫‪ -4‬المريض يغمض عين والدكتور يغمض العين المقابلة لها‬
‫‪ -5‬أهم جملة الزم تقولها وعليها الدرجة كاملة ‪ :‬ثبت عينك فى عينى ومتحركهاش ولما تشوف‬
‫صباعى قولى‬
‫‪ -6‬الدكتور يحرك صوابعه من بره لجوه بحركة سامبوكسة فى اربع اتجاهات مع استخدام اليد‬
‫المناسبة فى فحص ‪field of the vision‬‬
‫على سبيل المثال عند فحص العين اليمنى للمريض – المريض يقفل عينه الشمال والدكتور‬
‫يقفل عينه اليمين ‪:‬‬
‫حرك صوابع اليد اليسرى لفحص ال ‪lateral field‬‬
‫حرك صوابع اليد اليمنى لفحص ال ‪medial field‬‬
‫والعكس فى العين الشمال للمريض‬
‫‪ -7‬لما يقولك شايف ‪ ،‬قوله صباعى بيتحرك وال ال ‪ /‬ثابت وال ال ؟‬
‫‪ -8‬كرر الخطوات السابقة فى العين االخرى‬

‫‪Ocular cranial nerves CN3 : oculomotor , CN4: Trochlear, CN6 :‬‬

‫;‪Abducent‬‬

‫‪ Examination of ocular nerves ; examination of :‬‬

‫‪A. Inspection‬‬ ‫‪B. Power‬‬ ‫‪C. Reflexes‬‬

‫‪A. Inspection‬‬
‫‪1. Ptosis‬‬ ‫‪2. Squint‬‬ ‫‪3. Size of‬‬ ‫‪4. Nystagmus‬‬
‫‪Pupil‬‬

‫؛‪A. Nystagmus‬‬
‫‪ ‬طريقة الفحص‪:‬‬
‫‪ -1‬حط صباعك بزاوية ‪ 30‬درجة على العين لبره على مسافة ‪ 30‬سم‬
‫مالحظة ‪ :‬لو حطيت صباعك بزاوية ‪ 180‬درجة على العين‬

‫عضالت العين تتعب اوى ويبان ‪ Nystagmus‬فى اى شخص عادى‪ ،‬وده اللى اسمه‬
‫‪Nystagmus feature‬‬

‫‪ -2‬خليه يبص عليه لمدة حوالى ‪ 30‬ثانية‬

‫‪ -3‬يتم الفحص مرة للعين اليمين ومرة للعين الشمال‬
‫‪ -4‬يتم الفحص فى كل عين ‪ :‬مرة لفوق ويثبت عينه ومرة لتحت ويثبت عينه‬
‫‪115‬‬
 ‫‪ -5‬وبعد كده لو فيه ‪ Nystagmus‬حدد ال ‪:‬‬
‫‪A. Power‬‬
‫‪Each eye separate:‬‬

‫‪ ‬طريقة الفحص‪:‬‬
‫قواعد الفحص ‪:‬‬
‫‪ ‬تكلم العيان وتشاورله الحركات مع بعض‬
‫‪ ‬العيان يثبت رقبته ويقفل عينه بإيده‬
‫‪ ‬ثبت رأسه بايدك‬
‫‪ ‬اطلب منه انه يحرك عينه مش راسه‬

‫‪CN 6‬‬ ‫ابدأ من المنتصف ثم عينك لبره ‪lateral‬‬ ‫‪-1‬‬

‫‪rectus‬‬
‫‪CN 3‬‬ ‫وهى بره فوق ‪ SR‬ثم تحت ‪IR‬‬ ‫‪-2‬‬
‫ارجع ابدأ من المنتصف ثم عينك لجوه‬ ‫‪-3‬‬
‫‪medial rectus‬‬
‫وهى جوه لفوق ‪IO‬‬ ‫‪-4‬‬
‫‪CN 4‬‬ ‫ثم تحت ‪SO‬‬ ‫‪-5‬‬

‫)‪Both eye together (conjugate eye movement‬‬

‫ال تختبر اال اذا كانت كل عين حركتها سليمة لوحدها وإال اصبح عبثا‬
‫تطبق القواعد‪ ،‬ثم فحص حركة العينين معا فى االربع اتجاهات ‪ :‬‬
‫‪1-‬‬ ‫عينيك االتنين فوق‬
‫‪2-‬‬ ‫عينيك االتنين تحت‬
‫‪3-‬‬ ‫عينيك االتنين يمين‬
‫‪4-‬‬ ‫عينيك االتنين شمال‬

‫‪116‬‬
 B. Reflexes
 Reflex A. Accommodation B. Pupillary Light
(near) reflex: reflex:
Normal pupil is RRR (round , regular , reactive to light & Accommodation(
 Technique  ‫هات صباعك من بعيد وقوله‬ 1- ‫افصل ما‬
20 ‫تابع صباعى لحد حوالى‬ ‫بين العينين بأن‬
‫سم‬ ‫تضع يدك حاجز‬
 ‫ قول للعيان‬: )‫او (عند الطلب‬ 2- ‫حط الضوء‬
‫يبص على مكان بعيد ويركز‬ ‫على العين من‬
‫فى نقطة فيه‬ ‫الجنب (ويفضل‬
‫وفجأة حط صباعك قدامه وقوله‬ )‫والنور مقفول‬
‫بص على صباعى‬ 3- ‫راقب‬
‫سرعة ضيق‬
‫(الحدقة‬Direct)
4- ‫شيل‬
‫الضوء‬
5- ‫بص على‬
‫العين التانية االول‬
‫ثم ضع الضوء مرة‬
‫اخرى‬
6- ‫راقب‬
‫سرعة ضيق‬
‫الحدقة فى العين‬
‫(التانية‬Indirect)

 Examination of CN:
CN5 CN 7 CN 9,10
Examination by Inspection, Motor Power, Sensory & Reflexes

CN 5 ; Trigeminal nerve :

 Hint of anatomy :
 It is mixed nerve “motor & sensory”
 Mainly sensory to face
 Supply motor fibers for muscles of mastication

117
 ‫‪ Its nucleus takes bilateral supply from pyramidal tracts , it’s formed‬‬
‫‪of :‬‬
‫‪1. Inspection for holloing‬‬
‫شوف هل فى تجويف ‪:‬‬

