The Hands and the Tongue
Lets look at the patient, not just the Labs, images, EKGs,
i.e. Expanding our physical exam skills and findings:
The Hands:
Examination of the hand can reveal several physical
findings helpful for diagnosis
Start the exam with the Handshake:
Moist and warm hands think….
nervousness, thyrotoxicosis
 look for tremor, eye signs
Inability to let go your hand think….
Myotonia
Look for other signs of myotonic dystrophy:
 hatchet face, cataracts, baldness, myopathic facies
Physical Examination:
Inspection
Palpation
Range of motion
Stability
Muscle and Tendon Function
Nerve Assessment
Vascular Assessment
Integument Assessment
Inspection: Look For….
Discoloration
Deformity
Muscular atrophy
Trophic changes (sweat pattern, hair growth)
Swelling
Wounds or scars
Also: compare to normal hand
Discoloration:
Redness: cellulitis
White: arterial blockage
Blue/purple: venous congestion
Patches of blue/purple: trauma
Black spots/lines: rule out melanoma
Other color producing processes:
fungi, viruses, psoriasis
Osteoarthritis:
Heberden’s nodes: DIP
Bouchard’s nodes: PIP
Rheumatoid Arthritis
Boutonniere deformity:
flexion of PIP and extension of DIP
Swan neck deformity:
extension of the PIP, flexion of DIP
Dupuytren’s Contractures:
Palmar or digital fibromatosis
Flexion contracture
Painless nodules near palmar crease
Male> Female
Epilepsy, diabetes, pulmonary dz, alcoholism
Mallet Finger
Hyperflexion injury
Ruptured terminal extensor mechanism at DIP
Incomplete extension of DIP joint or extensor
lag
Treatment: stack splint
Muscle Atrophy:
Generalized: may indicate disuse
Specific muscle groups:
suggest nerve pathology
 Thenar atrophy: carpal tunnel syndrome
 Interossei atrophy: cubital tunnel or cervical spine
problem
Subcutaneous atrophy:
often after local steroid injection
Range of Motion
Assessment
Nerve Assessment
Radial: test dorsal thumb-index web space
Median: test palmar surface of index or thumb
Ulnar: test palmar aspect of little finger
Digital nerves: test each the radial and ulnar side
of each fingertip on the palmar aspect
Proximal median nerve
dysfunction
Thenar atrophy, inability to
flex 1st & 2nd fingers at PIP

aka Pope’s Hand or Hand of Benediction
Ask patient to use both hands to make and
“Okay” sign by forming a circle with thumb
and index finger
Median nerve palsy may make
one hand produce a pinched circle
Ulnar nerve damage
hypothenar atrophy and inability
to flex 4th & 5th digits at the PIP
aka Claw Hand
Froment’s Sign:
Ask patient to hold a piece of paper between thumb
and index finger
If you can pull paper away (a positive Froment’s
sign), it suggests that an ulnar palsy has weakened
the thumbs strength of opposition
Special Tests: Finkelstein’s
Used to test for deQuervain’s tendonitis
inflammation of the EPB and APL
tendons in the 1st extensor
compartment
Patient is asked to make a fist with
the fingers overlying the thumb
Examiner then ulnarly deviates the wrist (gently)
Positive findings: pain along the 1st compartment
Special Tests: Tinel’s
A provocative test for carpal tunnel syndrome
The examiner percusses with two
fingers directly over the distal palmar
crease in the midline
Positive test: patient reports paresthesias in
the median distribution when the nerve is
percussed
Special Tests: Phalen’s
A provocative test for carpal tunnel syndrome
The patient’s wrist is held in maximum flexion for two
minutes
Positive test: patient reports paresthesias in the
median distribution
Special Tests: Allen’s
Tests ulnar and radial artery blood flow
Patient makes a tight fist and examiner manually
occludes both radial and ulnar artery
Examiner releases one of the vessels and examines
for reperfusion in the long finger
Abnormal test:

hand reperfusion > 5 seconds
Test is repeated for the other artery
Nail Abnormalities:
Clues to Systemic Disease
Clubbing:
First described by Hippocrates in 5th century B.C
thickening of the soft tissue beneath the proximal nail
plate that results in sponginess of the proximal plate and
thickening in that area of the digit
Important causes of clubbing
Lungs:
LUNG CANCER
clubbing is in general an ominous sign for this
“beware of the yellow clubbed digit”
 Yellow from nicotine, and clubbed from cancer
PUS in the lung
bronchiectasis as in CF
Lung abscess and empyema
FIBROSIS
but has to be considerable fibrosis to do this
COPD IS NOT A CAUSE OF CLUBBING
even though some textbooks say so–if it were clubbing
would be a pretty useless sign, and many VA patients
would have clubbing, but they don’t
Important causes of
clubbing
Heart Causes:
R to L shunts, Endocarditis, Pericarditis,
atrioventricular malformations
There are other causes of clubbing, outside the
heart and lungs
Inflammatory bowel disease, cirrhosis, congenital
heart disease, fistulas
Pseudoclubbing:
distinguished from clubbing by the preservation of
the nail-fold angle and bony erosion of the
terminal phalanges on radiography
changes in fingers are the result of soft-tissue
collapse owing to severe bone erosions of the
terminal phalanges
Pitting:
caused by defective layering of the
superficial nail plate by the proximal nail matrix
any localized dermatitis (e.g., atopic or chemical
dermatitis) that disrupts orderly growth in that area also
can cause pitting
Psoriasis, Reiter’s syndrome, incontinentia pigmenti,
alopecia areata
usually is associated with psoriasis
 affecting 10 to 50 percent of patients with that disorder
Paronychia:
Inflammation of the nail folds–red, swollen, often
tender
Frequent immersion in water a risk factor for chronic
paronychia
If an abscess has formed, the recommended
treatment is to drain the abscess by doing an I&D
Herpetic Whitlow:

