General examination

General examination with grading & clinical reasoning of each is given in this PPT.

1. DR. MEGHAN PHUTANE GENERAL EXAMINATION

2. Built Nourishment Vitals Temperature Pulse Respiratory Rate Blood pressure

3. Pallor Icterus Cyanosis Clubbing Lymphadenopathy Oedema

4. Built Skeletal structure in relation to age & sex of individual TALL STATURE Causes – Simple or primary gigantism Endocrine Genetic Metabolic SHORT STATURE Dwarfism Causes – Hereditory /genetic Chromosomal Constitutional Nutritional Endocrine Skeletal Systemic disease

5. Nourishment Normal person is well nourished as regards proteins, fats, carbohydrates, vitamins & minerals. NUTRIENT DEFICIENCY Proteins Rough skin, pedal edema, brittle hair Fats Cachexia (hollowing of cheeks, loss of hip shape, flat abdomen) Carbohydrates Difficult to detect because of gluconeogenesis from fats & proteins Vitamins Different for all water soluble & fat soluble vitamins Minerals Iron – pallor Calcium - tetany

6. Temperature Refers to temperature of viscera & tissues of body. Kept normal by maintaining balance between heat gain & loss. Regulated by hypothalamus. Recorded with mercury thermometer – kept in position for about a minute. Sites – Axilla (common) Oral (lot of perspiration) Rectal (in cholera) Normal temp – 36-37.5degrees Diurnal variations – lowest during 2-4am; highest in the afternoon.

7. Sr. no. Category Temp in degree celsius Temp in degree fahrenheit 1 Hypothermia 35 95 2 Subnormal 35.0 – 36.7 95 – 97 3 Normal 36.7 – 37.2 98 – 99 4 Mild fever 37.2 – 37.8 99 – 100 5 Moderate fever 37.8 – 39.4 100 – 103 6 High fever 39.4 – 40.5 103 – 105 7 Hyperpyrexia > 40.5 > 105

8. Types of fever – Continuous fever Remittent fever Intermittent fever Hectic or septic fever Pel ebstein type Low grade fever Causes of fever – Infection Neoplasm Vascular Traumatic Immunological Endocrine Metabolic Hematological Physical agents Miscellaneous

9. Pulse As ventricles eject blood, a pressure wave (pulse) is transmitted and can be felt by fingers.

10. Pulse assessment – Rate (no. of beats / min) - 60-100/minute Tachycardia Bradycardia Rhythm- Regular Regularly irregular Irregularly irregular F orce, volume, tension Equality Peripheral pulses Radio radial/ radio femoral delay Apex pulse deficit

11. Sites - Radial Brachial Axillary Carotid Temporal Femoral Popliteal Posterior tibial Dorsalis pedis

12. Respiratory Rate Number of breaths per minute Tachypnea - > RR Bradypnea - < RR

13. Blood pressure Systolic BP is controlled by stroke volume & arterial vessels stiffness whereas diastolic BP by peripheral resistance. BP varies with respect to respiration, emotions, exercise, position, meals, tobacco, alcohol, bladder distention, temperature, pain, circadian rhythm, age, race, obesity & arrhythmias.

14. Korotkoff sounds

15. Apparatus – Mercury sphygnomanometer Aneroid meter Electronic BP meter

16. Pallor Paleness of skin & mucous membrane either as a result of diminished circulating RBCs or diminished blood supply. Sites – Lower palpable conjunctiva Tongue Soft palate Palm & nails Causes – Anemia Vasoconstrictions Cutaneous

17. Icterus Technical term for jaundice Yellow coloration of body tissues

18. Cyanosis Bluish discoloration of nails due to reduced Hb in capillary blood. Types – Central Peripheral Due to abnormal pigments Mixed