‫‪zygoma ،temporalis muscle‬فوق ال‬

‫‪zygoma ، masseter‬تحت ال‬

‫‪ ،‬هل الناحيتين زى بعض وال أل ‪symmetry‬شوف ال‬

‫‪2- Motor Power‬‬

‫‪A. Temporalis muscle‬‬ ‫‪B. Masseter muscle‬‬

‫امسك العضلة وحس ال ‪ bulk‬وقول للعيان جز حط ايدك على العضلة وقول للعيان جز على‬
‫سنانك وسيب‬ ‫على سنانك وسيب‬
‫‪C. Pterygoid muscles‬‬
‫كل ‪ Pterygoid muscle‬تزق الفك للناحية المقابلة‬
‫العضلتين معا تنول الفك لتحت مباشرة‬
‫‪ -1‬قوله افتح بقك وشوف حركة الفك ‪:‬‬
‫لو نزل فى النص يبقى فى حاجة من اتنين‪:‬‬ ‫لو حود الناحية الثانية ‪ :‬تستفيد ان ‪:‬‬
‫‪ ‬ان الفك بيشاور على الناحية الضعيفة الناحيتين ضعيفة‬
‫الناحيتين سليمة‬ ‫(فكسان عيان)‬
‫ازاى تفرق ‪against resistance‬‬ ‫‪Unilateral LMNL ‬‬
‫‪ ‬حط ايدك الشمال فوق راسه علشان تثبتها‬
‫فتتضمن انه يستخدم فكه مش راسه‬
‫‪ ‬حط ايدك اليمين تحت فكه واضغط لفوق‬
‫جامد وقوله افتح بقك‬
‫‪In bilateral weakness or paralysis :‬‬
‫‪inability to open mouth against‬‬
‫‪resistance‬‬
‫‪ -2‬ممكن تختبر كل ‪ Pterygoid muscle‬على حده (عند الطلب)‬
‫‪ ‬حط ايدك الشمال فوق راسه علشان تثبتها فتتضمن انه يستخدم فكه مش راسه‬
‫‪ ‬حط قبضة ايدك اليمين على جانب الفك وقوله حاول تزق ايدى ( الحظ انك بتختبر‬
‫العضلة بتاعة الناحية المقابلة)‬
‫انت كده بتفحص اى جزء من ال ‪ Pterygoid muscle‬؟ بفحص ال ‪lateral part‬‬

‫‪118‬‬
 ‫‪3- Sensation:‬‬
‫‪Sensation from the face are carried through trigeminal branches:‬‬

‫‪1. Ophthalmic branch : skin over forehead :‬‬

‫‪2. Maxillary branch : skin over cheeks‬‬
‫‪3. Mandibular branch : skin over lower jaw‬‬
‫‪Except the : skin over the angle of mandible which is supplied by C2‬‬

‫‪For pain‬‬ ‫‪for touch‬‬

‫‪ ‬طريقة الفحص‪ :‬إبدأ بالسليم ودايما اسأله حاسس هنا زى هنا ؟‬

‫‪ -1‬استخدام دبوس لفحص ال ‪ Pain‬استخدم قطنة لفحص ال‪touch‬‬
‫‪ -2‬اطلب من العيان ان يغمض عينيه‬
‫‪ -3‬مقارنة االحساس فى الناحيتين ‪ :‬ناحية اليمين وناحية الشمال فى الثالث مناطق (‪، 2 ، 1‬‬
‫‪)3‬‬
‫‪ -4‬مقارنة االحساس بين اربعة مناطق (‪)4 ،3 ،2 ، 1‬على ناحية واحدة (تفرق ما بين ال‬
‫‪ organic‬وال ‪hysterical‬‬
‫‪ -5‬مقارنة االحساس فى ناحية واحدة بين ‪:‬‬
‫‪ ‬حتة ‪ enteral‬جنب االنف‬
‫‪ ‬وحته ‪Peripheral‬‬

‫‪4- Reflexes:‬‬
‫‪1. Corneal‬‬ ‫‪2. Jaw reflex‬‬
‫‪(conjunctival) reflex‬‬ ‫‪“temporalis‬‬
‫”‪masseter reflex‬‬
‫& ‪ Stimulus‬‬ ‫قول للعيان يبص الناحية التانية‬ ‫قول للعيان افتح بقك نص‬ ‫‪‬‬
‫‪technique‬‬ ‫و‪ ،‬ليه؟‬ ‫فتحه‬
‫‪To avoid photic‬‬ ‫حط صباعك ال ‪index‬‬ ‫‪‬‬
‫‪stimulation‬‬ ‫تحت الشفة السفلى فى‬
‫اعمل سن للقطنة وتعالى من‬ ‫تجويف الذقن‬
‫جنب العيان والمس عينه بالقطنة‬ ‫اخبط صباعك بال‬ ‫‪‬‬
‫‪ hammer‬من فوق لتحت‬
‫فى الطبيعى مايحصلش اى‬ ‫‪‬‬
‫حاجة‬

‫‪119‬‬
 ‫‪CN7: facial nerve‬‬

‫‪A. Upper face‬‬ ‫‪B. Lower face‬‬

‫‪ Frontalis‬‬ ‫‪ Orbicularis‬‬ ‫‪ buccinator‬‬ ‫‪ Retractor‬‬
‫‪muscle‬‬ ‫‪oculi‬‬ ‫‪anguli‬‬
‫‪2- motor power‬‬

‫‪A. Upper face‬‬

‫‪ Frontalis muscle‬‬ ‫‪ Orbicularis oculi‬‬
‫‪Without resistance‬‬
‫قول للعيان ‪ :‬ارفع حواجبك بص للسقف‬ ‫زر على عينك جامد‬
‫شوف الحاجبين ارتفعوا زى بعض وال أل‬
‫التجاعيد ظهرت على الناحيتين وال أل‬
‫‪With resistance‬‬
‫اطلب من المريض انه يرفع حواجبه وانت‬ ‫زر على عينك جامد ومتخلنيش افتحهم وحاول‬
‫ضاغط بايدك جامد‬ ‫تفتحها للعيان‬

