By

Dr. NAJAM UN NASIR

ASSISTANT PROFESSOR
MEDICINE
THE PERSON WHO CAN
EXPLAIN THE MEANING
OF “ COLOUR” TO A
“BLIND” CAN EXPLAIN
ANY THING IN LIFE.
(UNNAMED)
Clubbing
Upper lid retraction
 Graves‘ disease
 rim of sclera, visible between the lower margin of the
upper lid and the cornea in the relaxed position of
forward gaze
Cushing's syndrome
 Moon face and
 plethora
facial nerve palsy
 faces are asymmetrical
Prognathism n Overbiting lower
teeth
 Malocclusion of the teeth
 In an acromegalic patient, the lower teeth overbite the
upper teeth owing to the prognathism of the lower jaw
Onycholysis
 the nails separate from the nail beds and become thin
and discoloured
 occurs in a variety of dermatological disorders,
particularly in psoriasis
Myxoedema/Hypothyroidism
 There is often some degree of periorbital oedema,
thickening of the nose and lips, malar flush with a
yellowish tinge, sparse hair, and dull eyes with
noncommunicative looks
 The patient is usually excessively clothed, mentally
and physically slow, obese with nonpitting oedema of
the legs and face
Bilateral ptosis
 Causes of ptosis
 Congenital ….Levator muscle/oculomotor nerve
maldevelopment may be unilateral or bilateral
 Local disease…. Dehiscence of levator aponeurosis,
inflammatory (e.g. chalazion, stye),infiltrative (e.g.
amyloidosis, lymphoma,etc.)
 Myopathic… Myasthenia, botulism, myotonic
dystrophy, chronic progressive external
ophthalmoplegia
 Neuropathic Horner's syndrome, oculomotor paresis,
tabes dorsalis, Guillain-Barre syndrome, mid-brain
lesion, facial paresis, frontal lobe lesions
Treatment of myasthenia with
edrophonium
 Before and 1 min after intravenous edrophonium
Right 6th cranial nerve palsy
 Winging of scapula with mild muscular wasting
Measles
 the blotchy erythematous maculopapular rash
 which rapidly coalesces to large, irregular blotches,
appears on the face and trunk
chicken pox (varicella)
 macules, papules, vesicles and .pustules appear
simultaneously on the face and the trunk
Spider naevus
 Although spider angiomas may be present occasionally
in normal subjects (mostly females) without any
reason, they are usually associated with hepatocellular
disease and with hyperoestrogenic states such as
pregnancy and oral contraceptive therapy.
Iron deficiency anaemia
 bald tongue with atrophied papillae and angular
inflammation
Systemic lupus erythematosus
 Butterfly rash distribution
Multiple, creamy
xanthelasma papules
 familial hypercholesterolaemia
Neurofibromatosis
 multiple skin coloured and pinkish papules and
nodules. Note the larger swelling in the neck caused by
a neurofibrosarcoma
Pitting of the nails
 Psoriasis
Down syndrome facies
 Upward slanting, almondshaped eyes with open
mouth
 Prominent epicanthic fold
Marked lid retraction
 thyrotoxic facies.
Angular cheilitis
 An acute inflammation of the lips with painful
fissuring and scaling (cheilitis) at the angles of the
mouth (angular cheilitis, angular stomatitis)

Causes
 physical damage to the lips by sunlight or cold wind.
 Deficiency of the vitamin B complex, especially of
riboflavin
Herpes simplex
 intact vesicle and mucosal ulceration
Haemangioma
Herpes zoster
 involving the eye,
 along the distribution of the ophthalmic branch of the
fifth cranial nerve
 The surrounding skin becomes red and oedematous.
 The pain can be excruciating but sometimes ceases
after the outbreak of the eruption. Unfortunately, in
many patients the pain persists for months and even
years.
Orbital cellulitis
 The redness and swelling seen only on the eyelids
swollen and chemosed eyelids.
 infection spreads most frequently from a nasal sinus
but occasionally it may be caused by a retained foreign
body or a staphylococcal septicaemia.
 retrobulbar neuritis, which may progress to optic
atrophy. Panophthalmitis may develop, with the
danger of extension to the meninges and brain
Raccoon eyes
 Bluish discolouration of the extravasated blood after a
fracture of the anterior cranial fossa
Addison's disease
 Dark palmar creases
 marked pigmentation may also be found on the
exposed areas of the skin such as the fingers palmar
creases elbows
Subconjunctival haemorrhage
 Spontaneous subconjunctival haemorrhages are the
result of the rupture of small vessels from increased
intravascular pressure, during the explosive and
repetitive bouts of coughing associated with
whooping cough and in patients with hypertension.
