general physical examination of a patient.ppt

Systematic evaluation of a patient

1. General physical examination Dr Kamabu Fiston Mmed surgery-KIU

2. Introduction DOCTORS SHOULD BE OBSERVANT, LIKE A DETECTIVE; “CONAN DOYLE ” Look at the patients general appearance…at the face ,hands and body

3. Preparing the Patient for an Examination Emotional – explain exactly what will occur Physical – offer the bathroom and instruct the patient on how to disrobe and don a exam gown Positioning and draping – help patient assume needed exam position and drape to provide privacy

4. Preparing the Patient for an Examination: Positioning and Draping Positions facilitate physician’s examination Assist the patient to appropriate position Make as comfortable as possible Cover with appropriate drape Keep patient warm Maintain privacy / modesty

5. 5 Examination Positions Sitting Supine or prone Dorsal recumbent Lithotomy proctologic Trendelenburg's Fowler’s Sims’ knee-chest

6. Sitting Supine / Recumbent Dorsal recumbent Preparing the Patient for an Examination: Positioning and Draping (cont.)

7. Lithotomy Trendelenburg’s Fowler’s Prone Preparing the Patient for an Examination: Positioning and Draping (cont.)

8. Sims’ Knee-Chest Proctologic Preparing the Patient for an Examination: Positioning and Draping (cont.)

9. Examination framework Each system-based examination is divided into the following categories : Inspection (looking) Palpation (feeling) Percussion (tapping) Auscultation (listening)

10. Examination Methods Inspection Visual examination Assesses posture, mannerisms, and hygiene Size, shape, color, position, symmetry Presence of abnormalities Palpation Touch texture, temperature, shape Presence of vibration or movements Superficial or with additional pressure

11. Examination Methods (cont.) Percussion Tapping and striking the body to hear sounds or feel vibrations Determine location, size, or density of structure or organ Auscultation Listening to body sounds Assess sounds from heart, lungs, and abdominal organs

12. Examination Methods (cont.) Manipulation Systemic moving of a patient’s body parts Range of motion of joints Mensuration Measuring Height and weight Length or diameter of extremity Growth of uterus during pregnancy

13. 1. Mental and emotional state Try to make some initial assessment of the patient's intelligence and mental and emotional state. But recognize that this initial impression may be inaccurate. Eg . anxious person: restless, with wide palpebral fissures and sweating palms. In depression , the lowered mood, inability to concentrate or make decisions, mental retardation, apathy or even obvious misery may be clearly evident

14. 2. Physical attitude Consider the patient's posture. Eg : Patients with heart failure sit up because they may become dyspnoeic if they lie flat ( orthopnoea ). Patients with abdominal pain due to peritonitis lie still. Patients with colic are restless or may even roll about in a futile attempt to find relief. People with painful joint diseases often have an attitude of helplessness. Various neurological disorders produce characteristic abnormal postures

15. 3. Gait Always observe the gait while patient walks The gait is best observed as the patient walks into the consulting room, before the formal assessment commences.

16. 4. General appearance Much can be learned from a general inspection of the patient's physique Is the appearance consistent with the patient's chronological age? Is he or she tall, short, fat, thin, muscular or asthenic? Are there any obvious deformities, and is the body proportionate? Height should be roughly equal to the fingertip-to-fingertip measurement of the outstretched arms, and twice the leg length from pubis to heel.

17. Body weight and height All patients should be weighed with accurate scales and have their height recorded (ideally using a stadiometer ). Body mass index The body mass index (BMI) is a useful estimate of body composition and related health risk. The World Health Organization (WHO) has classifi ed BMI as follows: 19–25 = normal 25–30 = overweight 30–40 = obese >40 = extreme or morbid obesity  

18. 5. Facial appearance Observe the patient's face The cheeks give information regarding the patient's health: In anaemia and hypopituitarism they are pale; In the nephrotic syndrome they are pale and puffy; In cases of mitral stenosis there is sometimes a bright circumscribed flush over the malar bones; In many persons who lead an open-air life they are red and highly coloured ; In congestive heart failure they may also be highly coloured , but the colour is of a bluish tint which cannot be mistaken for the red cheeks of weather-beaten people.

19. 6. The skin a. Pallor depends on the thickness and quality of the skin, and the amount and quality of the blood in the capillaries. Generalized pallor may also occur in severe anaemia . Anaemia , however, is a feature of 'the colour of the blood rather than that of the patient' and the colour of the skin may be misleading. The colour of the mucous membranes of the mouth and conjunctivae gives a better indication, as does the colour of the creases of the palm of the hand.

20. b. Yellowness is usually due to jaundice. Jaundice (icterus) refers to a yellow pigmentation of those tissues in the body that contain elastin (skin, sclerae , and mucosa) and occurs from an increase in plasma bilirubin (visible at >35 μmol /L ). A pale lemon-yellow tint is characteristic of haemolytic jaundice; In obstructive jaundice there is a dark yellow or orange tint . In obstructive jaundice there may be scratch marks from itching evoked by bile salts. In rare cases yellowness may be due to carotenaemia .

21. c. Pigmentation Heavy metals-lead, bismuth, iron, haemochromatosis there is blue grey pigmentation in the hard palate Drugs- antimalarials , OCPs(brown/black pigmentation anywhere in the mouth) Addisons disease Peutz-jeghers syndrome Malignant melanoma

22. d. Cyanosis Blue discoloration of the skin and mucous membranes, I t is due to the presence of deoxygenated haemoglobin in the superficial blood vessels. Occurs when there is more than 50g/L of deoxygenated haemoglobin in the capillary blood. Types-central and peripheral Central cyanosis- abnormal amount of deoxygenated haemoglobin in the arteries and that a blue discoloration is present in parts of the body with good circulation. Eg : tongue. Peripheral cyanosis- occurs when blood supply to a particular part of body is reduced, eg : lips in cold weather becomes blue but the tongue is spared.