‫‪B. Lower face‬‬

‫‪ buccinator‬‬ ‫‪ Retractor anguli‬‬ ‫‪ Orbicularis oris‬‬
‫‪Without resistance‬‬
‫انفخ بقك‬ ‫ورينى سنانك (متقولش افتح بقك)‬
‫جامد‬

‫انفخ بقك جامد ومتخلنيش افضيه ‪With‬‬

‫‪resistance‬‬
‫‪3- Sensation: TASTE sensation of anterior 2/3 of tongue by corda tympani‬‬

‫انواع التذوق ‪:‬‬

‫حادق – حامض – حنضل‬

‫ملح – ليمون – صبر‬

‫‪ ‬طريقة الفحص‪:‬‬
‫‪ .3‬شد اللسان لبره ونشف بشاشه‬ ‫‪ .1‬ممنوع العيان يتكلم اثناء الفحص ‪ .2‬العيان يغمض عينيه‬
‫‪ .6‬يكتب او يشاور بايده لو حاسس‬ ‫‪ .5‬ضع المادة على الجزء الذى تريد‬ ‫‪ .4‬قسم اللسان يمين وشمال‬
‫بالطعم‬ ‫اختباره‬

‫‪120‬‬
CN: CN9 : glossopharyngeal , CN10 : vague, CN 11 ; cranial part of
accessory:
1- Inspection & Motor power
‫العيان يفتح بقه‬

tongue depressor ‫اللسان ب‬

) deviated ‫ اصال‬tip ‫ الن ال‬tip‫ (مش على ال‬base of the uvula ‫ وبص على ال‬Torch

Uvular deviation to healthy side : contralateral unilateral LMNL

If central Uvula: ‫خلى العيان يقول آآآآه‬

Symmetrical elevation of soft palate : Normal

Non mobile uvula and palate : Bilateral palsy either in bilateral UMNL or
bilateral LMNI

2- Sensation :
GENERAL & TASTE sensation of posterior 1/3 of the tongue

How to test taste sensation in posterior 1/3 of tongue

It’s tested by using electric current (4 mill – ampere) metallic taste

3- Reflexes
CN 8: Cochlea – vestibular nerve

A. Cochlear part : test acuity of hearing using :

1. Watch test 2. Rinne’s test 3. Weber test

 Technique
 The acuity of the  Using vibrating  Place tuning fork in
patient’s hearing is tuning fork, compare the middle of head
compared to that of air conduction (in
the examiner’s front of ear) with
 If there is diminution of bone conduction (on
patient acuity for mastoid process)
hearing do the
following test

121
 Vestibular part :
1- Vestibule – ocular reflex or 2- oculo – cephalic reflex or doll’s
caloric reflex test eyes reflex
 Aim :
 Awes function of internal ear  Bed side test to evaluate
Vestibular function
 Differentiate between causes of
nystagmus
 Technique
Patient lie supine, his head flexed 30 Patient lies on his back , with his
so that the lateral semicircular canal is shoulder at the end of the bed . his
vertical generate a maximal response head , projecting beyond bed , is
Each ear is douched with water for 40 supported by examiner hand
seconds Head is then fully extended and
30 c (70 below normal) turned to one side
44 c (7 above normal) Patient’s eye should remain open
After a short interval , test should be
repeated with head extended and
rotated to other side

CN 11 ; accessory nerve
 Stem mastoid  Trapezius
1- Inspection
 Head tilt to affected side  Shoulder depression

2-Motor power
‫الزم‬
exposed ‫ تكون‬muscle ‫ ال‬
‫ تواجه العضله‬
Against resistance 
‫من قدام العيان‬ ‫ من وراء العيان‬
‫ (كل عضله تزق الرقبه‬: ‫ كل عضلة لوحدها‬-1 ‫حط ايدك االتنين على كتف العيان وزق وقوله‬
)‫الناحية العكسية‬ ‫ارفع كتافك فوق‬
‫حط ايدك على جنب فكه وقوله زق ايدى‬
‫وحس العضلة الناحية التانية‬
‫حط ايدك التانية بنفس الطريقة وحس العضلة‬
‫االخرى‬
‫ (العضلتين مع بعض‬: ‫ العضلتين مع بعض‬-2
)‫يزقوا الرقبة لتحت‬

122
 ‫حط ايدك تحت ذقنه وقوله زق ايدى وشوفهم‬
‫وحسهم االتنين‬
N.B : sternomastoid & trapezius are proximal muscles , so receive pyramidal
supply from both sides

CN 12 ; hypoglossal nerve
2-Motor
A. Without resistance: ‫اطلب من العيان يطلع لسانه لبره‬
B. With resistance: ‫تزق من بره بصباعك ولسان العيان يزق ايدك من جوه‬
 N.B:
‫ سليم‬12th CN ‫ مصاب وال‬7th CN ‫ تجد ال‬hemiplegia ‫كثيرا عندما تفحص عيان ال‬

4: Meningeal Irritation = Examination of neck

Opisthotonos Lassegue’s sign Kernig’s sign

5: Examination of motor system

1. Inspection 2. Palpation 3. Percussion 4. power 5. Co-

of the for the for ordination
muscle muscle fasciculation
state tone & myotonia

:‫ قواعد الفحص‬
Expose four ‫نظم نفسك‬
limbs a) Start by healthy b) UL then c) distal d) use
side , then LL then your both
diseased side ; proximal hands
compare both

‫ شروط خاصة حسب االختبار‬

Inspection :

A. Abnormal involuntary Movements e.g. athetosis, pathological

fasciculations , chorea , dystonia
1- Describe : see details later in parkinsonism case

