Interactive Guide to Physical Examination
calculating ability: Calculating ability may be useful to evaluate dementia. However, an individual's education and life experience may influence performance. To test for this, ask the patient to perform a straightforward computation problem (e.g. "What is 6 plus 3?"). Go to page
carotid artery, bruit of: A bruit refers to an audible sound resulting from turbulent blood flow. Carotid bruits may indicate accelerated blood flow in the artery because of kinking or may represent atherosclerotic disease of the carotid. A carotid bruit in an otherwise asymptomatic patient is thought to be a poor indicator of the risk for cerebrovascular accidents however. In contrast, patients with carotid artery atherosclerosis are more likely to die of ischemic heart disease than of cerebrovascular disease. Go to page
carotid impulse:
hyperkinetic: A hyperkinetic impulse suggests a widened pulse pressure and increased left ventricular stroke volume. This can be seen in high cardiac output states such as anxiety, anemia, thyrotoxicosis, patent ductus arteriosis in children, or systemic arteriovenous fistulas. Classically, this can also be seen in aortic regurgitation where a large volume of blood is ejected forward during systole but then regurgitates back into the ventricle during diastole. Go to page
hypokinetic: A hypokinetic pulse may be the result of a reduction in left ventricular stroke volume such as in volume depletion, myocardial infarction with poor ventricular pumping function, any cause of shock or low blood pressure. The examiner should however distinguish this pulse from pulsus parvus et tardus. Go to page
chest, shape of: The shape of the chest may affect the mechanics of respiration. Severe kyphosis may impede respiratory expansion and cause distortion of underlying sounds so that interpretation of auscultory findings may be difficult. With aging there is an increase in the anteroposterior diameter leading to softer breath sounds. This may also be seen in chronic obstructive lung disease. Go to page
choreiform movements: Choreiform movements are rapid, jerky, purposeless movements of various parts of the body. Classically this may involve the hands, legs, or face. There are both acquired and hereditary forms. Classic manifestations of chorea can be seen in adults with Huntingtons Disease. In children, cerebral palsy is a common cause of chorea. Go to page
chronic fibrotic lung disease: Chronic fibrotic lung disease is a spectrum of disorders with different etiologies. They are similar in that the pathologic changes primarily affect the interstitial tissue leading to necrosis, scarring, and fibrosis. The lungs become "stiffer" and pulmonary expansion therefore becomes limited.
clonus: Clonus may be elicited at any joint, however the easiest to test and visualize may be at the ankle joint. Support the knee in a partly flexed position. Briskly dorsiflex the foot and maintain it in dorsiflexion. Normally this does not elicit any particular response. With central nervous system disease you may feel a rapid, rhythmic, beating of the foot against your hand as it moves between dorsiflexion and plantar flexion. It is this abnormal rhythmic beating that is termed clonus. Go to page
clubbing: Clubbing is due to subungual proliferation of tissue between the nail plate and the bone, resulting in floating of the nail or a spongy feeling at the nail plate and obliteration of the unguophalangeal angle. Clubbing may be seen in the setting of various pulmonary diseases as well as other systemic conditions. Go to page
coma: A comatose patient is unarousable despite noxious or painful stimuli. They do not respond at all to events or stimuli in the environment. Go to page
consciousness, level of: Level of consciousness is assessed by evaluating the patient's ability to respond appropriately. Lethargic patients are drowsy, are arousable, but fall asleep easily. They will look at the examiner and respond appropriately to questions. Obtunded patients are aroused with effort, will look at the examiner and respond, but respond slowly and often inappropriately. They show evidence of confusion and are unaware of their surroundings. Stuporous patients are only aroused with painful stimuli (rubbing the sternum or pinching an arm), and lapse into unresponsiveness as soon as the painful stimulus is removed. Comatose patients are entirely unarousable, do not open their eyes nor respond in any way. Go to page
constructional ability: Ask the patient to copy a picture (for example a diamond or a cube) or draw the face of a clock and place the hands at a specified time. This ability may be impaired with impairment of motor function, even from arthritis. However, assuming normal motor function and vision, your patient should be able to do this accurately. With dementia or parietal lobe lesions the patient will demonstrate poor constructional ability. Go to page
contraindicated: Dilation of pupils with a mydriatic agent is contraindicated if the patient has had cataract surgery and a lens implant, if there has been recent head trauma such that following pupillary reactivity is essential, or if there is suspicion of narrow angle glaucoma. Glaucoma is suspected if the patient has symptoms or a history of this, or if you have found physical examination evidence (a red eye or bowing of the iris). Go to page
copd: Chronic obstructive pulmonary disease is characterized by increased resistance to airflow during expiration with resultant airtrapping and an increase in residual volume. As a result, the lungs are hyperinflated and therefore may move only marginally with deep inspiration. In addition, there is usually hyperresonance to percussion over these overinflated lungs. Go to page
cornea, opacities of: Opacities of the cornea may suggest the presence of cataracts. Go to page
crackles: Crackles, or rales, are brief, nonmusical, discontinuous sounds. They may be high or low pitched and tend to be heard during inspiration. They may be indicative of fluid or infection in the alveolar spaces, or of inflammation of the interstitium. The latter tend to be very fine, high-pitched, "velcro" like sounds. If the rales clear with coughing, this suggests they are due to secretions in the airway such as can be seen in bronchitis or with prolonged recumbency. Go to page
cranial nerves, well defined syndromes of: There are several well defined syndromes of cranial nerve defects. Unilateral deficits involving CN V, VII, and VIII are suggestive of a lesion or tumor at the cerebellopontine angle. Unilateral deficits involving CN III, IV, V1, and VI are suggestive of a cavernous sinus lesion. A unilateral deficit of CN VI and VII suggests a lesion in the pons where CN VII loops over the VIth nucleus. Go to page
cyanosis: Cyanosis is a blue discoloration of the skin or appendages due to excessive concentration of reduced hemoglobin in the blood. Cyanosis is most easily observed around the lips or at the fingertips and under nailbeds. Go to page
