General examination

Plan of Conduction & Scheme of Recording

1. Clinical examination Plan of Conduction & Scheme of Recording Chiranjeevi Kumar Department of Physiology AIIMS Bhopal

2. Three sections Vital data. General examination. Systemic examination.

3. 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

4. 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)

5. 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?

6. 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

7. 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

8. 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

9. General examination General Appearance Hands and arms Skin Face Eyes Mouth Neck Oedema Lymph nodes Vital Signs Temperature Pulse Respiration Rate Blood Pressure

10. General Appearance G eneral state of health : Healthy/ill/comfortable/Distressed Body Built and Nutritional status Height Weight BMI Obese/lean Tall/short Muscular/ Asthenic / Cachexic S tate of awareness or level of consciousness Facial feature/expression/ Mood/Attitude Speech （ tone/voice) Position/posture and Gait Personal Hygiene Breath/Odor

11. G eneral state of health : Healthy/ill/comfortable/Distressed

12. Body Built

13. 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.

14. Gigantism Dwarfism

15. Malnutrition

16. S tate of awareness or level of consciousness

17. Facial feature/expression/ Mood/Attitude

18. 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

19. 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

20. 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 expression The stare in hyperthyroidism

21. Hypothyroidism The most common cause is the Hashimoto’s thyroiditis, affects appr. 1% of adult population This 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.

22. Speech And Language

23. 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

24. Compulsive supine position The patient lie down on the beck, with two legs bending. Acute peritonitis

25. Compulsive prostrate position Rachis disease - in order to relief the tenderness of back muscles.

26. Compulsive side down position in patients with one sided pleurisy or pleurorrhea

27. Orthopnea A n 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

28. Squar down position It has been seen in patients with congenital heart disease

29. 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

30. 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.

31. Gait : a way or manner of walking G ait abnormalities describe unusual and uncontrollable problem with walking

32. Personal Hygiene

33. Personal Hygiene

34. Breath/Odor

35. HANDS and ARMS Nails Clubbing Koilonychia Leuconychia Palmar erythema Dupuytren’s contractures Hepatic flap

36. 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

37. HANDS Palmar erythema Dupuytren’s contractures

38. ARMS Spider naevi ( telangiectatic lesions) Bruising Wasting Scratch marks (chronic cholestasis )

39. Conjuctival pallor (anaemia) Sclera: jaundice, iritis Cornea: Kaiser Fleischer’s rings (Wilson’s disease) Xanthelasma (primary biliary cirrhosis) Parotid enlargement (alcohol) FACE, EYES …

40. Jaundice

41. Pale Conjunctiva, due to severe anemia

42. Parotid enlargement Xanthelasma fat builds up under the surface of the skin.

43. Evaluation of Frontal and Maxillary Sinuses

44. MOUTH Breath (fetor hepaticus ) Lips Angular stomatitis Cheilitis Ulceration Peutz-Jeghers syndrome Gums Gingivitis, bleeding Candida albicans Pigmentation Tongue Atrophic glossitis Leicoplakia Furring

45. Atrophic glossitis Thrush

46. NECK AND CHEST Cervical lymphadenopathy Left supraclavicular fossa ( Virchov’s node) Gynaecomastia Symmetry of the chest

47. 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

48. Cyanosis

49. 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

50. 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

51. 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

52. Macule A macule is small, flat, distinct colored area of skin Does not include a change in skin texture or thickness

53. Rosela Rosela is a skin lesion that is small, solid, and raised. It may be seen in measles, drug rashes, eczema

54. Papule A papule is defined as a small (5 millimeters or less), solid lesion slightly elevated above the surface of the skin.

55. Maculopapulae It is plate lesion with redness around the papules It can be seen in scarlet fever and drug-induced rashes

56. 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

57. Herpes zoster Vesicles in a unilateral dermatomal pattern are typical of herpes zoster

58. 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

59. 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

60. 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.

61. 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

62. Grading Edema

63. Protruded eyeballs and periorbital edema

64. Lymph nodes The lymph nodes are distributed all over the body The general physical examination can only palpate the superficial lymph notes

65. Palpating Anterior Cervical Lymph Nodes

66. Lymph nodes of the head and neck

67. Cervical adenopathy Massive right side cervical adenopathy due to metastatic, intraoral squamous cell cancer.

68. Palpation of Epitrochlear Lymph Nodes

69. Palpation of the Axilla

70. Left Axillary Adenopathy

71. Lymph nodes Lymph node enlargement either localized or systemically Localized : lymphadenitis tuberculosis malignant metastasis (gradually and painless) Systemically: lymphadenitis lymphoma leukemia

72. Vital signs---pulse 60~100 /min Childhood Emotion Aged Night

73. Vital signs---blood pressure

74. 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 -

75. 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.

76. Thank You