GPE-SCP2-1.pptxkekekwmwmksmdmdlmfnwjnwndndn

nejebnsndnsnn

1. Overview of History Taking & General Physical Examination (GPE) DR.MUHAMMAD SHAHZAD MAHMOOD

2. Overview of History Taking HISTORY OF THE PATIENT Name , age, sex, address, marital status, occupation, religion Date of admission Date of examination Chief complaints (in chronological order, from longest to shortest duration) History of present illness (HOPI) History of past illness (including any operation) Family history Personal history

3. Socioeconomic history Psychiatric history Drug and treatment history History of allergy (to drugs, diet or anything else, skin rash associated with allergy, treatment taken for allergy) History of immunization Menstrual and obstetric history (in female) Other history – Travelling to other places or abroad, working abroad (may be related to hepatitis B, HIV, etc.), contact with TB patient (mention, if relevant).

4. BEFORE START OF HISTORY TAKING Careful history taking is the most fundamental and important aspect of a clinical case. Skill for good history taking can be achieved by regular practice, allocating time and having patience . Diagnosis is possible only by taking a good history, even without unnecessary investigations . A correct diagnosis is missed, not because of lack of knowledge, but because of not listening attentively to the patient or not asking the relevant questions .

5. Always introduce yourself , in the following manner, “Good morning. I am Dr. … I would like to talk with you regarding your problems and if you kindly allow me, I would like to examine you” (In such a way, you can gain interest, confidence and cooperation of the patient. An intelligent patient may tell the diagnosis, treatment, etc.). Make a handshake and observe for any abnormality (like warm sweaty hand, tremor, slow relaxation of the handgrip). Check whether the patient is comfortable . Try to put the patient at ease (a good rapport may relieve distress on its own).

6. Be polite , gentle and respectful to the patient (history taking is an art and beginning of doctor-patient relationship , depending on which the patient will develop confidence on the doctor). While you are appearing in an examination , explain to the patient that, “This is an important examination in my life. Your cooperation is very essential for me”. While talking to the patient, watch him very carefully (patient may be anxious, apathetic or there may be obvious abnormality like myxedema, Graves’ disease or Parkinsonism). Observe the nature of speech or any voice change during talking with the patient. Notice nonverbal clues for the diagnosis.

7. You must develop a good clinical eye that is extremely essential to be a good clinician. While taking history , listen to the patient carefully , and at the same time, keenly observ e: From head to foot (gross abnormality may be obvious) Facial expression Posture Obvious pallor or jaundice Any swelling or goiter . By observation, the diagnosis may become obvious or this will provide important clue for the diagnosis (e.g . thyrotoxicosis, myxedema, Parkinson’s disease, Cushing’s syndrome).

8. Remember the following points: Occasionally, if the patient is unable to give the history (such as elderly, very ill, children or aphasia ), it is necessary to take history from the attendant or relative. This will also help to alert the physician, if anything is concealed by the patient. However, always try to take the patient’s consent first. If there is possibility of drug abuse or alcoholism , ask the patient very gently and with confidentiality . otherwise, the patient may either refuse or hide.

9. Many a times, the patient tells his history in his own words . There may be irrelevant informations given by him. But you should listen attentively with patience. Unnecessary part of the history should be avoided. Sometimes , the patient is uncooperative , irritable or angry . In such a case, you must be more careful to make every effort to calm him down. Even if you feel irritated or angry, never show this to the patient.

10. An intelligent patient may give a definite diagnosis . Even you can ask “do you know the name of the disease from which you are suffering? What drugs are you taking? Can you mention if any procedure has been performed (e.g. aspiration of pleural fluid, peritoneal fluid, etc.)?” This will give valuable informations regarding the diagnosis, past and present problem. If the symptoms do not correlate with the real diagnosis , proceed with further questions. He may tell the symptoms that he has forgotten or failed to mention. However, you will have to formulate a final history of the patient before presenting to the examiner.

11. Many patients may have multiple problems and multiple diagnoses. Organize to present the most 25 important diagnosis first. At the end, always ask the patient, “Would you like to say anything else?”

12. Summary of difficulties in taking history (however, usually this type of cases are not selected for the examination): The patient may be very unwell (because of severe pain, vomiting, breathlessness, agitated, profuse bleeding )—take the help of the attendant. Unconscious, semiconscious, confused or psychiatric patient – take the history from the attendant. Communication difficulties (such as learning disability, deafness, mutism, aphasia or dysphasia)— take history from the attendant. Emotionally disturbed (angry, uncooperative)—try to calm the patient with good behavior. Let the patient relax. If the patient does not wish to speak at all, ask him – “Would you like to write it down?” Language may be a problem in many cases . Carefully take the history from interpreter.

