How to differentiate between transmitted and expansile pulsations

If you are palpating a swelling like an abdominal swelling infront of the aorta, You have to decide whether the mass you feel is pulsatile/expansile in itself (in which case your fingers will move outwards A ) or whether the pulsation is transmitted through other tissue (in which case your fingers will move upwards B ).See diagram below

Also in transmitted pulsation you can make this pulsation disappear if you can move the swelling away from the aorta ( if you put the patient in the knee-elbow position, an enlarged intra-abdominal swelling which was transmitting aortic pulsation will get away from the aorta and the pulsations will disappear)

How to test Hepatic flap (asterixis)

Ask the patient to stretch out their hands in front of them with the hands dorsiflexed at the wrists and fingers outstretched and separated (see the fig.below).

The patient should hold that position for at least 15 seconds. If flap is present, the patient's hands will move in jerky, irregular flexion/extension at the wrist and MCP joints. The flap is nearly always bilateral. May be subtle and intermittent.
This is characteristic of encephalopathy due to liver failure.
If a sign of hepatic encephalopathy in a patient with previously compensated liver disease, it may have been precipitated by infection, diuretic medication, electrolyte imbalance, diarrhoea or constipation, vomiting, centrally acting drugs, upper GI bleeding, abdominal paracentesis, or surgery.
Source :oxford handbook of clinical examination

Different arterial pulse waveforms and example causes

This is best assessed at the carotid artery. You are feeling for the speed at which the artery expands and collapses and force with which it does so. It takes some practise to master and it may be useful to imagine a graph such as those shown in the figure below,also Some examples are present:

Aortic stenosis: a slow rising pulse, maybe with a palpable shudder. Sometimes called anacrotic or a plateau phase.
Aortic regurgitation: a collapsing pulse which feels as though it suddenly hits your fingers and falls away just as quickly. You could try feeling at the brachial artery and raising the arm above the patient's heart. Sometimes referred to as a waterhammer pulse.
Pulsus bisferiens: a waveform with 2 peaks, found where aortic stenosis and regurgitation co-exist.
Hypertrophic cardiomyopathy: this pulse may feel normal at first but peter out quickly. Often described as jerky.
Pulsus alternans: an alternating strong and weak pulsation, synonymous with a severely impaired left ventricle in a failing heart.
Pulsus paradoxus: pulse is weaker during inspiration (causes include cardiac tamponade, status asthmaticus, and constrictive pericarditis).

Graphical representation of different arterial pulse waveforms and their causes

Inspecting a skin lesion

 # Inspect each lesion carefully and note¦
-Grouped or solitary? Pattern if grouped .
-Distribution/location:

• Symmetrical/asymmetrical?
• Peripheral?
• In only light exposed areas?
• Dermatomal?

-Colour.
-Shape.
-Size.
-Surface.
-Edge.
-Nature of the surrounding skin.

Gynecomastia Versus Pseudogynecomastia

Gynecomastia is defined as a benign enlargement of the male breast resulting from a proliferation of the glandular component of the breast.Gynecomastia can clinically be detected by the presence of a rubbery or firm mass extending concentrically from the nipples.
Although gynecomastia is usually bilateral, it can be unilateral.

Pseudogynecomastia ( also called lipomastia ) is characterized by fat deposition without glandular proliferation.

TO SEE appearance of Pseudogynecomastia in x-ray

CLICK HERE

You can differentiate between true gynecomastia and pseudogynecomastia by a simple test made clinically by having the patient lie on his back with his hands behind his head. The examiner doctor then places a thumb on each side of the breast, and slowly brings the thumbs together. In true gynecomastia, a ridge of glandular tissue will be felt that is symmetrical to the nipple-areolar complex. With pseudogynecomastia, the fingers won't meet until they reach the nipple.

You can click on image to enlarge

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Ellena's Neurological Exam

Video illustration shows neurological examination of infant reflexes.