The thyroid gland: history and examination

By Vinod Ramachandran

Year 3, Monash University Malaysia

23 Mar 2016


This article is titled “History and examination of the thyroid gland”. It has a definite focus towards a patient with a thyromegaly, but it can also be considered a guide to the history and presentation of a patient with a swelling in the neck.


    Demographic details

  1. Age
  2. Simple goiter; girls approaching puberty and pregnancy; multinodular, solitary nodular goiters and colloidal goiters; women in their 20s and 30s; Papillary carcinoma; young girls; follicular carcinoma; middle aged women; Anaplastic carcinoma; old age; Hashimoto’s disease; middle aged women

  3. Sex
  4. Majority of thyroid disorders are seen in women. Thyrotoxicosis is much commoner in females than in males; Thyroid carcinomas occur three times more often in females

  5. Occupation
  6. Thyrotoxicosis may appear in individuals working under stress & strain

  7. Residence
  8. Endemic goiter due to iodine deficiency. Certain areas known to have low iodine content in the water and food


  9. Swelling
  10. How to take a history of swelling is described in the presentation titled “Mass, history and examination”. The same questions should be asked, including onset, duration, rate of growth, and appearance of symptoms such as pain. Does it cause symptoms that relate to pressure effects on nearby structures? A swelling that appears after trauma may be a hematoma, not a thyroid swelling. Benign swellings grow slowly; malignant swellings (like an anaplastic cancer of the thyroid) usually grow faster. Note that papillary cancers of the thyroid usually grow slowly. Goitres are painless, unless the patient has thyroiditis. Anaplastic carcinomas infiltrate surrounding structures and often cause pain.

    Special features of neck swellings

  11. Adjacent structures: trachea, esophagus, recurrent laryngeal nerves
  12. Ask about the effect of the swelling on the

    a. trachea, causing breathing difficulty and stridor.

    b. esophagus, causing dysphagia.

    c. recurrent laryngeal nerve, causing hoarseness.

    The thyroid may also press on the carotid, but that will be evaluated during examination.

  13. Hyperthyroidism and hypothyroidism
  14. In a patient with a neck swelling that may be the thyroid gland, look for symptoms of hyperthyroidism and hypothyroidism

    Hyperthyroidism: Heat intolerance, raised appetite, weight loss, sweating, palpitations, tiredness, agitation/nervousness, dyspnea; also diarrhea, menstrual changes (commonly amenorrhea), insomnia

    Hypothyroidism: Weight gain, loss of appetite, constipation, cold intolerance, hoarseness of voice, decreased hearing, hair loss, dry skin, hand pain (carpal tunnel syndrome), angina pectoris, intellectual/ motor slowing (excessive sleeping), muscle cramps, (commonly menorrhagia)

    Past, treatment, family, and dietary history

  15. Medications
  16. Ask about treatment the patient has taken, and its effects on the swelling. Drugs (some may be goitrogenic)

  17. Family history
  18. Some thyroid disorders have a familial predilection.

  19. Dietary history
  20. Dietary habits are important as vegetables of the brassica family (cabbage, kale, rape) are goitrogens. If there is insufficient iodine in the diet, an iodine-deficiency goiter may develop.


    General physical examination

  21. Body habit
  22. Patients with thyrotoxicosis are usually thin and underweight. Patients with hypothyroidism are usually obese and overweight. In case of carcinoma of thyroid; signs of anaemia and cachexia may be present, especially with anaplastic cancers. Patients with early papillary cancer are usually well-preserved.

  23. Alertness and motor activity
  24. Patients with thyrotoxicosis may show hyperkinetic movements. Voice changes may occur with hypothyroidism, and with thyroid cancers.

  25. Hands
  26. Patients who are hyperthyroid may show features such as fine tremors, onycholysis, palmar erythema, warm and sweaty palms, and clubbing. Xanthomas, cool and dry palms, and cyanosis suggest hypothyroidism.

  27. Vital signs
  28. Pulse and blood pressure: Tachycardia and other arrhythmias occur in hyperthyroidism, while bradycardia and hypotension indicate hypothyroidism.

  29. Eyes
  30. The eye signs of hyperthyroidism include exophthalmos, chemosis, conjunctival injection, corneal ulceration, opthalmoplegia, lid-lag, lid retraction, and others. The eye signs of hypothyroidism include periorbital edema, loss of outer third of eyebrows, and xanthelasmas near the eyes.

