General physical examination of modern diagnostic method

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1. GENERAL EXAMINATION DR. SHUBHAM SADH ASSOCIATE PROFESSOR

2. 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

3. Instruments And Equipment : Stethoscope Sphygmomanometer Thermometer Torch Tongue depressors Measuring tape Note:- Exam begins the minute you first see the patient Exam continues throughout your patient interaction

4. 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

5. General appearance (built, weight, BMI etc.) Nourishment Vitals Temperature Pulse Respiratory Rate Blood pressure

6. Pallor Icterus Cyanosis Clubbing Lymphadenopathy Oedema

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

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

9. Body Built

10. 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.

11. Gigantism & Dwarfism

12. Malnutrition

13. 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

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

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

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

17. 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

18. 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.

19. 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

20. 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

21. Pulse As ventricles eject blood, a pressure wave (pulse) is transmitted and can be felt by fingers. 60~100 /min Childhood Emotion Aged Night

22. 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

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

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

25. 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.

26. Korotkoff sounds

27. Apparatus – Mercury sphygnomanometer Aneroid meter Electronic BP meter

28. 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 – Anaemia Vasoconstrictions Cutaneous

29. Pallor P ale color of the skin and mucous membrane due to deficiency of hemoglobin . (hemoglobin in carried in the RBCs) There are many causes of pallor : Anemia : M ost common Heart disease Sleep deprivation Shock : septic , Anaphylactic, Cardiogenic, Neurogenic or hypovolemic

30. Pallor is also seen in case of Endocrine defect : long standing diabetes leading to keratin deposition in the skin Hypothyroidism with or without anemia H ypopituitarism leading to decrease in the melanin stimulatory hormone Pallor is seen in : * Palm creases * Conjunctiva. * And mucous membranes

31. Iron Deficiency Anemia - koilonychia

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

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

34. Cyanosis

35. 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

36. 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, Reynaud's phenomenon ) Mixed (acute left ventricular failure, mitral stenosis) Due to abnormal pigments ( methemoglobinemia , sulfhemoglobin )

37. 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

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

39. Palpating Anterior Cervical Lymph Nodes

40. Lymph nodes of the head and neck

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

42. Palpation of Epitrochlear Lymph Nodes

43. Palpation of the Axilla

44. Left Axillary Adenopathy

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

46. 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)

47. 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

48. 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

49. 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

50. Grading Edema

51. 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

52. 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

53. 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

54. 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