1- pattern 2- static or 3- slow or 4- regular or 5- fine or flappy

kinetic rapid irregular (coarse) tremors
123
‫‪2- distribution‬‬
‫‪UL or LL or both , head & neck , Unilateral or bilateral, distal or proximal‬‬
‫‪B. posture of the patient:‬‬
‫‪C. circumference of the muscle = state of the muscle:‬‬
‫‪D. dysplastic (trophic) changes:‬‬
‫‪E. deformity in the skeletal system‬‬
‫‪2-Palpation of muscle tone‬‬ ‫شرط خاص هنا ‪ :‬الزم تقول للعيان سيب‬
‫نفسك‬
‫‪A. In upper limbs‬‬ ‫‪B. In lower limbs‬‬
‫‪1. Wrists by shaking method‬‬ ‫‪1) Ankles by shaking method‬‬
‫‪ ‬اليد اليمين تمسك اليد او القدم اليمين و اليد الشمال تمسك اليد او القدم الشمال (اليمين باليمين‬
‫والشمال بالشمال)‬
‫‪ ‬يتم فحص الناحيتين مع بعض‬
‫‪ ‬تهز من فوق لتحت او من الجنب للجنب‬
‫& ‪2. Elbows by passive flexion‬‬ ‫& ‪2) Knees by passive flexion‬‬
‫‪extension‬‬ ‫‪extension‬‬
‫‪ ‬ايدك الشمال تثبت المفصل اللى قبل الذى تختبره‬
‫‪ ‬ايدك اليمين تثنى وتفرد ال ‪limb‬‬
‫‪ ‬لو الحالة ‪hypertonia‬‬
‫‪ ‬لو ال ‪tone‬عالى فى االول ويسيب فى االخر ‪spasticity )claps knife‬‬
‫‪ ‬لو ال ‪ tone‬عالى من االول لالخر ‪ : rigidity‬لو معهاش ‪ tremors‬اسمها ‪lead pipe‬‬
‫لومعاه ‪ tremors‬اسمها ‪cog wheal‬‬

‫‪3) Shoulder : Gower’s test‬‬ ‫‪4) Hip‬‬

‫‪ ‬المريض جالس والدكتور وراه‬ ‫‪ ‬خلى العيان يفرد رجليه على االخر‬
‫‪ ‬استخدم ايديك االتنين‬
‫‪ ‬ضع ايديك اليمين فوق ال ‪ankle‬وايدك‬
‫‪ ‬حط ايدك تحت باطه فى الناحيتين معا‬ ‫الشمال فوق ال ‪knee‬‬
‫‪ ‬واخطف الكتف لفوق‬ ‫‪ ‬ثم ‪:‬‬
‫‪ ‬النتيجه‬
‫‪a. Rolling technique‬‬
‫‪ ‬الكتف ينزل ويطلع طبيعى‬ ‫‪ ‬دحرج رجله رايح جاى‬
‫‪normotonia‬‬ ‫‪b. Circumduction:‬‬
‫‪ ‬الكتف كأنه هيتخلع ‪hypotonia‬‬ ‫‪ ‬ارفع رجل العيان ولفها فى حركة‬
‫‪ ‬الكتف ناشف‪hypertonia‬‬ ‫دائرية‬
‫‪ ‬النتيجة‬
‫الرجل تلف معاك زى العجلة ‪hypotonia‬‬
‫الرجل مخشبه ‪hypertonia‬‬
‫‪5) Both hip & knee by passive elevation‬‬
‫‪ ‬حط ايدك تحت ال ‪ distal thigh‬ورجله‬
‫مفروده على السرير واخطف لفوق وسيب‬
‫‪ ‬مميزات طريقة الخطف ‪ :‬تختبر ال ‪tone‬‬
‫فى ال ‪ knee‬وال ‪hip‬‬
‫‪124‬‬
 ‫ متحددش انواع ال‬: ‫ عيوب طريقة الخطف‬
hypertonia
‫ النتيجة‬
a. Normal b. Hypertonia c. Hypotonia
‫ركبته تتثنى وكعب رجله‬ ‫رجله كلها تطلع حته واحده زى‬ ‫ركبته تتثنى ورجله تتفرد‬
‫ميترفعش‬ ‫ المسطره‬If hypotonia is bilateral –
trog position

3. Percussion:
a. Mayotonia b. Mayotoni c. Mayotoni d. Mayotoni
congention a a a
(hypertrophice atrophica aequisita paradoxic
) a

4. Muscle power:

‫ شروط خاصة بهذا االختبار‬

‫ نظم نفسك فى كل مفصل فى الحركات بهذا الترتيب‬-1
 Flexion .. extension
 Abduction .. adduction
 External rotation .. internal rotation
against resistance ‫ ومرة‬Without resistance ‫ اعمل االختبارات مرة‬-2
Without resistance -‫أ‬
‫ ادى العيان االمر وانت بتمثل الحركة بايدك‬
against resistance -‫ب‬
‫ وايدك الشمال تثبت المفصل اللى قبل الذى تختبره وقول للعيان قاومنى‬resistance ‫ايدك اليمين تعمل‬

‫ من الطبيعى انك ما‬Without resistance ‫ الحركة اللى العيان معرفش يعملها من نفسه‬-3
against resistance ‫تختبرهاش‬

I. Upper limbs
I. Hand; fingers ‫صوابعك‬
Without resistance
Flexors (flexor Extensors (extensor Abductors (dorsal
digitorum) digitorum interossei)
‫ صوابعك‬- ‫اقفل – اثنى‬ ‫افرد صوابعك‬ ‫فنطهم – ابعدهم‬

125
 ‫اقفل صوابعك جامد على‬ ‫افرد صوابعك جامد ‪ ...‬متخلنيش‬ ‫ابعد صوابعك جامد ‪...‬‬
‫صوابعى ‪ ..‬متخلنيش اطلعهم‬ ‫اتنيهم ‪ ...‬قاومنى‬ ‫متخلنيش اضمهم ‪ ...‬قاومنى‬
‫قاومنى ‪hand grip‬‬
‫للتميز اوى كمل وقوله افتحهم‬
‫بسرعة ‪ ..‬ليه؟‬
‫‪To exclude voluntary‬‬
‫‪myotonia‬‬
‫‪Without resistance‬‬
‫‪Adductors (palmar‬‬ ‫‪Opposition(opponents‬‬ ‫اعمل وضع ‪Lumbricals‬‬
‫ضمهم)‪interossei‬‬ ‫)‪pollicis‬‬ ‫الكتابة‬
‫سبح – عد على صوابعك‬
‫‪With resistance‬‬ ‫ايدك اليمين تعمل ‪ resistance‬وايدك الشمال تثبت ال ‪wrist‬‬
‫اعمل حلقة بصباعك الصغير على ضم صوابعك على الورقة جامد‬ ‫اعمل وضع الكتابة ‪...‬‬
‫‪ ...‬متخلنيش اشدها ‪ ..‬قاومنى‬ ‫الكبير متخلنيش اعدى منهم ‪..‬‬ ‫متخلنيش اعدى صوابعى من‬
‫قاومنى‬ ‫صوابعك ‪ ..‬قاومنى‬
‫كفك (يفضل االختبار واالصابع مقفولة )‪2. wrist :‬‬
‫‪Without resistance‬‬
‫& ‪Flexors (flexor carpi – radialis‬‬ ‫& ‪Extensors (Extensor carpi – radialis‬‬
‫اثنى كفك )‪ulnaris‬‬ ‫افرد كفك )‪ulnaris‬‬
‫‪With resistance‬‬ ‫ايدك اليمين تعمل ‪ resistance‬وايدك الشمال‬
‫تثبت ال ‪elbow‬‬
‫اثنى كفك ‪ ..‬زق على ايدى‬ ‫افرد كفك جامد ‪ ...‬زق على ايدى‪..‬‬

