"Patients will judge you not by the number of diplomas on the wall but by the manner and ease you do the least maneuver"


- William Osler

Dr. Verghese's Lab Coat

Neck Veins

Head/Neck - part 1

Hand Exam

Head/Neck - part 2

Fixed Split Second Heart Sound

Head / Neck

Submandibular Gland

  • V – Vascular

    • hemangiomas​

  • I – Inflammatory (Acute sialadenitis)

    • viral

      • mumps, HIV, coxsackievirus, parainfluenza types I and II, influenza A, and herpes

    • bacterial

      • ​Staphylococcus aureus, Streptococcus viridans, Haemophilus influenzae, Streptococcus pyogenes, mycobacterial (typical and atypical), cat-scratch disease (Bartonella henselae) and Escherichia coli

    • fungal

      • actinomycosis​

    • obstruction (stone, stricture, tooth brush bristles, finger nails)

    • sarcoid

  • N – Neoplastic (likely to be malignant)

    • pleomorphic adenoma (malignant transformation risk)​

    • Warthin tumor

    • Hodgkin's and non-Hodgkin's lymphomas

    • cystic metastases from squamous cell carcinoma within Waldeyer's tonsillar ring

    • Castleman's disease

  • D – Degenerative / Deficiency

  • I – Idiopathic, Intoxication

  • C – Congenital

    • ​Branchial anomalies 

      • ​cysts, sinuses, and fistulae

    • cystic hygromas (lymphangiomas)

    • dermoids

  • A – Autoimmune / Allergic

    • ​Sjögren disease

    • Heerfordt syndrome

  • T – Traumatic

  • E –  Endocrine

    • diabetes​

    • hypothyroidism

    • malnutrition

Neck Veins


  • JVP?

  • waveforms?

  • find pulsation of neck veins

    • venous will have a bifid quality that changes with respiration and position of the bed

    • arterial waveform is palpable

  • a wave:

    • atrial contraction

    • occurs before S1

  • v wave

    • AV valve bulging into atrium

    • after S1

  • draw a line from sternal angle, measured in cm and add 5cm to it

Hand / Nails

Hand is examined

  • feel the pulse (rate, rhythm, volume)

  • feel the temperature (warmth, sweaty)

  • cyanosis?

  • feel for Dupuytren's contracture

  • feel epitrochlear nodes

Finger Nails




Beau's lines

  • caused by diseases that cause ALL of the nails to grow slowly or even cease to grow for short intervals

  • the transverse grooves (the point of arrested growth) is parallel to the lunula

    • coronary occlusion

    • hepatic disease

    • anti-cancer agents

    • renal disease 

    • infections


Mees' bands

  • white tranverse line or bands (instead of grooves) also parallel to the lunula

  • nails grows 1mm per week (measuring the width of these lines can help determine the duration of the antecedent acute illness

    • posioning (chronic arsenic posioning)

    • acute systemic illness​


Thenar Atrophy


Interossei Atrophy

  • cubital tunnel or cervical spine problem

Palmar erythema

  • portal hypertension

  • chronic liver disease

  • thyrotoxicosis

  • polycythemia

  • rheumatoid arthritis

  • hand-foot-mouth disease (Coxsackievirus A)

  • rocky mountain spotted fever

  • secondary syphilis

  • Kawasaki disease

Neck Veins


Cardiac Auscultation

  • Split S2 

    • RBBB

    • infundibular pulmonary stenosis

    • pulmonary HTN

    • atrial septal defect (fixed)

    • right heart failure (fixed)

  • Fixed Split S2

    • listen over pulmonic region

  • Loud P2

    • pulmonary hypertension

    • atrial septal defect


  • Percussion

Breathing Pattern

Biot's breathing

  • hypercapnea/hyperventilation and apnea (can be regular or irregular)

  • shallow breaths

  • seen with pons damage

  • poor prognosis

Cheyne -Stokes

  • crescendo/decrescendo with some regularity

  • DDx: 

    • pontine damage​

    • CHF

    • CVA

    • meningitis


  • hyperpnea seen with acidosis, rapid, deep and labored breathing

  • DDx: 

    • DKA​

    • uremia

Ataxic Breathing

  • irregular breathing with very long apneic pauses

  • shallow and deep respiration

  • steady deterioration 

  • medullary damage

  • DDx: strokes, traumas

... but I would more especially commend the clinician who, in acute diseases, by which the bulk of mankind are cutoff, conducts the treatment better than others.
Hippocrates, 400 BC