19. SR. NO. CENTRAL PERIPHERAL 1 Mechanism Diminished arterial O2 saturation Diminished flow of blood to the local part 2 Sites On skin & mucous membrane (tongue, lips, cheeks) On skin only 3 Temperature of limb Warm Cold 4 Clubbing & polycythemia Usually associated Not associated 5 Local heat Cyanosis remains Cyanosis abolished 6 Breathing pure O2 Cyanosis decreases Cyanosis persists

20. Causes Central Cardiac (congenital cyanotic heart disease, congestive cardiac failure) Pulmonary (COPD, collapse or fibrosis of lungs, pulmonary AV fistula) Abdominal hepato pulmonary syndrome High altitude Peripheral (Cold, Shock, Increased blood viscosity, reynod’s phenomenon ) Mixed (acute left ventricular failure, mitral stenosis) Due to abnormal pigments ( methemoglobinemia , sulfhemoglobin )

21. Lymphadenopathy It is inflammatory or non inflammatory enlargement of lymph nodes. Examination – Sites Number Tender/Non-tender Discrete/matted Consistency Fixed/Mobile Overlying skin Sinus

22. Sites – Neck ( submental , submandibular, tonsilar , cervical, posterior auricular, occipital) Supraclavicular fossa Axillary glands (apical, anterior, posterior, medial & lateral group) Supratrochlear Inguinal Scalene nodes

23. Causes- Inflammatory Neoplastic Hematological immunological Generalised in cases of – TB HIV Secondary syphilis Lymphatic leukemia sarcoidosis

24. Clubbing Bulbous enlargement of soft parts of terminal phalanges with both transverse & longitudinal curving of nails. Occurs due to interstitial oedema & dilation of arterioles & capillaries. Causes – Pulmonary (bronchiectasis, lung abscess, TB) Cardiac (infective endocarditis, atrial myxoma ) Alimentary (ulcerative colitis, biliary cirrhosis) Endocrine (thyroid acropachy , acromegaly) Miscellaneous (hereditary, idiopathic)

25. Grade Description Grade 1 Softening of nail beds Grade 2 Obliteration of the angle between the nail and the nail bed Grade 3 Swelling of subcutaneous tissues over the base of nail causing overlying skin to be tense, shiny & wet; increasing nail curvature; resulting in Drumstick appearance or Parrot beak appearance Grade 4 Swelling of fingers in all directions associated with Hypertrophic pulmonary osteoarthropathy causing pain & swelling of hand & wrist

26. Oedema Collection of fluids in interstitial spaces or serous cavities. Becomes evident only when 5-6lits of fluid is accumulated. Types – Pitting Non-pitting Sites – Common in lower limbs (dependant area) Mechanism – Increased capillary permeability Increased capillary pressure Decreased osmotic pressure Damaged lymphatic drainage

27. Causes Bilateral edema Cardiac (CCF,LVF) Renal ( nephrotic syndrome) Hepatic (liver cirrhosis) Venous (IVC obstruction) Endocrine (myxedema) Allergic ( angioneurotic ) Toxic (epidemic) Nutritional (anemia, beriberi) Unilateral edema Lymphatic ( filariasis , radiations, metastasis) Traumatic Infectious Metabolic Venous Hereditary

28. Based on Pitting depth and Duration : 1+ :   ≤ 2mm pitting that disappears rapidly 2+ :  2-4 mm pitting that disappears in 10-15 seconds 3+ :  4-6 mm pitting that may last more than 1 minute; dependent extremity looks fuller 4+ :  6-8 mm pitting that may last more than 2 minute; dependent extremity is grossly distorted

29. Based on Pitting depth and Rebound time: 1 + :  2 mm pit that rebounds immediately 2+ :  4 mm pit that rebounds after few seconds 3+ :  6 mm pit that rebounds after 10-12 seconds 4+ :  8 mm pit that rebounds after > 20 seconds

30. Severity of Bilateral pitting edema: 1 + (mild):  Both feet/ankles 2+ (moderate):  Both feet + lower legs, hands or lower arms 3+ (severe):  Generalized bilateral pitting edema, including both feet, legs, arms and face