‫كوعك ‪elbow‬‬
‫‪Without resistance‬‬
‫اثنى كوعك ‪Flexors (biceps ,‬‬ ‫افرد كوعك )‪Extensors (triceps‬‬
‫)‪brachioradialis‬‬
‫‪With resistance‬‬ ‫العيان فى ‪mid -position‬‬
‫اليمين حول ال ‪ forearm‬تعمل ‪resistance‬‬
‫من غير ما تغير وضعها وايدك الشمال تثبت ال‬
‫‪shoulder‬‬
‫اثنى كوعك جامد ‪ ...‬شد على ايدى‬ ‫افرد كوعك جامد ‪ ..‬زق على ايدى‬
‫(يفضل الفحص والمريض جالس ‪ ..‬الزم تقولها للدكتور) ‪ :‬دراعك ‪3. shoulder‬‬
‫‪Without resistance‬‬
‫‪ Flexors(anterior fibers of‬‬ ‫‪ Extensors (posterior fibers of‬‬
‫دراعك لقدام لو جالس او لفوق )‪deltoid‬‬ ‫دراعك لورا لو جالس او لتحت )‪deltoid‬‬
‫لو نايم‬ ‫لو نايم‬

‫‪126‬‬
 ‫‪With resistance‬‬ ‫يتم فحص الدراعين معا الن مفيش‬
‫مفصل تثبته‬
‫اعمل ايدك زى الكماشة حول ال‪arm‬‬
‫عشان تعمل ‪ resistance‬وتقول للدكتور‬
‫ويفضل والعيان جالس‬
‫زق دراعك لقدام لو جالس (او لفوق لو‬ ‫لتحت لو نايم) جامد ‪ ..‬متخلنيش ارفعهم‬
‫نايم) جامد ‪ ...‬متخلنيش انزله ‪ ..‬قاومنى‬ ‫نزل رجلك لتحت جامد‬

‫‪Without resistance‬‬
‫‪Abductors (supraspinatus , deltoid ,‬‬ ‫‪Adductors ( pectorals majat‬‬
‫جنح )‪trapezius‬‬ ‫‪pectoralis assisted by latissimus‬‬
‫) ‪dorsi & tests‬‬

‫‪With resistance‬‬ ‫يتم فحص الدراعين معا الن مفيش مفصل‬

‫تثبته‬
‫اعمل ايدك زى الكماشة حول ال‪ arm‬عشان تعمل‬
‫‪ resistance‬وتقول للدكتور ويفضل والعيان‬
‫جالس‬
‫جنح دراعك لبره جامد ‪ ..‬زق ايدى لبره‬ ‫ضم دراعك لجوه ‪ ...‬زق ايدى لجوه‬
‫‪Without resistance‬‬
‫سرح شعرك ‪External rotation‬‬ ‫‪internal rotation‬‬
‫حط ايدك فى جيبك او بايدك اليمين المس جيبك‬
‫الشمال والعكس صحيح‬
‫‪With resistance‬‬
‫ضع ال ‪ arm‬فى زاوية قائمة ‪ :‬زق ايدى اليمين ضع ال ‪ arm‬وال ‪ forearm‬فى زاوية قائمة ‪:‬‬
‫زق ايدى اليمين لبره جامد‬ ‫لجوه‬

‫‪II.‬‬‫‪Lower limbs‬‬
‫‪I.‬‬ ‫صوابع رجليك ‪Toes‬‬
‫‪Without resistance‬‬
‫صوابع رجليك لفوق ‪Dorsiflexion‬‬ ‫صوابع رجليك لتحت ‪Planter flexion‬‬
‫‪With resistance‬‬ ‫ايدك اليمين تعمل ‪ resistance‬وايدك الشمال‬
‫تثبت ال ‪ankle‬‬
‫ارفع صوابع رجليك لفوق جامد ‪ ...‬شد على ايدى‬ ‫نزل صوابع رجليك لتحت جامد ‪ ...‬زق على‬
‫ايدى‬

‫‪127‬‬
 2.Ankle ‫وش رجلك‬
Without resistance
Flexion ( anterior tibial muscle : Planter Flexion (calf muscles ;
tibialis anterior peroneus longus gastrocnemius , soleus, plantaris) ‫وش‬
brevis)‫وش رجلك لفوق‬ ‫رجلك لتحت‬
With resistance ‫ وايدك الشمال‬resistance ‫ايدك اليمين تعمل‬
knee ‫تثبت ال‬
‫ شد على ايدى‬... ‫ارفع وش رجليك لفوق جامد‬ ‫ زق على ايدى‬... ‫نزل وش رجليك لتحت جامد‬

3. knee‫ركبتك‬
Without resistance
Flexors )Hamstrings: semi – Extensors ) quadriceps ; vastus
tendinosis , membranous biceps medialis , laterallis , intermedius,
femoris) ‫اثنى ركبتك على‬ rectus emojis ) ‫افرد ركبتك‬
With resistance mid-position ‫خلى رجل العيان‬
‫ تعمل‬leg ‫ايدك اليمين كماشة حول ال‬
hip ‫ وايدك الشمال تثبت ال‬resistance
‫شد على ايدى‬.. ‫اثنى ركبتك عليك جامد‬ ‫ زق على ايدى‬.. ‫افرد ركبتك جامد‬