  31. Face
  32. Patients with hypothyroidism may have dry skin and hair, and yellow discoloration of the face and palms due to hypercarotenemia that results from slowing down of hepatic metabolism of carotene.



  33. Mass
  34. Inspect the swelling as for a mass. Note the location, size, shape, surface, edges, margins, overlying skin, pulsatility, and adjacent structures (particularly the trachea). Dilated veins may indicate compression of the superior vena cava.

  35. Four special features of neck swellings
  36. Inspect the swelling for:

    a. Look for movement with swallowing. You may need to ask the patient to swallow some water.

    b. Thyroglossal cysts (but usually not the thyroid glands) move with protrusion of the tongue.

    c. Look at the adjacent structures, especially the trachea.

    d. Look for pressure on the thoracic inlet (Pemberton’s test).


    Palpate from behind.

  37. Mass
  38. Palpate the swelling as for a mass. Note the tenderness, temperature, location, size, shape, surface, margins, edges, fixity, consistency, and thrill. Consider fluctuation and transillumination. Tenderness indicates thyrotoxicosis. A raised temperature indicates inflammation: thyrotoxicosis, or an abscess. Thrills occur in thyrotoxicosis. Be sure to check if you can get below the gland.

    The “Lahey’s test” is a palpation of the thyroid from the front. Its objective is to feel the posterior part of the gland.

  39. Three special features of neck swellings
  40. Inspect the swelling for:

    a. Examine the trachea.

    b. Perform Kocher’s test.

    c. Feel the carotid (Berry’s sign).


  41. Percuss the swelling for one special feature of a neck swelling
  42. Although most swellings do not need percussion, there are some exceptions (e.g. a suspected kidney mass). In neck swellings, one should percuss the upper sternum for a possible retrosternal extension of the goiter.


  43. Auscult the swelling, as any other mass. Look for a bruit. Toxic thyroids may produce bruits. Carotid body tumors of the neck (which are, of course, not related to thyroids) also produce bruits.
  44. Nodes

  45. Cervical lymph nodes
  46. Always examine the cervical nodes.

    Examination for thyroid function

  47. Hyperthyroidism
  48. Evaluate the patient for hyperthyroidism. The commonest features of hormonal dysfunction are in the eyes, which have already been examined during general physical examination. Other general features of hyperthyroidism include pretibial myxedema.

  49. Hypothyroidism
  50. Evaluate the patient for hypothyroidism .

    Examination of other systems

  51. Neurological examination
  52. Patients with hyperthyroidism may have neurological changes such as anxiety, proximal muscle weakness, and increased tendon reflexes. Patients with hypothyroidism may have changes such as mental dullness (even coma), hearing loss, and decreased tendon reflexes.

  53. Examination of the rest of the body
  54. The other systems: cardiovascular, respiratory, and others should be examined for completeness.


  • Talley NJ, O’Connor S. The thyroid. In: Clinical Examintion, a Systematic Guide to Physical Diagnosis. 7th edition, Australia: Elsevier; 2014, p355-61.
  • Das S. A Manual on Clinical Surgery. 10 ed. Kolkata: Somen Das; 2013.
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Striae distensae (stretch marks)

Jery Park, Year 3, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia

6 Mar 2016

Striae distensae are a common scarring on the skin. They can be erythematous, violaceous or hyperpigmented linear striations.

There are 2 main types:

  1. Striae rubra
  2. Striae alba

Striae rubra presents in striae distensae before progressing to striae alba in the course of 6 to 10 months.

Common causes are: pregnancy, rapid weight gain or loss, rapid growth, bodybuilding exercise and medications(particularly topical and systemic corticosteroids).

Striae distensae are commonly found on abdomen, breasts, medial upper arms, hips, lower back and thighs.

