General examination
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Transcript of General examination
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Clinical examination Plan of Conduction & Scheme of Recording
Chiranjeevi Kumar
Department of Physiology
AIIMS Bhopal
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Three sections
• Vital data.
• General examination.
• Systemic examination.
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Vital Data
• Name Of The Institution :
• Name Of The Doctor:
• Ward No:
• Cot No :
• Case No :
• Date:
• Name Of The Patient :
• Age :
• Sex :
• Religion :
• Caste :
• Married Or Single :
• Children :
• Occupation :
• Income
• Address
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General History
• The general history is organized into the following
sections:
• Identifying data (ID)
• Chief complaint (CC)
• History of the present illness (HPI)
• Past medical history (PMHx)
• Family history (FHx)
• Medications (MEDS) and Allergies (ALL)
• Social history (SHx)
• Review of systems or functional inquiry (ROS/FI)
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History of Present Illness • Symptom characterization:• 0 =Onset and duration• P = Provoking and alleviating factors• Q = Quality of pain (e.g. sharp, dull, throbbing)• R = Does the pain radiate?• S = Severity of pain ("on a scale from 1 to 10, 10 being the
most severe")• T =Timing and progression ("Is the pain constant or
intermittent? Worse in the morning or at nighttime?")• U = "How does it affect 'U' in your daily life?“• V = Deja vu ("Has this happened before?")
• W ='What do you think it is?
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General examination• General examination is actually the first step of physical
examination and Key component of diagnostic approach.• Inspection is the major method during general
examination, combining with palpation, auscultation, and smelling.
• Aims to – Assess patient's general condition – Detect manifestations of internal & systemic diseases
• 3 components: – History taking – Clues are the symptoms – Physical exam - Clues are the signs – Investigations - Clues are test results
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Instruments And Equipment :
• Stethoscope
• Sphygmomanometer
• Thermometer
• Torch
• Wooden tongue depressors
• Measuring tape
• Note:-
• Exam begins the minute you first see the patient
• Exam continues throughout your patient interaction
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Prerequisites: • Examination environment• Hand Washing • Proper light • Privacy & Confidentiality• Presence of a chaperon when examining female
patients • Correct position of Doctor & Patient - Ideally examiner
should be on right side of patient • Proper Exposure • Ensure your hands are warm
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General examination– General Appearance– Hands and arms– Skin– Face– Eyes– Mouth– Neck– Oedema– Lymph nodes– Vital Signs
• Temperature• Pulse• Respiration Rate• Blood Pressure
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General Appearance• General state of health: Healthy/ill/comfortable/Distressed • Body Built and Nutritional status
– Height – Weight– BMI– Obese/lean– Tall/short– Muscular/Asthenic/Cachexic
• State of awareness or level of consciousness• Facial feature/expression/ Mood/Attitude• Speech( tone/voice)• Position/posture and Gait• Personal Hygiene• Breath/Odor
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• General state of health: Healthy/ill/comfortable/Distressed
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• Body Built
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I. Sheldon's Anthropometric Types.
• ENDOMORPHIC - in whom viscera and abdomen tend to
dominate the body.
• MESOMORPHIC - in whom the muscular tissue dominates the
body
• ECTOMORPHIC - in whom the skin, bones and the head
dominate the body..
II. Clinical types.
• Asthenic or hyposthenic has a slender or a weak figure.
• Sthenic or Hypersthenic has a broad and muscular figure.
• Normosthenic or Orthosthenic is midway between the above
two.
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GigantismDwarfism
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Malnutrition
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• State of awareness or level of consciousness
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Facial feature/expression/ Mood/Attitude
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Acromegaly
The enlargement of the frontal and maxillary sinuses results in an prominent brow and long face
Growth of mandible leads to a jutting jaw (prognathism).
Alveolar bone growth causes the teeth to separate
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Acromegaly
Macroglossia. There is also generalized visceral enlargement
Broadening and enlargement of the hands and feet due to increased periosteal growth as well as thickening of the skin
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Graves’ disease
Ocular involvement is mediated by one or more distinct but still poorly characterised orbital-stimulating immunoglobulins:Proptosis, due to increased volume and edema of retrobulbar fat. Shortened extraocular muscles, because of the muscle infiltration and fibrosis result in upper lid retraction. Conjunctival erythema, and periorbital edema are evident.