4.Hip : ‫رجلك‬
Without resistance
Flexors) ilea -psoas) ‫ارفع رجلك‬ Extensors ) gluteus maximum) ‫نزل‬
‫رجلك‬
With resistance ‫يتم فحص الرجلين معا الن مفيش مفصل‬
‫تثبته‬
‫ عشان‬thigh‫اعمل ايدك زى الكماشة حول ال‬
resistance ‫تعمل‬
‫ زق ايدى لفوق‬... ‫ارفع رجلك لفوق جامد‬ ‫ زق ايدى‬... ‫نزل رجلك لتحت جامد‬
‫لتحت‬

Without resistance
Abductors (gluteus Medius , Adductors ) adductors group :
minimums)‫ابعد – افتح ردلك‬ adductor magus longus , brevis ,
pectineus , gracilis) ‫ضم رجلك‬
With resistance ‫يتم فحص الرجلين معا الن مفيش مفصل‬
‫تثبته‬

128
 ‫اعمل ايدك زى الكماشة حول ال‪ thigh‬عشان‬
‫تعمل ‪resistance‬‬
‫افتح رجليك جامد ‪ ...‬زق ايدى لبره‬ ‫ضم رجلك جامد ‪ ...‬زق ايدى لجوه‬
‫‪Without resistance‬‬
‫حط رجل على رجل ‪External rotation‬‬ ‫والعيان قاعد على الكرسى ‪internal rotation‬‬
‫قوله المس بركبتك اليمين الركبة الشمال والعكس‬

‫‪With resistance‬‬
‫ضع ال ‪ thigh‬وال ‪ leg‬فى زاوية قائمة‬ ‫ضع ال ‪ thigh‬وال ‪ leg‬فى زاوية قائمة‬
‫زق ايدى اليمين لجوه جامد‬ ‫زق ايدى اليمين لبره جامد‬

‫‪Without resistance‬‬
‫‪Flexors‬‬ ‫‪Extensors‬‬
‫العيان يربع ايده او يحطها تحت راسه وقوله هم‬ ‫العيان يحط ايده ورا راسه وقوله قوم طياره‬
‫براسك‬
‫حط ايدك على جبهته او راسه من ورا وتقوله هم ‪With resistance‬‬
‫‪2. With resistance‬‬

‫ايدك اليمين تعمل ‪ resistance‬وايديك الشمال تثبت ال ‪wrist‬‬

‫‪Muscles & action‬‬

‫)‪1- Opponeos policies .. opposition (see before‬‬
‫اعمل حلقة بصباعك الصغير على الكبير متخلنيش اعدى منهم ‪ ..‬قاومنى‬
‫‪2- Abductor policies longus ..‬‬ ‫… ‪3- Abductor policies‬‬
‫‪Abduction‬‬ ‫‪Abduction‬‬
‫المقاومة تكون على جانبى ال‪thumb‬‬ ‫المقاومة تكون على جانبى ال‪thumb‬‬
‫ارفع صباعك لفوق جامد ‪ ..‬ومتخلنيش انزله ‪..‬‬ ‫ضم صباعك لجوه جامد ‪ ..‬ومتخلنيش ابعده ‪..‬‬
‫قاومنى‬ ‫قاومنى‬
‫‪4- Flexor policies longus ..‬‬ ‫… ‪5- Extensor policies brevis‬‬
‫‪Flexion‬‬ ‫‪Extension‬‬
‫المقاومة تكون من االمام ‪against‬‬ ‫المقاومة تكون من الخلف ‪against‬‬
‫‪distal phalanx‬‬ ‫‪inter -phalangeal joiar‬‬
‫اثنى صباعك جامد ‪ ..‬متخلنيش افرده ‪..‬‬ ‫افرد صباعك جامد ‪ ..‬متخلنيش اتنيه ‪..‬‬
‫قاومنى‬ ‫قاومنى‬

‫‪129‬‬
 1- Co-ordination
 Technique ‫اتكلم له وشاور فهمه‬
a. Finger – to nose test b. Finger – to Finger test
‫وانت مفتح هات صباعك من بعيد على‬ ‫وانت مفتح هات صباعينك االتنين من بعيد على‬
)‫مناخيرك (يعاد وهو مغمض‬ )‫بعض (يعاد وهو مغمض‬
c. Finger – to fixed doctor’s d. In LL : heel – to knee test
Finger test ‫وانت مفتح هات كعبك على ركبتك ومشيه‬
‫وانت مفتح هات صباعك من بعيد على‬ )‫على قصبة رجلك (يعاد وهو مغمض‬
‫صباعى‬

1. Upper limbs:
Normal deep reflexes:
1) Brachioradialis reflex or What is inverted supinator
supinator reflex : (C 5 -6) reflex?
120 ‫الكوع زاوية‬  Causes : lesion at c 5 segment
mid-way between ‫ايد العيان‬ & root
supination& pronation  Components
‫اخبط بالناحية العريضة على‬ 1- Lost biceps reflex
1- Inch above radial styloid 2- Exaggerated triceps reflex
process 3- Inverted supinator reflex
(flexion of Fingers instead
of flexion of elbow)
2- Biceps reflex : (C 5 -6) 3- Triceps reflex (Triceps
brachialis reflex) (C 6 -7)
120 ‫ الكوع فى زاوية‬ 90 ‫ الكوع فى زاوية‬
‫ بصباعك‬stretch ‫ زود ال‬ ‫بانك تشد على‬more stretch ‫ ممكن تعمل‬
‫ايد العيان‬
‫ اخبط بالناحية المدببة وعينك على ال‬ ‫ اخبط بالناحية العريضة وعينك على ال‬
Triceps Triceps