What to look for in a patient with striae

Characteristic Variants Clinical implications
Color Red (erythematous) or violet (violaceous): “striae rubra” During pregnancy, rapid weight gain or loss, rapid growth, bodybuilding exercise and medications (particularly topical and systemic corticosteroids)
White: “striae alba” Past pregnancy
Location Lateral borders of hips, and over the back at the upper sacral region only Puberty striae in boys
Over the hips posteriorly and laterally, extending to the posterolateral thighs Puberty striae in girls
Chest, and back in the area between the scapulae and the sacral bones Bodybuilders, striae related to lifting or stretching
Breasts, entire anterolateral abdomen mostly below the umbilicus Pregnancy
Intertriginous areas* Striae distensae secondary to topical corticosteroid use
Particularly prominent and widely distributed Cushing’s syndrome

*Intertriginous: where two skin areas may touch or rub together,eg axilla

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Dilated abdominal veins, examination of

Gerald Tan, Year three, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia

Last updated 26 Feb 2016

What to look for in a patient who has dilated abdominal veins

Characteristic Sign Differential diagnosis
Location Periumbilical Caput medusae
Over costal margin Congenital (no clinical revelance)
Flow (below umbilicus, obstruct from 2 points to determine) Towards legs Caput medusae due to portal hypertension
Towards head Obstructed inferior vena cava


Caput medusae: There exist anastomoses from the superficial epigastric veins to the portal vein via the paraumbilical veins. These veins carry oxygenated blood from the mother to the foetus and usually close after birth. In portal hypertension, the veins re-canalise and cause a caput medusae. The flow goes down because the blood is trying to go to the great saphenous vein from the superficial epigastric veins .

Dilated veins in IVC obstruction:  Deoxygenated blood cannot be returned normally to the heart. The abdominal veins stagnate and build pressure, overcoming the normal valves. Blood from the great saphenous vein can backflow into the superficial epigastric veins which anastomose with the lateral thoracic vein, which is a tributary of the axillary vein. The flow goes up because the blood is trying to go to the SVC due to IVC obstruction [Snell].


In the picture above, note the dilated veins over the chest and abdomen. This patient had a superior mediastinal tumor occluding the superior vena cava (see the CT scan below).


This CT scan slice is taken just before the tracheal bifurcation. You can see the trachea (on the patient’s right), and the esophagus (to the left of the trachea). Above the trachea is the arch of the aorta, opacified by contrast. The superior vena cava is not visible, since it has been flattened by the tumor.


  • Browse NL, Black J, Burnand KG, Thomas WEG. The abdominal wall, herniae and the umbilicus. In: Browse’s Introduction to the Symptoms and Signs of Surgical Disease, 4th Edition, Taylor & Francis Group, UK, 2005. Page: 385.
  • Snell RS. The Abdomen. In: Clinical Anatomy by Regions, 9th edition, Lippincott Williams & Wilkins, Maryland. Pages: 96, 98, 126, 195.
  • Talley NJ, O’Connor S. The gastrointestinal examination. In: Clinical Examination, 7th Edition, Elsevier Australia, New South Wales, 2014. Pages: 196, 197.
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Umbilicus, examination of

Ng Wei Yao, Chong Yee Ting, Year 3, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia

Last updated 28 Feb 2016

This table lists some abnormalities of the umbilicus. If, on abdominal examination, the umbilicus looks abnormal, this table provides a useful guide for examining it.

Location Normal Umbilicus is usually located almost in the middle of the line joining the tip of xiphoid process and the top of the pubic symphysis. [1]


Displaced upwards (a) Due to swelling arise from pelvis/ pelvis mass.

(b) Enlargement of uterus during pregnancy [2]

Displaced downwards Ascites – Tanyol sign


Shape [1] Inverted Normal
Everted Ascites
Tucked-in Obesity


Bulging mass Presence *Umbilical hernia

– Expansile impulse on coughing. [3]


*Sister Mary Joseph Nodule

– hard, palpable nodule

– suggestive of intra-abdominal carcinoma, especially gastric malignancy. [1]


* Umbilical adenoma

– raspberry-like tumour with a tendency to bleed

– due to prolapse of the mucosa of the unobliterated distal end of vitello-intestinal duct. [4]

Absence Normal

(periumbilical area)

Presence of bluish decolorisation Cullen sign [5]

Indicates hemoperitoneum. One cause is severe, hemorrhagic pancreatitis which has bled into the peritoneal cavity.

