Using your right hand to apply pressure over the patient’s shoulder, feel for the apical lymph nodes using your left hand
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Central group can be felt just below the apical group
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Anterior group can be felt on the anterior axillary fold
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Posterior group can be felt on the posterior axillary fold
↓
Lateral group is felt with examiner’s right hand by palpating over the patient’s humerus
Drainage areas of axillary lymph nodes:
Chest wall with breast
Parietal pleura
Upper limb.
Fig. 2C.36: Method of examining scalene lymph nodes. Fig. 2C.37: Method of examining right apical group (axillary) lym
nodes.
Fig. 2C.38: Method of examining right central group (axillary) lymph
nodes.
Fig. 2C.39: Method of examining right anterior group (axillary
lymph nodes.
Fig. 2C.40: Methods of examining right posterior group (axillary)
lymph nodes.
Fig. 2C.41: Method of examining right lateral group (axillary) lym
nodes.
Fig. 2C.42: Method of examining left apical group (axillary) lymph
nodes.
Fig. 2C.43: Method of examining left central group (axillary) lym
nodes.
Fig. 2C.44: Method of examining left anterior group (axillary) lymph
nodes.
Fig. 2C.45: Method of examining left posterior group (axillary
lymph nodes.
Fig. 2C.46: Method of examining left lateral group (axillary) lymph
nodes.
Fig. 2C.47: Method of palpation of epitrochlear lymph nodes (b
thumb).
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Fig. 2C.48: method of palpation of epitrochlear lymphnodes (b
three fingers).
Epitrochlear Group of Lymph Nodes
Situated on medial aspect of the elbow, about 4–5 cm above the humeral trochlea.
Epitrochlear station drains the lymph from the last two or three fingers and from the medial aspect of
the hand itself.
For examining the right elbow—rest the right elbow of the patient on the right hand palm of the
examiner and feel the lymph node with thumb as shown in the f igure 2C.47 or by placing three
fingers as shown in the f igure 2C.48.
Systemic causes of epitrochlear lymphadenopathy:
Secondary syphilis
Non-Hodgkin’s lymphoma (NHL)
Human immunodeficiency virus
Disseminated tuberculosis
Sporotrichosis
Cat scratch disease.
Inguinal Lymph Nodes
Horizontal group Vertical group
Palpated along the inguinal ligament Palpated vertically downwards from the midpoint of inguinal ligament
Drains:
External genitalia
Scrotum
Perineum
Anal canal below dentate line
Drains:
Lower limb
Popliteal Lymphadenopathy
Palpate the popliteal fossa with the knee in semiflexed position
Systemic diseases associated with enlargement include:
NHL
Disseminated TB
HIV.
Para-Aortic Lymphadenopathy
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Relax abdomen. With 2 hands placed over the epigastrium—one should feel for the enlarged lymph nodes by deep
palpation.
Enlarged in:
Lymphomas
Testicular malignancies
Tuberculosis.
Mesenteric Lymph Nodes
Examined along the line of attachment of the mesentery, from the right iliac fossa medially toward the
umbilicus.
Enlarged in:
HIV
Lymphomas
Ulcerative colitis.
Mediastinal Lymph Nodes
D’Espine sign is a bronchophony/whispering pectoriloquy heard over the vertebral spines (on the
back) below the level of tracheal bifurcation; below the fourth thoracic spine (T4
) in adults.
It indicates tracheobronchial (mediastinal) lymphadenopathy.
Nutritional deficiencies
Vitamin deficiency Manifestation
Fat-soluble vitamins
Vitamin A, Retinol Night blindness, keratomalacia, and Bitot’s spots
Vitamin D, ergo/cholecalciferol Rickets/osteomalacia
Bone pain, costochondral beading
Proximal myopathy
Vitamin E, tocopherol Hemolysis, posterior column signs, ataxia, muscle wasting, retinitis pigmentosa-like
changes, and night blindness
Vitamin K, phylloquinone, and other menaquinones
Bruising, purpura, nose, and GI bleeds
Water-soluble vitamin (B-complex and vitamin C)
B1
(Thiamine) Wernicke/Korsakoff
Beriberi
Nystagmus
Sixth cranial nerve palsy
Ataxia
Acidosis
Dementia
Paraesthesiae
Neuropathy
Cardiac failure
Anemia
B2
(Riboflavin) Ariboflavinosis
Angular stomatitis, glossitis, and magenta tongue
B3
(Niacin) Pellagra
Dermatitis on sun-exposed areas
Dementia
Poor appetite, difficulty sleeping
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Confusion, sore mouth
B4
(Adenine)* Immune dysfunction
Aging
B5
(Pantothenic acid) Nausea
Abdominal pain
Paraesthesiae, burning feet
B6
(Pyridoxine) Poor appetite
Lassitude
Oxaluria
B7
(Biotin) Dermatitis,
Depression, lassitude,
Muscle pains,
Electrocardiogram abnormalities, blepharitis
B8
(Inositol)* Depression and other psychiatric manifestations
B9
(Folic acid) Macrocytic anemia,
Thrombocytopenia and
Megaloblastic bone marrow
B10
(PABA)* Free radical damage
Sun burns and skin rashes
B11
(Salicylic acid) * Works in tandem with vitamin B12
B12
(Cobalamin) Subacute combined degeneration of spinal cord
Macrocytic anemia, icterus, knuckle pigmentation
Vitamin C (Ascorbic acid) Scurvy
Poor wound healing, fatigue, limb pain, scorbutic rosary
Difficulty sleeping, gingivitis, perifollicular purpura
Hyperkeratosis
* Vitamin B4, 8, 10, and 11 are no longer labeled as vitamins, as they do not fit the official definition of vitamin.