13. HISTORY TAKING “A good history is the biggest and most important step towards the correct diagnosis .” After asking full name, age, sex, address, occupation, marital status, etc. start by the chief complaints.

14. Chief Complaints Start by asking “ Would you please tell me what’s wrong with you?” Or, “ Why are you admitted in the hospital? ” Or, “ What are your presenting problems ?” Or, “What has been the trouble recently ?” Try to elicit the main complaints with their time frame. Precise chronology and sequence of events are very important Note the symptoms of longest duration , followed by the other symptoms in decreasing order, finally mentioning the symptom with shortest duration (suppose fever for 6 months, headache for 3 months, loss of appetite and weakness for 1 month).

15. History of present illness Elaborate the chief complaints in details mentioning the following (mnemonic: OD PARA ): O nset —How did it start? When did it start? D uration —How long? P rogression —Is it progressive or static? A ggravating factors—What makes it worse? R elievin g factors—What makes you feel better ? A nything else—Do you have anything else to mention?

16. Information in patient’s own words is more valuable, but sometimes leading questions are also necessary . Vague symptoms , such as “not feeling well”, “head is hot”, “stool is not clear”, etc. should be precisely clarified. If a symptom is irrelevant, it may be ignored. Inquire whether the patient has been suffering from diabetes mellitus, hypertension or bronchial asthma or other chronic illness. Record the patient’s own words, avoid using medical terms . For example, instead of “dyspnea ”, mention “difficulty in breathing”, “vomiting of blood” should be noted instead of “hematemesis ”, instead of “anorexia” mention “loss of appetite ”.

17. History of past illness Every history of the past illness, including any event during childhood or infancy, should be recorded, as follows: Previous diseases with its details (duration, treatment taken, whether hospitalized). History of any operation , injury, trauma and procedure (catheterization, endoscopy, colonoscopy, biopsy ). History of any investigatio n . Ask about diabetes mellitus , hypertension or other chronic illness. In case of CLD, enquire about past history of jaundice or if the patient has cardiac problem, enquire about history of rheumatic fever , hypertension, dyslipidemia . Ask about childhood illnesses including birth complications, immunization history, development and diseases.

18. Family History Detailed history of all the members of the family is very important. Ask about the following: Number of family members (parents, spouse, children, etc.) Their state of health . Ask – “Are they in good health?” “Do they have any illness? (e.g. ask about history of tuberculosis, hypertension, diabetes mellitus, dyslipidemia, ischemic heart disease, thyroid disorder, bronchial asthma, etc .) If death among family members , enquire the cause of death Ask about hereditary conditions (e.g. thalassemia), inquire regarding marriage among relatives.

19. Personal history Occupation (exact nature of work) Marital status Dietary habit H obby , pet keeping (cows, dog, rabbit, pigeon, etc.), interest, games, any source of entertainment Tea or coffee, betel nut Smoking (with number of sticks daily with duration) or tobacco chewing—ask technically specially in females who feel shy. If the patient is an ex-smoker, ask when he has stopped smoking and the number of sticks with duration that he used to smoke. Also, enquire any possibility of passive smoking . Alcohol (how much and how long, daily, weekly, occasional, place of drinking—home, outside, alone or socially). Be strategic as patient may not be forthcoming.

20. History of drug abuse including alcohol, intravenous drug use, sharing of needles. Enquire about drug dependency, any social or physical problem arising from drug use. Again be careful regarding the confidentiality of the information. Sexual exposure or sexual practice including homosexuality, polygamy, etc. (ask strategically, without embarrassing the patient).

21. Socioeconomic history Home and its surrounding environment—nature of house such as apartment, slum area, wooden house , living status, over-crowding, water supply and sanitation Office environment Income and employment Social and family relationship Any dependents at home? Who else at home? Who visits the house? (relatives, neighbor, friends).

22. Drug and treatment history Details of drugs (previous and present) History of drug allergy, drug intolerance or reaction Treatment already received for present illness History of any transfusion (blood, plasma, blood product, normal saline or other fluid) received.

23. Immunization History History of immunization is very relevant (hepatitis B, tuberculosis, tetanus).

24. Traveling history Travel or job outside the country (helpful for diagnosis of malaria, amebiasis , hepatitis B, HIV).

25. Psychiatric history Any symptoms related to anxiety, depression, dementia, hallucination, delusion, phobia, sleep pattern.

26. In female patient, always remember to ask 3 P – Period (menstrual history, such as amenorrhea, polymenorrhea , menorrhagia) Pill (oral contraceptive pill or other contraceptive method) Pregnancy (obstetric history, e.g. number of child, age of last child, postpartum hemorrhage, abortion or repeated abortion).