23. Oedema Edema refers to fluid accumulation in the subcutaneous tissues and implies an imbalance of the Starling forces (intravascular pressure or reduced intravascular oncotic pressure), causing fluid to seep into the interstitial space. Types: Pitting type : Apply firm pressure on the shin of tibia or 2cm above the medial malleolus for 20-30 s and see for pitting. Causes: Congestive cardiac failure, nephrotic syndrome, liver cirrhosis, hypoproteinemia Non pitting type : Graves disease (non pitting due to deposition of hyaluronic acid), filariasis (lymphatic obstruction)

24. Hydration Examination Begin with looking around the patient for any obvious clues, including fluid restriction signs, urinary catheter bag, or nutritional supplements. Inspect face for sunken orbits (sign of moderate–severe dehydration).

25. Mucous membranes • Inspect the tongue and mucous membranes for moisture. • Dehydration will cause these surfaces to appear dry Skin turgor Assess by gently pinching a fold of skin on the forearm, holding for a few moments, and letting go. With normal hydration, the skin will promptly return to its original position, whereas in dehydration, skin turgor is reduced and the skin takes longer to return to its original state.

26. Capillary refill • Test by raising the patient’s thumb to the level of the heart, pressing hard on the pulp for 5 seconds and then releasing. Measure the time taken for the normal pink color to return. • Normal capillary refill time should be <2 seconds; a prolongation is indicative of poor blood supply to the peripheries.

27. 7. The hands Nail Pallor Cyanosis Koilonychia : nail become thin, brittle and concave ( spoon_shaped ). Seen in long standing iron deficiency anemia. Clubbing

28. CLUBBING - There is ↗ curvature of the nails. Early clubbing is seen as a softening of the nail bed, but this is very difficult to detect. Progressive clubbing leads to a loss of the nail angle at the base and eventually to a gross longitudinal curvature and deformity. Objectively check for clubbing by putting the patient’s nails back to back Clubbing leads to a loss of the diamond-shaped gap . CAUSES 1)Cardiovascular -cyanotic congenital heart disease, IE 2) Respiratory -lung carcinoma -bronchiectasis, lung abscess, emphyema -lung fibrosis 3)Gastrointestinal - cirrohis , IBS, Coeliac disease 4)Thyrotoxicosis 5)Familial

29. b. Fingers Heberdn’s node : these are bony swelling on the side of terminal interphalangeal joint, and are osteophytes seen in osteoarthritis Osler’s node : these are pea size painfull , swellings in the pulps of terminal phalanges. Seen in infective endocarditis and are due to vasculitis. Joint swelling

30. c. Palm Pallor Pallor erythema : redness of the thenar and hypothenar eminences, feature of hepatic failure, pregnancy, rheumatoid arthritis and oral contraceptive therapy. sweating

31. 8. The neck Thyroid Neck vein Lymph nodes

32. thyroid With the patient's neck slightly extended, inspect the area below the cricoid cartilage. Ask him/her to take a sip of water, extend the neck again and swallow. Watch for the superior movement of the gland, carefully noting its contour and any asymmetry. Thyroid palpation is best carried out from behind, with the patient's neck slightly extended, but not so much that the neck musculature is tightened.

33. Position both hands to encircle the neck, with the fingers slightly flexed, such that the tips of the index fingers lie just below the cricoid in order to palpate the isthmus. Now rotate the fingers down and slightly laterally in order to feel the lateral lobes, including the inferior border. The anterior surface of each lobe should be no larger than the terminal phalanx of the patient's thumb. Note: size, diffuses (singe nodule or multiple nodule), consistency, tenderness

34. Neck vein Jugular vein Look the venous pulsations in the internal jugular vein along the anterior border of the Sternomastoid and measure vertical distance from the highest point of venous pulsation to the sternal angle. If it is more than 3cm it is abnormal.

35. Lymph nodes Note: Site. size. Number. Consistency. mobility (with reference to each other, to overlying skin and to underlying structure). Tenderness. discharge or sinuses.

36. Axillae To examine the nodes at the right axilla: The patient should be sitting comfortably and you should stand at their right-hand side. Support their right arm abducted to 90° with your right hand. Examine the axilla with your left hand. To examine the nodes at the left axilla: Perform the same maneuver as for the right, but on the opposite side.

37. Inguinal With the patient lying supine, palpate their inguinal region along the inguinal ligament—the same position as when feeling for a hernia or the femoral pulse. There are two chains of superficial inguinal lymph nodes—a horizontal chain that runs just below the inguinal ligament, and a vertical chain that runs along the saphenous vein.

38. Epitrochlear nodes Place the palm of your right hand under the patient’s slightly flexed right elbow and feel with your fingers in the groove above and posterior to the medial epicondyle of the humerus . Popliteal This is best examined by passively flexing the knee and exploring the fossa with the fingers of both hands—much like feeling for the popliteal pulse

39. 9. The feet The feet must not remain obscured under bedclothes or socks during the examination. Pitting oedema may be recognized only in the ankles and dorsal surfaces of the feet. The condition of the skin of the feet is especially important in diabetics and the elderly The dorsalis pedis and posterior tibial pulses may be reduced or absent.

40. TEMPERATURE PULSE RESPIRATION ODOURS : The odour of diabetic ketosis ('sweet and sickly‘); that of uraemia as ' ammoniacal or fishy'; and that of hepatic failure as 'mousy‘, but too much reliance on such delicate distinctions is unwise. Halitosis (bad breath) is common in patients whose dental hygiene has been poor, and is associated especially with chronic gingivitis (periodontal or gum disease).