Absence of bluish discoloration Normal


Discharge Urine Patent urachus [4]
Faecal + mucous Patent vitello-intestinal duct [4]
Seropurulent discharge with characteristics foul-smelling odor Omphalitis [5]
Blood (during menstruation) Endometrioma [5]
Veins Dilated veins around the umbilicus (“caput medusa”) Cirrhosis

  • Browse N. The abdominal wall, hernias and the umbilicus, In: Burnand KG, Black J, Corbett SA, Thomas WEG (editors) Browse’s Introduction to The Symptoms & Signs of Surgical Disease, 5th edition, CRC Press, 2015, pages: 478-479.
  • Das S. Examination of an abdominal lump. In: A Manual on Clinical Surgery, 10th edition, Dr S Das, Kolkata, 2013, pages: 531
  • Das S. Examination of chronic abdominal conditions. In: A manual on Clinical Surgery, 10th edition, Dr S Das, Kolkata, 2013, page 486.
  • Das S. Examination of chronic abdominal conditions. In: A Manual on Clinical Surgery, 10th edition, Dr S Das, Kolkata, 2013, page 516.
  • Talley NJ, O’Connor S. The Gastrointestinal Examination. In: Clinical Examination, 7th edition, Elsevier Australia, New South Wales, 2014, pages: 195-196.
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Melody Shu Ling Tsen, Harkamal, Joshua, Zi Ning

Year 3, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia

22 Feb 2016

What to ask in a patient who complains of vomiting of blood

The following is a guide to the questions one should ask a patient who complains of vomiting of blood:

Symptoms: Hematemesis
1.       Volume of blood: Less than 20mL in 24 hours Slowly bleeding peptic ulcer
More than 250mL in 24 hours Eg. Carcinoma, cystic fibrosis, bronchiectasis and tuberculosis


2.       Color of blood: Bright red Indicates upper gastrointestinal bleeding is more acute or more severe, or originates more proximally than the stomach

Eg. Mallory-Weiss Tear

Dark brown/ Coffee ground Classic sign of upper gastrointestinal bleeding.

Eg. Peptic Ulcer, damage to the mucosa due to NSAIDs or SSRIs


3.       Associated Symptoms: Retching & Vomiting episodes
(before Hematemesis)
Eg. Mallory-Weiss Tear
Weight Loss + Appetite Loss Eg. Malignancy (Stomach Cancer/ Oesophageal Cancer)
4.       Medications NSAIDs (inhibits the gastric prostaglandins, gastric mucosa is unprotected) / Anticoagulant Ibuprofen/ Aspirin
5.       Liver Alcohol ·         How much?

·         Duration

·         Standard drink

Hepatitis ·         Immunisation

·         Travel history

Intravenous injection Leads to Hepatitis
Diet Leads to fatty liver,  scarring of the liver, cirrhosis, portal hypertension, esophageal varices and hematemesis


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Blood in the stools (hematochezia)

Ng Jay Shen, Gerald Tan Chen Jie, Kang Hui Wen, Year three, Monash University Malaysia

Updated 22 Feb 2016

Hematochezia is blood in the stools (Greek, hemato- (from haima, blood); chezo, to go to stool). Different dictionaries define it as “bleeding per rectum”, “bright red blood in the stools”, and maroon or red blood in the stools”. Perhaps the best use of hematochezia is simply to differentiate it from melena.

How to take a history from a patient who complains of bleeding per rectum

The following is a brief account of what to ask while taking a history of a patient who complains of blood in the stools.

  1. Onset
    • Sudden, quick onset suggests anal fissure or dysentery
    • Long time, gradual onset suggests Inflammatory bowel disease, colon cancer, polyps, haemorrhoids
  2. Colour
    • Bright red: this indicates a very distal source of bleeding, especially anorectal disorders such as haemorrhoids, fissure, and rectal cancer. Often, bleeding from a colonic cancer, diverticulosis, or ulcerative colitis is bright red as well.
    • Maroon or dark red, but not black colored bleeding occurs from ileal or colonic disorders. Bleeding Meckel’s diverticulum, angiodysplasias of the right colon, ulcerative colitis, diverticulosis causing bleeding: in these cases the blood is maroon or dark red, and sometimes bright red (see the note “Color” below). The further the source is from the anus, the darker is the color of the blood.
    • Dark, tarry stools imply Melena, not hematochezia. This occurs in upper gastrointestinal lesions such as erosive gastritis, peptic ulcer disease, Mallory- Weiss tears, esophageal varices, esophagitis, and duodenitis.
  3. Location [Penner and Majumdar, 2015; emedicine Health, 2016]
    • On the toilet paper: blood seen only on the toilet paper after defecation typically occurs in haemorrhoids and fissures.
    • Mixed with stools: bleeding that originates above the surgical anal canal is usually mixed with stools. Examples include polyps and cancer.
    • On top of stools: bleeding that oritinates from lesions distal to the anorectal junction often presents as a drop or two of blood on the surface of the stools. It occurs in anal fissures and haemorrhoids
  4. Volume
    • Massive bleeding is usually caused by diverticular disease, ulcerative colitis, angiodysplasia, colonic varices, small bowel arteriovenous malformations, and bleeding Meckel’s diverticulum.
    • Small bleeds are typical of hemorrhoids, fissure, and colon cancer. Bleeding from colon cancer may be occult, and picked up only on testing the feces for blood.
  5. Clots
  6. Clots indicate large bleeds, and suggest conditions such as angiodysplasia and diverticulosis.