27. 3P MAFTOSA: P resent history P ast history P ersonal history M edication (drug) A llergy F amily history T raveling history O ccupation S ocial history A nything else (psychiatric history, extra history in female patient, immunization history, etc.)

28. systemic

29. CASE PRESENTATION (SAMPLE) AFTER HISTORY TAKING Pain in epigastrum

30. Chief complaints Pain in the epigastric region for … months Heart burn, nausea and belching for … months.

31. History of present illness: The patient states that he was quite well … months back. Since then, he has been suffering from frequent pain in the epigastric region. The pain is burning or dull aching in nature , more marked in empty stomach, like hunger pain. It is relieved by taking food or antacid. Sometimes , the pain appears at the late hours of night, awakening the patient from sleep, relieved by taking food or antacid. The patient also complains of occasional nausea and belching for … months. There is no history of vomiting, hematemesis, melena, anorexia, weight loss or weakness . His bowel and bladder habits are normal.

32. History of past illness : Nothing significant. Family history: His parents are alive and in good health. His wife and two children are good health. There is no history of similar illness in his family. Personal history: He is a government service holder. He smokes about 20 to 30 sticks of cigarettes per day for the last 25 years. There is no history of taking alcohol. Socioeconomic history: He comes from a middle class family and lives in a brick built house with good sanitation and water supply. Drug history: He occasionally takes antacids, ranitidine and omeprazole for his illness. However, there is no history of taking any NSAIDs or steroid.

33. Summary Mr …, a 42-year-old, serviceman, normotensive, nondiabetic, smoker, used to take 20 to 30 sticks per day , hailing from …, presented with frequent pain in the epigastric region for ... months. The pain is burning or dull aching in nature, more marked in empty stomach, like hunger pain. It is relieved by taking food or antacid. Sometimes, the pain appears at the late hours of night, awakening the patient from sleep, relieved by taking food or antacid. The patient also complains of occasional nausea and belching for … months . There is no history of vomiting , hematemesis, melena, anorexia, weight loss or weakness. His bowel and bladder habits are normal. He occasionally takes antacids, ranitidine and omeprazole for his illness . However, there is no history of taking NSAID or steroid . There is no similar illness in his family.

34. • Stethoscope • Pen torch • Measuring tape • Ophthalmoscope • Otoscope • Sphygmomanometer • Tendon hammer • Tuning fork • Cotton wool • Thermometer • Personal protective equipment (disposable gloves and apron) • Facilities for obtaining blood samples and urinalysis

35. Facial expression as a guide to diagnosis Poverty of expression Parkinsonism Startled expression Hyperthyroidism Apathy, with poverty of expression and poor eye contact Depression Apathy, with pale and puffy skin Hypothyroidism

36. Brief discussion and elaboration about Physical examination General examination Remember, “A doctor must be a good observer, like a detective” . So, before starting general examination , look carefully from head to foot.

37. Appearance (ill or well looking, depressed, anxious, Cushingoid , expressionless face ) Built (obese, emaciated or cachexic, tall, short, normal) Nutrition (well nourished, poor, normal) Anemia (see in palpebral part of conjunctiva, tongue, palm, nails, body as a whole). Mention whether it is mild, moderate or severe

38. Jaundice (see in sclera, under surface of the tongue, palm, body as a whole). Mention whether it is mild, moderate or severe (deep) Cyanosis (see in tip of the nose, lips, ear lobule, tongue, tip of the finger and toes). Comment whether the cyanosis is peripheral or central. Be aware of differential cyanosis (it means cyanosis in toes, not fingers)

39. Clubbing (see fluctuation of nail base, angle between the nail and its base, curvature of the nails, look for hypertrophic osteoarthropathy by pressing the lower end of tibia-fibula or radius-ulna).

40. Koilonychia (feel the nails for dryness, brittleness, flattening, thinning, spooning) Leukonychia (white spots in nail or white nail) E dema (in leg above the medial malleolus, in sacrum if the patient is recumbent ) Dehydration (skin turgor, dry tongue) Pigmentation (exposed parts, face, neck, palmar creases, knuckles, inner side of the mouth, recent scars )

41. Lymph nodes (examine systematically in different areas) Thyroid gland (palpable or enlarged) . If enlarged, examine in details Breasts (normal or enlarged or any mass) Bony tenderness Body hair distribution (including head, to see alopecia)

42. Pulse (rate/min) Blood pressure Temperature (record in Centigrade or Fahrenheit) Respiration (number of respiration per minute, mention if any abnormality found) .