Facial expressionThe stare in hyperthyroidism
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Hypothyroidism
• The most common cause is the Hashimoto’s thyroiditis, affects appr. 1% of adult populationThis woman demonstrates the typical hypothyroid facies. She also had a slow, hoarse, deep voice and lassitude (state of feeling very tired in mind or body).
• Dull, puffy facies. Edema does not pit with pressure. The lateral eyebrows are thin.
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Speech And Language
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Position & Posture • It refers to patient’s body status and the general way of holding
the body• Divided into:• Active• Passive• Compulsive
• Active position The patient can move his/her body freely, without any restriction It can be seen in normal adult, patients with mild diseases or at
earlier stage of the diseases
• Passive position The patient can’t adjust or move his/her body It occurs in extremely sick or patients with unconsciousness
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• Compulsive supine position The patient lie down on the beck, with two legs bending. Acute peritonitis
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Compulsive prostrate position Rachis disease - in order to relief the tenderness of back muscles.
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Compulsive side down positionin patients with one sided pleurisy or pleurorrhea
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Orthopnea An abnormal condition in which a person must keep the head elevated (sit or stand) to breathe deeply or comfortably (orthopnea) or wakes up suddenly in the middle of the night short of breath. It can be seen in patients with lung or heart disease
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Squar down position It has been seen in patients with congenital heart disease
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• Compulsive rest position When patient suffers an angina attack it will force them to rest.
The heart is then able to return to it’s normal working level
• Toss & turn position (alternative position)
• Opisthotonos It is an abnormal posturing condition characterized by
rigidity and severe aching of the back, with head thrown backwards
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The typical position of COPD patients
An elderly patient who looks chronically ill. He is unable to speak more than two or three words at a time due to shortness of breath. He has intercostal muscle retraction when breathing and sits upright. Hi is thin with diffuse muscle wasting.
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Gait : a way or manner of walkingGait abnormalities describe unusual and uncontrollable
problem with walking
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Personal Hygiene
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Personal Hygiene
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Breath/Odor
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HANDS and ARMS• Nails
– Clubbing– Koilonychia– Leuconychia
• Palmar erythema• Dupuytren’s contractures• Hepatic flap
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Nicotine Staining Onycholysis: Separation of Nail from Underlying Bed
Onychomycosis: Fungal Infection of the Nail
Paronychia: Infection of skin adjacent to nail of middle finger
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HANDS
Palmar erythema Dupuytren’s contractures
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ARMS• Spider naevi (telangiectatic lesions)• Bruising• Wasting• Scratch marks (chronic cholestasis)
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• Conjuctival pallor (anaemia)• Sclera: jaundice, iritis• Cornea: Kaiser Fleischer’s rings (Wilson’s disease)• Xanthelasma (primary biliary cirrhosis)• Parotid enlargement (alcohol)
FACE, EYES …
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Jaundice
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Pale Conjunctiva, due to severe anemia
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Parotid enlargement
Xanthelasmafat builds up under
the surface of the skin.
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Evaluation of Frontal and Maxillary Sinuses
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MOUTH• Breath (fetor hepaticus)• Lips
– Angular stomatitis– Cheilitis– Ulceration– Peutz-Jeghers syndrome
• Gums– Gingivitis, bleeding– Candida albicans– Pigmentation
• Tongue– Atrophic glossitis– Leicoplakia– Furring
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Atrophic glossitis Thrush
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NECK AND CHEST• Cervical lymphadenopathy• Left supraclavicular fossa (Virchov’s node)• Gynaecomastia• Symmetry of the chest
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Skin
• The skin is the largest organ of the body
• One of the best indicators of general health
• The examination of the skin is dependent on inspection, but palpation of a skin lesion must also be performed
• The color changes include
– Pallor
– Cyanosis
– Yellow skin (Icterus)
– Redness
– Pigmentation
– Discoloration
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Cyanosis
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Discoloration Vitiligo • It is a skin condition in which there is loss of pigment
from areas of skin resulting in irregular white patches with normal skin texture
• Associated with pernicious anemia, hyperthyroidism, Addison’s disease
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Discoloration Leukoplakia• A precancerous lesion that develops on the tongue or
the inside of the cheek as a response to chronic irritation• Occasionaly, leukoplakia patches develop on the female
external genitalia
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Rashes • Skin rashes are frequently one of the manifestation of systemic
diseases, and hence, they are important for the diagnosis of some
special diseases
• The different rashes may occur in infectious disease, dermentological
disease, drug or other allergic materials
• The rashes have some special regular patterns and sharps
• Types of rashes
– Macule
– Roseola
– Papules
– Maculopapulae
– Urticaria
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Macule
• A macule is small, flat, distinct colored area of skin • Does not include a change in skin texture or thickness
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Rosela • Rosela is a skin lesion that is small, solid, and
raised. It may be seen in measles, drug rashes, eczema
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Papule
• A papule is defined as a small (5 millimeters or less), solid lesion slightly elevated above the surface of the skin.