  7. Mucus
  8. Patients with inflammatory bowel disease (ulcerative colitis, Crohn’s), acute dysentery, irritable bowel syndrome, and hemorrhoids often also complain of a discharge of mucous.

  9. Smell
  10. Melena produces a particularly offensive smell. Black stools due to drugs, such as charcoal, are not as foul-smelling.

  11. Pain
  12. Pain at the anus during, or immediately after defecation, occurs in patients with anal fissure

Note that hematochezia and melena are different. Hematochezia is a term used for red blood in the stools. It indicates lower gastrointestinal bleeding. Melena is a term used for black stools. It indicates upper gastrointestinal bleeding.

The color of the blood darkens as the source of the bleeding moves away from the anus. This is because in the gut, hydrochloric acid from the stomach oxidizes the heme iron from ferrous to ferric. The heme becomes “hematin”, which cannot carry oxygen [Vasudevan, 2013].
Blood color may be described as bright red, maroon (darker), burgundy, rosewood (very dark red), and, finally, black [Greensleeves Hubs, 2015.
Fine and coworkers [1999] showed that bleeding from anorectal sources, such as an anal fissure or hemorrhoids, was almost always bright red. Bleeding from colonic conditions like diverticulosis or inflammatory bowel disease was bright red in about 50% of cases, and maroon in the rest. Bleeding from lesions of the cecum or small bowel was bright red in 20% of cases, and maroon or burgundy-rosewood in most patients. Obviously, any lesion can cause bright red bleeding, but the most distal lesions rarely cause dark colored blood in the stools.


  • Centre for Digestive Diseases, (2009). Rectal Bleeding. [online] Available at: [Accessed 20 Feb. 2016].
  • Fine KD, Nelson AC, Ellington T, Mossburg A. Comparison of the Color of Fecal Blood With the Anatomical Location of Gastrointestinal Bleeding Lesions: Potential Misdiagnosis Using Only Flexible Sigmoidoscopy for Bright Red Blood per Rectum. Am J Gastroenterol 1999;94:3202-10.
  • emedicine Health. Hemorrhoids. accessed 19 April 2016.
  • Greensleeves Hubs. Shades and tones of red., uldated 22 October 2015, accessed 19 April 2016.
  • Longmore JM, Wilkinson IB. Gastroenterology. In: Oxford Handbook Of Clinical Medicine, 9th edition, Oxford: Oxford University Press, 2014, pages: 246,252.
  • Penner RM, Majumdar SR. Patient information: Blood in the stool (rectal bleeding) in adults (Beyond the Basics). UpToDate,, updated 3 September 2015, accessed 19 April 2016.
  • Talley NJ, O’Connor S. The gastrointestinal history. In: Clinical Examination, 7th edition, Elsevier Australia, N.S.W., 2014, pages: 178-179.
  • Vasudevan DM, Sreekumari S, Vaidyanathan K. Textbook of Biochemistry for Medical Students. Jaypee Brothers Medical Publishers, New Delhi, 2013, p273.
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Ling Jin Hin, Chung Yuan Ming, Year 3, Jeffrey Cheah School of Medicine and Health Sciences, Monash
Dr Suneet Sood

Last updated February 24, 2016


Literally, “claudication” means limping. However surgeons use the term primarily to denote reproducible muscle pain in the limbs that occurs during exercise and is caused by ischemia. Most patients describe the pain as cramping in character [Spronk, 2015], and moderate in severity. It is intermittent in the sense that pain stops when the patient rests. Pain is reproducible within the same muscle groups, and goes away after 2-5 minutes of rest. In its most typical form the location of claudication is the calves during walking, but in the lower limb the site may depend on the level of arterial occlusion.