These haemorrhages also occur in patients with a
blood dyscrasia such as aplastic anaemia and
thrombocytopenia
Arcus senilis
 annular infiltration of lipid in the peripheral rim of the
cornea
 It is an ageing process and usually occurs in the sixth
or seventh decade. It starts as a crescentic grey-white
line at the upper or lower margin of the cornea. It
gradually spreads around the whole cornea as an
annular ring leaving a line of clear cornea between it
and the limbus. Its importance lies in its association
with hypercholesterolaemia and diabetes mellitus
when it appears under the age of 40 years
Yellow discolouration of sclera
Graves' disease
 diffuse enlargement of the thyroid gland
 eye signs
Superior vena caval
obstruction
 engorged jugular veins and suffused face
Von Recklinghausen's
disease (neurofibromatosis)
 Cafe-au-lait spots:
 sharply demarcated, Hypermelanosis macules
Rheumatoid arthritis
 Ulnar deviation of the fingers
 Marked subluxation of the Metacarpophalangeal
joints
Palmar erythema
 Severe liver disease
 Rheumatoid arthritis
Chronic gouty arthritis
 An ulcerated tophus revealing a yellowish-white urate
deposit
tuberous xanthomata
 Familial hypercholesterolaemia:
Heberden's node
 nodular swellings of the terminal interphalangeal
joints
 characteristic features of osteoarthrosis of the hands.
Raynaud's phenomenon
 vasospasm causing pallor of the fingertip
 cyanosed, tapering, sometimes gangrenous fingertips,
with shiny and flattened pulps
Raynaud's disease
 Fingertips with gangrenous areas in the pulps
 Idiopathic Raynaud's disease;
 Occupational causes (e.g. vibrating tools, drills, etc.);
 Systemic sclerosis;
 Connective tissue diseases (e.g. SLE, polymyositis,
 Sjogren's syndrome, rheumatoid arthritis);
 Cervical rib;
 Cryoglobulinaemia;
 Hypothyroidism.
Global wasting of the muscles
of the hand
 Motor neurone disease
 muscular dystrophy
 Charcot-Marie-Tooth disease
 cervical rib syndrome
Vitiligo
 Macular patches of hypomelanosis
Right Bell's palsy
 wide open right eye,
 smooth right face
Left cervical rib syndrome:
 Wasting of the thenar eminance
Claw hand
 The ulnar claw hand affecting principally the fourth
and fifth fingers. Note wasting of the muscles supplied
by the ulnar nerve
Tetany
 Typical carpal spasm (painful flexion of the
metacarpal joints and adduction of the thumb across
the palm
Koilonychia (spoon nails)
 Hereditary and congenital form
 Acquired forms
 Iron deficiency states (e.g. Plummer-Vinson
syndrome, polycythaemia rubra vera)
 Haematological(haemoglobinopathy,haemochromatos
is)
 Infections (e.g. fungal diseases)
 Endocrine disorders (e.g.acromegaly,hypothyroidism);
 Traumatic
 Malnutrition
 Connective tissue diseases
 Dermatoses (e.g. lichen planus, acanthosis nigricans,
Psoriasis
 multiple splinter haemorrhages
'Half-and-half' nails
 Terry's nail
 manifestation of hypoalbuminaemia
 associated with hepatic cirrhosis.
 Half-andhalf nails are found in 10% of patients with
the uraemia of chronic renal failure.
Deep venous thrombosis
 Diffuse swelling of the right leg
Paget's tibia
Paget's disease of bone
 affected tibia is often bent laterally (11.51) with bone
destruction followed by excessive bone deposition, a
high bone turnover, and an increased vascularity,
which is often demonstrable by warmness of the
overlying skin. The condition is often symptomless but
may produce intractable pain.
Effusion of the knee joint
 Effusion of the knee joint in a patient with rheumatoid
arthritis
Oedema
Varicose veins
 tortuous, engorged superficial veins
Cellulitis
 Diffuse swelling and erythema
Shingles
 Herpes zoster along the distribution of nerve
Blue sclera
 Osteogenesis imperfecta
 Albinism
 PKU
Lymphoedema
 Solid ,
 Non-pitting,
 Deforming swelling
Bilateral fluffy shadows in both
lung fields
 Bilateral pneumonia
 ARDS
 Pulmonary oedema
Bilateral fibrocystic changes
 Fibrosing alveolitis
 Cystic fibrosis
 Pneumoconiosis
Pulmonary TB
 Radiograph of a patient with pulmonary TB with left
upper lobe consolidation and cavitation within the
lesion (arrow).
 Left upper lobe collapse. Note the left upper zone
opacity (arrows) and signs of volume loss including
ipsilateral mediastinal shift.