43. (Other findings, though not seen routinely, should be mentioned if present or relevant to individual cases. Examples are – xanthelasma , corneal arcus, xanthomatous nodules, skin rash, alopecia, scratch mark , rheumatoid nodule, Dupuytren’s contracture, palmar erythema, Osler’s node, splinter hemorrhage , Heberden’s node, Bouchard’s node, gangrene or nail fold infarct or nail fold telangiectasia , ulceration, wasting, skin rash or Gottron’s patch, spider angioma , parotid gland enlargement , striae , purpura, vitiligo, deformity like kyphosis, scoliosis, lordosis ).

44. Note Mention if the patient has any cannula, catheter, N-G tube, CV line, A-V fistula, etc . Remember to examine the lower limb to see unilateral leg swelling, DVT, differential cyanosis, clubbing, ulcer or gangrene .

45. The nails in systemic disease Beau’s lines Transverse grooves Sequella of any severe systemic illness that affects growth of the nail matrix

46. Clubbing Loss of angle between nail fold and nail plate.

47. Onycholysis with pitting in psoriasis . ( painless separation of the nail from the nail bed .)  

48. Beau’s lines seen after acute severe illness ( indentations that run across the nails)

49. Leuconychia ( Condition where white lines or dots appear on your finger or toenails)

50. Koilonychia ( Spoon nails/Iron deficiency anemia)

51. Vitiligo ( Vitiligo is a condition in which the skin loses its pigment cells (melanocytes ))

52. Haemochromatosis with increased skin pigmentation   ( an inherited condition where iron levels in the body slowly build up over many years)

53. Hypercarotenaemia . A control normal hand is shown on the right for comparison (clinical condition characterized by yellow pigmentation of the skin)

54. Conjunctival pallor.

55. Smooth red tongue (glossitis) and angular stomatitis of iron deficiency .

56. Flushing(Redness)

57. Central cyanosis of the lips.

58. Scurvy. A Bleeding gums. B Bruising

59. Neurofibromatosis.

60. Marfan’s syndrome : A - Tall stature ( an inherited disorder that affects connective tissue )

61. Marfan’s syndrome, Long fingers.

62. Swollen right leg, suggesting deep vein thrombosis or inflammation

63. Lymphoedema of the right arm following right-sided mastectomy and radiotherapy.

64. Angio-oedema   ( a condition that can cause swelling of : The deeper layers of the skin)

65. Blister on a leg.

66. Petechiae ( pinpoint , round spots that appear on the skin as a result of bleeding)

67. Hypothyroidism Sparse, coarse hair and eyebrows, periorbital puffiness, dry , waxy skin, apathetic(no emotions) expression, Macroglossia

68. Graves’ disease (autoimmune thyrotoxicosis) Staring appearance due to lid retraction, proptosis, evidence of weight loss

69. Cushing’s syndrome Moon-shaped plethoric facies

70. Down’s syndrome

71. General Physical Examination

72. Approaching the physical examination General conduct: Doctors and medical professionals are in a position of trust . It is generally assumed that you will act with professionalism , integrity , honesty , and with a respect for the dignity and privacy of your patients. T he communication does not stop at the end of the history. You should also be alert to cultural and religious differences.

73. The right approach One important rule is that you should always stand at the patient's right hand side . This gives them a feeling of control over the situation (most people are right handed).

74. The examination framework Each system examination is divided into the following categories: Inspection (looking). Palpation (feeling). Percussion (tapping). Auscultation (listening). In addition, there may be special tests and other added categories

75. First impressions Diagnosis at first sight From the first moment you set eyes on the patient, you should be forming impressions of their general state of health. It takes experience and practice to pick up all the possible clues but much can be gained by combining common sense with medical knowledge. Ask yourself: 1. Is the patient comfortable or distressed ? 2. Is the patient well or ill ? 3. Is there a recognizable syndrome or facieses ? 4. Is the patient well nourished and hydrated ? Many of these features will be noted subconsciously, but you must make yourself consciously aware of them.

76. Bed-side clues In a hospital setting, there may be additional clues as to the patient's state of health in the objects around them. In other circumstances, look at objects that they are carrying or are visible in their pockets. Examples include oxygen tubing , inhalers , GTN spray , insulin injections , glucose meter , or cigarettes .