Arterial lesions in the distal superficial femoral artery will usually cause claudication in the calf muscle area. Atherosclerosis involving the aortoiliac area may cause thigh or buttock muscle claudication [Rowe, 2015].

The “claudication distance” is the distance that the patient can walk before claudication appears; it is also called the Maximum Walking Distance (MWD) [Rai, 2015]. As the disease progresses, the MWD shortens. Typically, when claudication occurs, the patient stops to rest, and the pain disappears. If arterial occlusion is minimal, the pain may actually be relieved if the patient continues to walk instead of resting. If, on the other hand, arterial occlusion is severe, the pain will be aggravated if the patient continues to walk (see Boyd’s classification). The pain of muscle ischemia does not radiate.

Boyd’s classification [Boyd et al, 1949]. Boyd classified the severity of claudication in 1949. This probably has little significance today in terms of therapy [Rai, 2015], but is reproduced here for its historical interest.

  • Type I: The blood supply and demand are equal. On continued walking the pain disappears. The equilibrium is attained just below the threshold of pain, therefore if the patient is asked to walk more quickly, the pain returns.
  • Type II: Most patients are in this group. The equilibrium is attained just above the threshold of pain. the patient stops walking because the pain persists, not because it is too severe.
  • Type III: The blood supply is so low that equilibrium cannot be attained. The pain is intolerable, and the patient must stop walking.
  • One must differentiate arterial claudication from neurological claudication, a symptom common in lumbar spinal stenosis [Comer, 2009]. In both neurological and vascular claudication, the patient develops pain on exercise. In vascular claudication, the patient gets relief on rest. In neurogenic claudication, the patient gets relief on resting and assuming a posture (e.g. stooping forwards) that will avoid compression on the nerve [Comer, 2009]. The peripheral pulses are palpable [Saha, 2013].

Taking a history of claudication

This table provides an outline of what to ask when a patient complains of intermittent claudication of the lower limbs. For more information on peripheral artery disease, see the post “Peripheral Artery Disease“.

Feature, characteristic Feature variant What the variant may mean
Location [Rowe, 2015] Buttock Lesion is in the aortoiliac vessels.
Calf Lesion is in the distal superficial femoral artery.
Side [Smith, 1990] Unilateral Femoral or Popliteal Disease
Bilateral Aortoiliac Disease
Claudication distance (also called “Maximum Walking Distance”, or MWD) [Rai, 2009; Boyd, 1949] Distance. As distance shortens, it indicates worsening of the disease. In advanced disease, the patient has pain even at rest (rest pain)
Character [Smith, 1990] Dull, aching pain. Maybe sharp Peripheral Artery Disease
Associated Symptoms [Smith, 1990] Tissue loss (e.g. ulcer) Peripheral Artery Disease
Paraesthesia Peripheral Neuropathy
Back pain Sciatica
Aggravating Factors [Smith, 1990] Pain worsening with exercise Peripheral Artery Disease
Alleviating Factors [Smith, 1990; Comer, 2009] Rest relieves the pain Peripheral Artery Disease
A specific posture relieves the pain Neurogenic claudication

  • Boyd AM, Ratcliffe AH, Jepson RP, James GWH. Intermittent claudication: a clinical study. J Bone Joint Surg 1949;31B:325-55
  • Comer CM, Redmond AC, Bird HA, Conaghan PG. Assessment and management of neurogenic claudication associated with lumbar spinal stenosis in a UK primary care musculoskeletal service: a survey of current practice among physiotherapists”. BMC Musculoskelet Disord 2009;10: 121.
  • Rai KM. Approach to Management of Chronic Lower Limb Ischemia. Journal of GMC-Nepal 2009, 2:77-88, accessible at, accessed 16 Jan 2015.
  • Rowe VL. Peripheral Arterial Occlusive Disease. Medscape,, accessed 16 Jan 2015.
  • Saha ML. Peripheral vascular disease. In: Bedside Clinics in Surgery, 2nd edition. Jaypee Brothers Medical Publishers, Kathmandu, 2013, p302-322.
  • Smith RB III. Claudication. In: Walker HK, Hall WD, Hurst JW (editors). Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990.
  • Spronk S. Management of patients with intermittent claudication: Dissertation, Erasmus Medical Center, Rotterdam, the Netherlands, available at,%20Sandra.pdf, accessed 16 Jan 2016.
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