Opacity right lower chest
obliterating right border of
heart
 Right middle lobe pneuonia
 Mass right middle lobe
Bilateral tension pneumothorax
 Bilateral tension pneumothorax due to barotrauma
from positive pressure ventilation. Note the fl attening
of the diaphragm.
 The presence of bilateral abnormality results in no
mediastinal shift.
 Note the collapsed lungs (arrows) and bilateral
hyperlucency
Homogenous opacity in right
upper lobe
 Pancoast tmour
 Aspergilloma
 Secondary deposits
 Consolidation
Multiple air-fluid level in the
right apex
staphylococcus pneumonia
Hydropneumothorax with
collapse
 COAD complicated by right hydropneumothorax. Note
the collapsed right lung (arrows) and the air-fluid level
(arrowheads), and the hyperlucency of pneumothorax
(asterisk).
Pulmonary oedema
 An example of congestive cardiac failure with perihilar
airspace densities in ‘bat’s wings’ distribution
representing pulmonary oedema
Masssive left pleural effusion
 The x-ray shows a homogenous shadow of the left
chest with an area of hyperlucency representing
normal lung surrounded by fluid. The lateral curved
shadow is called the “meniscus sign” and is indicative
of pleural fluid tracking up the side of the lung. The
mediastinum is pushed into the contralateral chest
Pleural effusion
 Total whiteout of a hemithorax. A. Unmarked film of a
massive pleural effusion
Surgical emphysema
Enlarged cardiac
shadow(pericardial
effusion/cardiomegaly)
 Tuberculosis
 CCF
 Hypo thyriodism
 Uremia
 Connective tissue disorders
 Malignancy
Mitral stenosis
Bilateral hilar lymphadenopathy
 Tuberculosis
 Sarcoidosis
 Lymphomas
Tension pneumothorax
 Marked shift of mediastinum to left due to right
tension pneumothorax
Hyperinflated lung fields
 COPD
Cavitation
 Tuberculossis
 Abscess
 Neoplasm
 Infarct
 Rheumatoid nodule
Rounded opacity with intact
demarcation
 Tumour
 Hamartoma
 Carcinoid
Non homogenous opacity right
lung field
 Pneumonia
 Encysted pleural effusion
Right sided pleural effusion
 TB
 Post pneumonic
 Connective tissue disorder
Acute subarachnoid
haemorrhage
 Non-contrast axial CT of the brain shows extensive
acute subarachnoid haemorrhage. Note the
hyperdense blood in the anterior interhemispheric fi
ssure, bilateral Sylvian fi ssures, basal cisterns,
ventricles and cortical sulci and the intraventricular
extension of haemorrhage into the lateral and 4th
ventricles. In simplistic terms, the normal CSF spaces
are ‘black’, but in this case all the CSF spaces are ‘white’
because of the presence of fresh blood.
RT.EXTRADURAL HEMATOMA
 Non-contrast axial CT of the brain showing an acute
right frontoparietal extradural haematoma(arrows)
with mass effect on the underlying brain and lateral
ventricles, midline shift to the left.
 The low density areas (arrowheads) within the
extradural indicate active bleeding.
SOL(abscess/tumour)
 Non-contrast (a) and contrast enhanced (b) axial CT
scans show an area of low attenuation in the right
frontal lobe with rim enhancement (arrows) and
perifocal white matter oedema (arrowheads). Note the
mass effect on the ipsilateral frontal/anterior horn.
Right cerebral infarct
 Non-contrast axial CT scan showing a wedge shaped
area of low attenuation (arrows), with effacement of
underlying cortical sulci, involving both grey and white
matter in the right MCA territory. Also note the mass
effect on the ventricles and contralateral shift. The
diagnosis is an acute right MCA territory infarct. The
arrowheads show a hyperdense thrombus in the
branches of the right MCA.
Cerebral hemorrhage
 Non-contrast axial CT scan showing a right thalamic
and lentiform nucleus haemorrhage (arrow) with
extension of blood into the lateral ventricle. The
location is typical for a hypertensive haemorrhage.
meningioma.
 Non-contrast axial CT showing a densely calcified
mass (arrow) in the posterior fossa on the right
Infarct with bleed
 Non-contrast axial CT scan in a patient with a known
left ACA infarct (arrows) on anticoagulant therapy with
recent clinical deterioration showing the presence of a
haemorrhage in the left caudate nucleus (arrowhead).
Regular sinus rhythm
Sinus brady cardia
Atrial fibrillation
Atrial flutter
1st degree AV block
2nd degree AV block type I
2nd degree AV block type II
3rd degree AV block
PVC’s
Acute inferior wall myocardial
infarction
 ST segment elevation in leads II, III ,aVF
 Reciprocal ST depressions in anterior chest leads
Acute anterior wall MI
 ST elevation in the anterior leads V1 - 6, I and aVL
 Reciprocal ST depression in the inferior leads