Occupational hazard for respiratory therapists
and housestaff who work around oral secretions
HSV-1 is the cause in ~ 60% of cases
HSV-2 cause in the remaining 40%
Diagnosis usually is clinical
Definitive diagnostic testing includes:

Tzanck test, viral cultures, serum antibody titers, fluorescent antibody
testing, or DNA hybridization
Self-limited disease
Treatment often is directed toward symptomatic relief
Use antibiotic treatment only in cases complicated by bacterial
superinfection
Acral lentiginous
melanoma
Accounts for about 2-3% of all melanomas
most common type of malignant melanoma among
Asians and dark-skinned individuals, with a particular
predilection for the soles of the feet
The involvement of the proximal nail fold (Hutchinson’s
sign) is considered
a clue to the diagnosis
Koilonychia:
represented by transverse and longitudinal concavity of the
nail -resulting in a “spoon-shaped” nail
Iron deficiency anemia, hemochromatosis, Raynaud’s
disease, SLE, trauma, nail-patella syndrome
Yellow nail:
Associated with:
Lymphedema, pleural effusion, immunodeficiency,
bronchiectasis, sinusitis, rheumatoid arthritis,
nephrotic syndrome, thyroiditis, tuberculosis,
Raynaud’s disease
yellow nail syndrome:
Triad of yellow slow-growing nails, lymphedema,
and pleural effusions
Splinter hemorrhage
longitudinal thin lines, red or brown in color, that
occur beneath the nail plate
Subacute bacterial endocarditis, SLE, rheumatoid
arthritis, antiphospholipid syndrome, peptic ulcer
disease, malignancies, oral contraceptive use,
pregnancy, psoriasis, trauma
Tongue
The tongue manifests the features
of many systemic illnesses and is a
natural site for oral pathology
On physical examination, there are several
characteristics that should be noted
Color
Texture
Size
Physical Examination:
Normal tongue
Dorsal surface
Pinkish-red color
Rough-appearing texture on the dorsal surface due
to the presence of papillae
three varieties with different sizes
Ventral Surface
similarly be pinkish-red
some vasculature may be visible
Tongue should fit comfortably in the mouth with
the tip against the lower incisors
Physical Examination: Normal tongue
Examination of the tongue should occur in the
following steps:
Have the pt touch the tip of the tongue to the roof of
their mouth and inspect the ventral surface
Have the pt protrude the tongue straight out and
inspect for deviation, color, texture, and masses
With gloved hands, hold the tongue with gauze in one
hand while palpating the tongue between the thumb
and index finger of the other, noting masses and
areas of tenderness
Physical Examination:
Normal tongue
Abnormal Tongue
Findings:
Smooth Tongue:
Most common cause is the use of dentures
Can also be a late sign of iron, folate, Vit B12 deficiency
Glossitis may also cause the tongue to appear smooth
Among women, low-estrogen states may cause a
“menopausal glossitis”
Discolored Tongue:
Due to a variety of conditions
Micronutrient deficiencies is perhaps the bestknown of these
B12 deficiency-> causing a sore, beefy-red tongue
Pellagra-> causing a black tongue
Geographic tongue:
Benign condition in which discolored, painless
patches of the tongue appear and then reappear,
often in a different distribution
Hairy Tongue:
Best-known condition causing the tongue to
appear hairy is Oral Hairy Leukoplakia
A black, hairy tongue consistent with aspergillus
overgrowth
Ulcers: Many different
causes
Inspecting ulcers, it is important to note:
size, number, color, distribution, and whether or not they
cause the patient any discomfort
Of particular concern is a single erythematous, often
painful ulcer that does not heal
May indicate that the patient has lingual or oral cancer
particularly if the patient uses tobacco and/or alcohol
Patient history and risk factors are important to note in
these cases
Aphthous ulcers:
Painful form of ulcer that is
most frequently encountered
Minor aphthous ulcers:
usually 2-8mm in size, spontaneously heal w/in 14 days
Major aphthous ulcers:
>1cm in size and may scar when they heal
Herpetiform ulcers:
pin-point size, often multiple, and may coalesce to form a
larger ulcer
These ulcers may result in odynophagia when they
occur toward the posterior surface of the
oropharynx
Microglossia:

May result from pseudobulbar palsy, the result of damage
to the upper motor neurons of the corticobulbar tracts that
innervate the tongue

This results in a small, stiff tongue
There may be an apparent microglossia resulting from
ankyloglossia, a congenitally short lingual frenulum
commonly called a “tongue tie”
Macroglossia:
Exam should include palpation of the sublingual
glands, will be displaced in true macroglossia


Macroglossia maybe congenitally present in acromegaly
New-onset macroglossia in an adult is essentially
pathognomonic for amyloidosis and should be treated as
such until proven otherwise
Fasciculation:
Indicative of lower motor neuron injury
May present with dysarthria or dysphagia
Amyotrophic lateral sclerosis is of particular concern
with new-onset of these
Can cause atrophy of tongue