2. CLINICAL SKILLS UNIT EDUCATIONAL LOOPS BY CHSE

3. Acknowledgements: All the images have been taken from the following source Diagnosis in colour Physical Signs in General Medicine Second edition Michael Zatouroff Mosby-Wolfe Published 1996 Copyright © Times Mirror International Publishers Ltd.

4. GCE EXAMINATION OF THE HAND  Inspect  Palpate and Feel Test for temperature and for moisture Tenderness Special tests Fists, Flairs and Finger Tests AVOID LISTS WITH THINGS YOU CAN’T EXPLAIN

5. GCE EXAMINATION OF THE HAND AVOID LISTS WITH THINGS YOU CAN’T EXPLAIN DON’T FORGET TO COMPARE THE FINDINGS OF BOTH SIDES

6. INSPECTION Size Symmetry Deformity Tradition and culture Habits or occupation Disorders and Diseases Colour

7. INSPECTION (CAN) BEGINS WITH THE PALM a)Size b)Shape c)Symmetry (left with right and same side) d)Tradition and culture e)Habits or occupation f)Disorders and Diseases g)Colour (palm or finger pulps)

8. TURN THE HAND OVER AND YOU CAN INSPECT BOTH THE NAILS AND THE HAND a)Nails b)Joints c)Lost limbs

9. NAILS AND NAILBEDS a)Allow fingers to be slighted flexed b)Observe nail beds c)Observe any irregularity of nails

10. Temperature can be felt with back of hand or palm Calluses can be felt for with palm Moisture is often detected best with finger pulps (very sensitive)

11. Once seen never forgotten, but seldom seen!! Clear deformity (arthritis mutilans caused by Psoriatic arthritis)

12. MAKE A FIST

13. FINGER FLAIRING

14. THIS TEST IS FOR MUSCULAR AND NEUROLOGICAL INTEGRITY MAKE A FIST THEN MAKE A FLAIR THEN DO THE THUMB-FINGER WALKING TEST

15. SELDOM SEEN TODAY, TABACCO STAINS OF AN ADDICTED SMOKER Note too, badly kept nails suggesting a patient who does not look after himself or herself.

16. Leuconychia – commoner than you think, Cause usually unknown may appear in several different way: Punctate, striate or even complete. This appearance is not at all like the white nails of hypoalbuminaemia or that caused by a fungal infection Striate Leuconychia Punctate Leuconychia

17. NAIL BED PALLOR - ANAEMIA There are two hands here one showing nail bed pallor due to anaemia the other for comparison

18. Leuconychia – (again) Did you see it? And what type?

19. Make sure that what you see in a hand is agreed with by your observations elsewhere Although some laughingly say that they can see pallor where ever it shows itself – be reasonable!!

20. FINGER CLUBBING WHEN MORE ADVANCED THE FINGER ITSELF DEVELOPES A DRUMSTICK APPEARANCE (BELOW) The cause is still uncertain but one suggestion is the release of platelet growth factors from platelet precursors trapped in the nail bed vasculature.