Pathological reflex normally absent , if present they denote UMNI , done only
in hyperflex
1- Supraspinatus (C3-4) 2- Finger flexion (C8-T1)
‫ العيان قاعد والكتف مكشوف‬ ‫ وحط‬90 ‫ اثنى صوبع اليد بزاوية‬
‫ واخبط فوقه‬spine scapula ‫ حس ال‬ ‫صوابعك ضد صوابعه كأنك هتبوس ايده‬
‫ اخبط على صوابعك من تحت‬
‫ هيشد على صوابعك او يقفل‬+ve ‫ لو‬
‫صوابعه‬
3- Wetenberg ( C8-T1) 4- Hoffman’s (C8 -T1)
130
 ‫‪ ‬شد صوابعك من صوابع العيان بتاعة‬ ‫‪ ‬امسك الصباع االوسط بتاع العين وثبت‬
‫نفس اليد (اليمين باليمين والشمال‬ ‫ال ‪ PIPJ‬واثنى ال ‪ DIPJ‬وسيبها فجأة‬
‫بالشمال)‬ ‫كأنك بتطرقعها‬
‫‪ ‬انت شد وهو يشد‬ ‫‪ ‬لو ‪ +ve‬صوابع العيان تتقفل وخصوصا‬
‫‪ ‬لو طبيعى ‪extension of the ..‬‬ ‫يحصل ‪flexion of thumb‬‬
‫‪thumb abduction‬‬
‫‪ ‬لو ‪flexion of thumb‬‬
‫‪abduction>> hyper - reflexia‬‬
‫)‪5- Pectoral (C5-T1‬‬ ‫)‪6- Deltoid (C5‬‬
‫‪ ‬حط صباعك على ال ‪anterior axillary‬‬ ‫‪ ‬حط صباعك على ال‪ Deltoid‬واخبط‬
‫‪ fold‬واخبط فوقه‬ ‫فوقه‬

‫‪II.‬‬ ‫‪Lower limbs :‬‬

‫‪Normal deep reflexes:‬‬
‫)‪1. Tendon knee jerk (quadriceps reflex ) (L2,3,4‬‬
‫‪A. Ordinary method‬‬ ‫‪B. Dangling (hanging) Technique:‬‬
‫‪ ‬اثنى الرجل ‪ 120‬على الناحيتين معا‬ ‫‪ ‬الرجل متدلية عاملة زاوية ‪90‬‬
‫‪ ‬ابحث عن ال ‪ tendon‬بايدك وهو الواقع بين ‪ ‬ارفع الرجلين مع بعض من تحت الركبة‬
‫حيث تجعل كعبه يا دوب مالمس السرير‬ ‫بروزين واحد اعلى الركبة واآلخر اسفلها (‬
‫‪ ‬حط ال ‪ thumb‬بتاع االيد اللى انت رافع‬ ‫هامة)‬
‫بيها بين ال‪2 knees‬‬ ‫‪ ‬اخبط الناحية العريضة على ال ‪tendon‬‬
‫‪ ‬ابحث عن ال‪ tendon‬بايدك التانية وهو‬ ‫وعينك على ال ‪quadricep‬‬
‫الواقع بين بروزين واحد اعلى الركبة واآلخر‬
‫اسفلها ( هامة)‬
‫‪ ‬اخبط الناحية العريضة على ال ‪tendon‬‬
‫وعينك على ال ‪quadriceps‬‬
‫‪2. Ankle reflex (triceps surae reflex , gastrocnemius soleus reflex) (S1 , 2‬‬
‫)‪mainly S1‬‬
‫‪A. Ordinary method‬‬ ‫‪B. Kneeling Technique‬‬
‫اتنى الرجل ‪ 90‬ليه؟ ‪to abolish action of‬‬ ‫‪ ‬العيان قاعد على حاجة مستواها عالى‬
‫بحيث رجلية متكونش المسة االرض مع ‪ gastrocnemius on knee‬وخليه كأنه حاطط‬
‫رجل على رجل وينيمها لبره‬ ‫نفس الخطوات السابقة‬
‫اعمل ‪ dorsi-flexion‬عشان تعمل ‪slight‬‬
‫‪stretch‬‬
‫اخبط بالناحية العريضه على ‪tendo-achillis‬‬
‫وعينك على ال ‪calf muscles‬‬
‫لو الدكتور سألك هتشوف ايه ‪ :‬قوله ‪planter‬‬
‫‪flexion & eversion‬‬
‫‪Pathological reflexes normally absent , if present they denote UMNL done‬‬
‫‪only in in hyperreflexia‬‬
‫‪131‬‬
 ‫)‪1. Adductor (L4‬‬ ‫‪2. patellar (quadriceps reflex) (L2‬‬
‫)‪,3,4‬‬
‫اعمل ‪ abduction‬و ‪external rotation‬‬ ‫‪‬‬ ‫‪ ‬ركبة العيان مفرودة ‪180‬‬
‫لل‪hip‬‬ ‫‪ ‬حط ‪your index‬بسيفه ‪above patella‬‬
‫دور على ال ‪ tendo-‬وده انك تطلع سنه فوق‬ ‫‪‬‬ ‫واخبط عليه من اعلى السفل‬
‫ال ‪adductor tubercle‬واعمل ‪rolling‬‬ ‫‪ ‬لو ‪ hyper reflexia‬الركبة تنط لفوق‬
‫هتحس كأن فى حبل تحت ايدك‬
‫دوس عليه بصباعك جامد علشان تزود ال‬ ‫‪‬‬
‫‪stretch‬‬
‫لو ‪hyper reflexia‬‬ ‫‪‬‬

‫‪Clonus in Limbs:‬‬

‫‪Search for Clonus only in hyperreflexia: Organic sustained Clonus in the‬‬

‫‪surest sign of UMNL‬‬
‫)‪1. Wrist Clonus (C8-T1‬‬
‫‪ ‬اسند ال ‪ forearm‬بايدك الشمال من الكوع وامسك ايده باليمين وطلعها لقدام حاجه بسيطه‬
‫وبعدين ارجع اعمل ‪ dorsiflexion‬فجأة‬
‫‪ Types of Clonus :‬‬
‫مرة او مرتين ‪ non sustained‬على طول ‪1) Sustained‬‬
‫هستيرى ‪ hysterical‬عضوى ‪2) Organic‬‬
‫‪ ‬تلغى ال ‪ stretch‬اللى انت عامله بدون ما يشعر المريض‬
‫‪ ‬الزم العيان يحس بانك لسه حاطط ايدك وفى نفس الوقت شد الناحية العكسية‬
‫‪ ‬لو استمر يبقى ‪hysterical‬‬
‫‪ ‬لو اختفى يبقى ‪Organic‬‬
‫‪ Organic sustained Clonus in the surest sign of UMNL‬‬
‫‪ ‬كل ‪ Clonus‬معاه ‪ UMNL‬وليس العكس‬
‫)‪2. Ankle Clonus (S1,2 mainly S1‬‬ ‫)‪3. Patellar Clonus (L2 ,3,4‬‬
‫‪ o‬اتنى رجله لقدام حاجه بسيطه وبعدين اعمل‬ ‫وشك لرجل العيان‬ ‫‪‬‬
‫‪ dorsiflexion‬فجأة‬ ‫خلى صوابعك مع بعض فى مواجهة‬ ‫‪‬‬
‫‪ o‬تالقى القدم بترقص فوق وتحت‬ ‫ال‪ thumb‬زى الكماشة‬
‫شد جلد الركبة لفوق شويه‬ ‫‪‬‬
‫ثم زق الركبة لتحت هتالقى الركبة بترقص‬ ‫‪‬‬
‫طالعة نازلة‬