Minerals
Iron Koilonychia
Smooth tongue
Anemia
Esophageal web
Copper Microcytic hypochromic anemia
Neutropenia
Scurvy-like bone lesions, osteoporosis
Zinc Acrodermatitis enteropathica
Peristomal/perinasal/perineal
Erythema, thin hair
Diarrhea, apathy, anorexia
Growth failure
Hypoglycemia
Distorted or diminished taste (hypogeusia)
Chromium Peripheral neuropathy, hyperglycemia
Selenium Cardiomyopathy
Iodine Goiter
Others
Protein deficiency Pitting edema
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Hair: thinning, easily pluckable with dyspigmentation or flag sign, and change in
texture to silken, sparse hair.
Dermatosis with desquamation of the so-called flaky-paint type, with or without
hyperpigmentation
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D. ANTHROPOMETRY
HEIGHT
Method of measurement of length/height
Recumbent length (Fig. 2D.1) is measured using an infantometer with a fixed head piece and
horizontal backboard, and an adjustable foot piece. The recorder supports the child’s head while
the examiner positions the feet and ensures that the head lies in the Frankfort horizontal plane.
Standing height (Fig. 2D.2) is an assessment of maximum vertical size. This stature measurement is
collected on all sample persons (SPs) aged 2 years and older who are able to stand unassisted.
Standing height is measured using a stadiometer with a fixed vertical backboard and an adjustable
head piece. Instruct the SP to stand with the heels together and toes apart. The toes should point
slightly outward at approximately a 60°angle. Check that the back of the head, shoulder blades,
buttocks, and heels make contact with the backboard.
Short Stature
Short stature is defined as a height that is below the 2.5th percentile or two or more standard deviations
below the mean for age and gender for a given population. A growth velocity that is below the 5th
percentile for age and gender is called growth deceleration (e.g. <5 cm/year after the age of 5 years).
Dwarfism is defined as short stature for the age of the patient. Most common causes of dwarfism are
familial short stature and constitutional delay of growth and puberty.
Fig. 2D.1: Measurement of recumbent length.
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Fig. 2D.2: Measurement of vertical height.
Cause of short stature
Constitutional (hereditary) Gurkhas, African pygmies
Endocrine Cretin (ratio between upper and lower segments is ≤1 with mental retardation)
Pituitary dwarf (short limbed, normal intelligence but may be associated with infantilism)
Froehlich’s syndrome (obese, diabetes insipidus, hypogonadism)
Cushing syndrome
Genetic Turner syndrome
Noonan syndrome
Hurler’s syndrome
Morquio’s syndrome
Multiple lentigines syndrome
Skeletal Ellis–Van Creveld syndrome (chondrodystrophic dysplasia, short arms, and legs)
Achondroplasia (short and bowed legs and arms, waddling gait)
Osteogenesis imperfecta
Acquired (in children) Rickets
Pott’s spine
Note: For detailed list and differential diagnosis of short stature refer to page No. 74–75 in Exam
Preparatory Manual for Undergraduates by Archith Boloor.
Tall Stature
When the height of an individual is far in excess of the average normal for the age and race (≥2
standard deviation of the mean height), the individual is considered to be tall in stature.
Causes of tall stature
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Tall stature with equal upper and lower segments or
equal arm span to height ratio
Tall stature with unequal upper to lower segment (ratio of ≤0.8) or arm
span to height (ratio of ≥1.05)
Constitutional tall stature
Pituitary giants
Sexual precocity
Thyrotoxicosis
Marfan syndrome (MFS)
Homocystinuria
Klinefelter’s syndrome
ARM SPAN
Method of Measurement of Arm Span
It is the distance between the tips of the middle fingers of one hand to the other when held abducted in
horizontal plane. The arm span to height ratio is normally equal or ≤1.05.
Clinical implication of arm span versus height ratio:
Age Ratio
At birth The arm span is typically less than length (by at least 2.5 cm)
10 years of age in boys and 12 years of age in girls The arm span exceeds height
Cause of increased arm span-height ratio:
Klinefelter syndrome
Homocystinuria
Marfan’s syndrome
Sotos syndrome
Hypogonadism
UPPER SEGMENT AND LOWER SEGMENT
Method of Measurement
The upper segment of the body is measured from the top of the head to pubic symphysis/pubic ramus
and the lower segment is measured from the pubic ramus to the floor.
Clinical implication of upper segment:lower segment (US:LS) ratio:
Age Ratio
Birth 1.7
3 years 1.33
5 years 1.17
10 years 1.0
>10 years <1.0
Causes of increased and decreased US:LS ratio:
Increased US:LS ratio Decreased US:LS ratio
Children with rickets, achondroplasia, and Turner syndrome (because of
decreased limb length)
Marfan syndrome (because of increased limb
length)
SKINFOLD THICKNESS
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