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Maculopapulae • It is plate lesion with redness around the
papules• It can be seen in scarlet fever and drug-
induced rashes
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Urticaria • Urticaria (hive) are raised red welts of variuos
size on the surface of the skin, often itchy, which come and go. It is associated with allergic reaction
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Herpes zoster
• Vesicles in a unilateral dermatomal pattern are typical of herpes zoster
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Subcutaneous hemorrhage • Bleeding into the skin & subcutaneous tissues• According to the size of bleeding, it may be subdivided
as follows: petechia <2mm purpura 3~5 mm ecchymosis >5mm
• A hematoma is a large collection that forms a lump
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Spider angioma
• Spider angioma is a group of abnormal blood vessel that produces the appearance of a spider-web on the surface of the skin
• A spider angioma lesion typically has a red dot in the center with reddish extensions radiating out for some distance around it
• Liver palms
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Spider angioma
From very small to 2 cm; pulsatility is often demonstrable, when pressure with a glass slide is applied. Distribution: upper trunk, face, arms.
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Edema
• Excessive build up of fluid in the tissues
• Either occurs throughout the body (generalized swelling)
or limited to a specific part of the body (localized swelling)
• It can be either pitting edema or non-pitting edema
• Mild : facial edema, peripheral edema
• Moderate: generalized edema
• Severe: generalized severe edema
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Grading Edema
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Protruded eyeballs and periorbital edema
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Lymph nodes• The lymph nodes are distributed all over the body• The general physical examination can only palpate the
superficial lymph notes
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Palpating Anterior Cervical Lymph Nodes
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Lymph nodes of the head and neck
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Cervical adenopathy
Massive right side cervical adenopathy due to metastatic, intraoral squamous cell cancer.
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Palpation of Epitrochlear Lymph Nodes
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Palpation of the Axilla
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Left Axillary Adenopathy
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Lymph nodes
• Lymph node enlargement either localized or systemically
• Localized : lymphadenitis
tuberculosis
malignant metastasis
(gradually and painless)
• Systemically: lymphadenitis
lymphoma
leukemia
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Vital signs---pulse
60~100 /minChildhood EmotionAgedNight
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Vital signs---blood pressure
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• Clinical Examination• Personal information• Name: Age: Sex: Address:• 1. General Findings• • General appearance - Normal/ Healthy• • Mental state/ intelligence/ consciousness–Patient conscious, co-operative, well oriented in time,
place and person • • Body Build• o Height - • o Weight - • o BMI - • o Nutritional Status– Normal or average• • Gait - Normal• • Pallor - Absent• • Icterus - Absent• • Cyanosis - Absent• • Clubbing - Absent• • Edema(foot)- Absent• • Lymph nodes – Not palpable• • JVP– Not visible• • Vitals• o Temperature– ….measured/febrile/afebrile• o Pulse - • o Respiration - • o BP -
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The systemic examination
• The various systems to be examined are :
• 1. Cardio - vascular system.
• 2. Respiratory system.
• 3. Digestive system .
• 4. Hemopoietic system .
• 5. Excretory system.
• 6. Reproductive system .
• 7. Endocrine system .
• 8. Nervous system .
• 9. Special senses.
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Thank You