‫‪132‬‬
N.B : Other Pathological reflexes (normally absent) ; in the face
1. Pouting or snout 2. Palmo -mental
 Light yapping of the closed lips  Search thenar eminence of the
near the midline by finger or by chin
handle of the hammer .. upward
movement of lips

 Superficial reflexes : Planter , Abdominal , cremasteric , gluteal&

Anal
Superficial reflex : : Planter reflex (S1,2 mainly S1)
Normal : flexor response Abnormal: Extensor
response
:‫ فكرته‬
‫ قدم العيان وشوف النتيجه فى الصباع الكبير‬stimulate ‫بطريقة ما‬
I. Technique of Babinski method:
‫ من القدم ثم لف‬lateral side ‫رجل العيان مفرودة على السرير واستخدم مفتاح وامشى على ال‬
‫مع نهايه الصوابع وقف قبل بداية الصباع الكبير‬
1. Normal : flexor response : Planter flexion toes
2. Abnormal

Superficial reflexes
1. Abdominal
Technique :
‫اكشف بطن العيان‬ .1
‫ قول للعيان خد نفس جامد وخرجه‬relax abdominal muscles ‫حاول انك‬ .2
‫ مكسوره‬tongue depressor ‫استخدم دبوس او نهاية‬ .3
‫ على الناحيتين‬level ‫ من بره لجوه فى ثالثة‬scratch ‫اعمل‬ .4
 Center :T6-T12
 Upper abdomen : T6-T8
 Middle abdomen T8-T10
 Lower abdomen T10 -T12
 Normal response : contraction of abdominal muscles ± pull of the
umbilicus towards the stimulator
 Significance : leveling in paraplegia

2. Examination of sensory system

1) Superficial 2) Deep sensation 3) Cortical sensation
sensation

133
 1. Superficial sensation
1. Pain 2. touch 3. temperature
‫استخدم دبوس‬ ‫باستخدام انابيب اختيار تحوى ماء استخدم فرشاه او قطن‬
‫بارد وماء ساخن‬

‫ ابدأ من رجلية صاعدا العلى وقوله هاشكك ولما االحساس يزيد قول و شاور‬o
 Compare distal with proximal part of the same limb , after finishing
do the opposite side
 Value : detect the level of stock & glove hyposthesia in peripheral
neuropathy
‫ واطلع حته حته‬very distal ‫أبدأ من ال‬

‫ بتاع الجوانتى والشراب‬level ‫ علشان تطلع ال‬، ‫قول للعيان هشكك ولما االحساس يزيد قول و شاور‬

 Circumferential comparison between lateral , medial, posterior

aspects of the limb , after finishing do the opposite side

2- Deep sensation
1- Sense of 2- Sense of 3- Vibration sense 4- Muscle 5- Nerve sense(
position movement (bone sense) sense(pressure electric sense)
sense)

1- Joint sense
2- Vibration sense

‫طريقة الفحص‬

‫ سليم‬Superficial& Deep sensation ‫الزم يكون ال‬

‫الزم العيان يقفل عينه فى كل الفحوصات‬

diseased ‫ ومتعملش فى الناحية ال‬normal ‫اعمل فى الناحية ال‬

‫شكة بالدبوس ف ايده وقوله الشكة فين‬ 2-tactile discrimination (2 points

‫العيان شكتين فى نفس الوقت‬
‫ سم (ولو فى الزهر‬4 ‫مسافة ما بين الشكتين‬
)‫ سم‬10
‫اسأل العيان دول واحده وال اتنين‬
)‫ حط حاجة معرفة فى ايد العيان ( قلم مثال‬4-graphostbesia
‫واسأله ده ايه‬
134
 ‫ارسم دايرة واكتب رقم ) على كف العيان واسأله انا‬
‫رسمت ايه؟‬
‫شك العيان شكتين بنفس القوه فى نفس الوقت فى نفس المكان على الناحيتين فى كل من كفيه ورجليه‬
‫واسأله حاسس بواحدة وال اتنين‬
‫لو حس باالتنين بقى ‪ cortex‬سليم‬
‫لو حس بشكة واحده يبقى ‪ cortex‬مضروب ‪cortical sensory loss‬‬

‫”‪This chapter is written by “MOA,‬‬

‫‪135‬‬
 For LONG CASE EXAM
THE 4 MAJOR SHEETS

1. PERSONAL HISTORY
Name, sex, age, live, born, occupation, marital status, offsprings, age of the
young offspring, special habits of medical importance” active or passive
smoking, addiction, shisha,…. If the pnt is smoker ask him how many
cigarette per day “the pack=20cigarettes” if he stopped smoking ask him
‫بقالك كام سنة مبطل تدخين؟ وكام سنة كنت بتدخن؟‬
2. MENSTRUAL HISTORY “FEMALES”
1. Age of menarche
2. Regularity “ disturbed or continuous”
3. Duration/cycle “4 days/28 days”

3. HISTORY OF ABORTION

How many times? Is it recurrent or not? “antiphospholipid $

4. HISTORY OF CONTRACEPTION

The method and duration

…………………………………………………………………

HPI “SEE LATER”

PAST HISTORY

 Similar attacks
 DM, HTN
 Hepatitis, TB
 Rheumatic fever, recurrent sore throat, bilharziasis
 Trauma, surgery, blood transfusion
 Fever hospital admission
 Drug ttt, radiotherapy
 Travelling to endemic areas

FAMILY HISTORY

Ask about :

 Similar conditions
136
 Consanguinity
 Hereditary diseases
 DM
 HTN
 ASTHMA
 EPILEPSY
 GOUT

‫ تم بفضل هللا‬,, ‫اللهم لك الحمد‬

^_^

Thank you 

137