Clinical Signs – The Forgotten Art! (Part II)

Introduction

Even with significant advances in medical technology, the first clinical evaluation still depends heavily on bedside examination. The capacity to derive important diagnostic insights from basic physical signs remains a core competency of an effective clinician. However, with increasing dependence on imaging and laboratory investigations, many such signs are no longer routinely elicited, particularly in fast-paced clinical environments.1-3

Unlike classical signs that are often descriptive and occasionally of limited sensitivity, there exists a subset of clinical signs that are highly practical, reproducible, and immediately informative. These signs frequently provide early diagnostic direction, help differentiate between competing clinical possibilities, and, in certain situations, may even obviate the need for urgent investigations.

For postgraduate trainees, mastery of these signs is particularly important. They form the backbone of clinical examinations such as objective structured clinical examinations (OSCEs) and viva voce, and more importantly, they cultivate a disciplined approach to patient evaluation. Recognising a ‘hung-up reflex’, eliciting a ‘Gower’s sign’, or identifying ‘Hoover’s sign’ in suspected functional weakness are examples of how bedside skills can directly influence clinical reasoning.

This review, as a continuation of the earlier discussion on forgotten clinical signs, shifts focus toward twelve high-yield, clinically actionable signs that every postgraduate student should be familiar with. These signs have been selected not only for their diagnostic value but also for their enduring relevance in everyday clinical practice.

Twelve High-Yield Clinical Signs Every Postgraduate

Must Know In modern clinical practice, rapid access to investigations has reduced reliance on bedside examination. However, certain clinical signs remain highly discriminative, elegant, and diagnostically powerful. This curated list highlights twelve such signs across multiple specialities that every postgraduate should confidently elicit and interpret.

1. Hung-up reflex (Woltman’s sign) (Hypothyroidism)

First described by: Henry Woltman.

Finding: Delayed relaxation phase of deep tendon reflex, especially ankle jerk (Figure 1).

Significance: Suggestive of hypothyroidism.

2. Facial (Malar) rash in systemic lupus erythematosus (SLE) (Dermatology/Rheumatology)

Explained in classical dermatology by Ferdinand von Hebra.

Finding: Appearance of a butterfly rash over the cheeks and nose, sparing the nasolabial folds (Figure 2).

Significance: Suggestive of SLE.

3. Gower’s sign (Neurology)

First described by: William Richard Gowers.

Finding: The patient usually uses their hands to “climb up” the thighs while rising (Figure 3).

Significance: It is suggestive of proximal muscle weakness (e.g., Duchenne muscular dystrophy).5

4. Lhermitte’s sign (Neurology)

First described by: Jean Lhermitte.

Finding: An electric shock sensation appears on neck flexion (Figure 4).

Significance: Usually seen in multiple sclerosis and cervical cord lesions.5

5. Cervical venous hum in severe anaemia

Finding: Continuous humming sound over the jugular veins, which is abolished by compression (Figure 5).

Significance: Suggestive of severe anaemia or a hyperdynamic circulation.

6. Hoover’s Sign (Functional vs organic weakness) (Neurology)

First described by: Charles Franklin Hoover (1908).

Method:

• The patient lies supine.
• The examiner places a hand under the heel of the "normal" leg.
• The patient is asked to lift the "weak" leg against resistance.

Findings:

• Organic weakness: Downward pressure is felt under the opposite heel.
• Functional (Non-organic) weakness: No pressure felt.

Principle: Based on crossed extensor reflex and synergistic muscle activation (Figure 6).

Clinical Significance: Differentiates between:

• True neurological weakness
• Functional (conversion disorder) weakness

Clinical Pearl:

“Absence of involuntary extension in the contralateral limb suggests non-organic weakness.”

7. Spider naevi (Hepatology/Pregnancy)

Finding: Central arteriole with radiating vessels (Figure 7).

Significance: Seen in chronic liver disease and pregnancy (hyperestrogenism).3

8. Gingival hyperplasia

Finding: Overgrowth of gums (Figure 8).

Causes:

• Phenytoin
• Cyclosporine
• Leukaemia
• Pregnancy

Significance: Clue to a drug effect or systemic disease.

9. Transillumination test of the testis (Surgery/Urology)

Finding:

• Hydrocele → Transilluminates
• Tumour → Does not transilluminate

Significance: Differentiates cystic from solid scrotal swelling (Figure 9)

10. Courvoisier’s law (Palpable gallbladder) (Surgery)

First described by: Ludwig Courvoisier.

Finding: Palpable gallbladder with painless jaundice (Figure 10).

Significance:Suggestive of malignant obstruction (not gallstones)

11. Argyll Robertson pupil (Neurosyphilis)

First described by: Douglas Argyll Robertson.

Finding:Accommodation present, light reflex absent (Figure 11).

Significance: Classic finding of neurosyphilis.

12. Internuclear ophthalmoplegia (INO) (Neurology)

Described by: David Cogan.

Finding:

• Failure of adduction of one eye.
• Nystagmus of the abducting eye (Figure 12).

Significance: Seen in multiple sclerosis. 9 Figure 11: Argyll Robertson pupil.