77. Set-up: Before commencing a formal examination , introduce yourself , explain what you would like to do and obtain verbal consent. Ensure that the patient has adequate privacy to undress . Make sure that you will not be disturbed . Check that the examination couch or bed is draped/covered by a clean sheet or disposable towel. If the patient is accompanied, ask them if they would like their companion/s to stay in the room. Check that any equipment you will require is available (torch, cotton wool, tendon hammer, stethoscope etc.). When ready, the patient should ideally be positioned supine with the head and shoulders raised to ~45

78. The handshake Observe your patient, introduce yourself and shake hands. This may provide diagnostic clues . Greet your patient in a friendly but professional manner . Information from a handshake: Features Diagnosis 1. Cold , sweaty hands Anxiety 2. Cold , dry hands Raynaud's phenomenon 3. Hot , sweaty hands Hyperthyroidism 4. Large , fleshy, sweaty hands Acromegaly 5. Dry , coarse skin Manual occupation, Hypothyroidism 6 . Deformed hands/fingers Trauma, Rheumatoid arthritis,

79. Odours Everybody has a natural smell. Excessive sweating and poor personal hygiene increase body odour and may be compounded by dirty or soiled clothing and stale urine. Tobacco's characteristic smell pervades skin, hair and clothing . The smell of alcohol on a patient's breath. Bad breath (halitosis) is caused by decomposing food wedged between the teeth, gingivitis, stomatitis, atrophic rhinitis and tumours of the nasal passages . S weetness of the breath (like nail varnish remover) in diabetic ketoacidosis due to acetone. F ishy or ammoniacal smell on the breath in uraemia . Foul-smelling belching in patients with gastric outlet obstruction.

80. 'Spot diagnoses' Many disorders have characteristic facial features : systemic sclerosis Hereditary haemorrhagic telangiectasia, Cushing syndrome. Patients with thalassemia have characterstic facial appearance. Major chromosomal abnormalities ( Down's syndrome, Turner's syndrome, Achondroplasia )

81. Vital signs It may also be appropriate to assess vital signs at an early stage. These usually include: 1. Temperature.(Temp.) 2. Blood pressure.(B.P) 3. Pulse. 4. Respiratory rate. (R/R) 5. Oxygen saturation. (O2) 6. Blood glucose.

82. Conscious level If necessary, a rapid and initial assessment of a patient's conscious level can be made using the AVPU scale or the Glasgow Coma Scale (GCS). AVPU A much more simplified score used in rapid assessment of consciousness and often by non-specialist nurses in monitoring conscious level. A = Alert V = responds to Voice P = responds to Pain U = Unresponsive

83. GCS This is an objective score of consciousness. (E4V5M6) There are 3 categories as below. 1. Eye opening (max 4 points): (ESPN) Spontaneously open------- 4 Open to (any) verbal stimulus-------3 Open in response to painful stimulus--------2 No eye opening at all---------1

84. Best verbal response (max 5 points) ( O ur C ountry WIN ) Conversing and orientated (normal)---------5 Conversing but disorientated and confused----------4 Inappropriate words(random words, no conversation)( Hotel,Cricket )----------3 Incomprehensible sounds ( moaning,Umm,eee etc )----------------2 No speech at all-------------1

85. Best motor response (max 6 points ) ( C ant L ive W ithout FAN s) Obeying commands (do as you are told) (e.g. raise your hand)---6 Localizing to pain (moves hand towards site of stimulus)--------5 Withdraws to pain (pulls hand away from stimulus)----------4 Abnormal flexion to pain (decorticate posturing)-----------3 Abnormal extension to pain ( decerebrate posturing)---------2 No response at all------------1 Note: Eye..Blind …NT…Not testable Verbal….Tube pass….NT

86. Colour The colour of the patient, or parts of the patient, can give clues to their general state of health and to particular diagnoses. Look especially for evidence of pallor , central and peripheral cyanosis , jaundice , and abnormal skin pigmentation .

87. Pallor: Facial pallor is often a sign of severe anaemia and is especially noticeable on inspecting the palpebral conjunctiva , nail beds , palmar skin creases and the mucous membrane . Ask the patient to look upward and gently draw down their lower eyelid with your thumb the conjunctiva should be red/pink. It is also a sign in shocked patients and those with vascular disease since peripheral vasoconstriction or poor blood flow causes skin and conjunctival pallor, even in the absence of blood loss.

88. Causes of pallor: 1. anemia : A. Microcytic (IDA, chronic blood loss). B. Macrocytic (megaloblastic anemia, Excess alcohol and hemolytic anemia). C . Normocytic (Anemia of chronic disease, CRF) 2. shock state : hypovolemic, anaphylactic ……. 3. peripheral vasoconstriction .(Pallor from vasoconstriction occurs during a faint or from fear . 4. Hypothyroidism .

89. Anemia(pallor)

90. Cyanosis: Cyanosis refers to a bluish discolouration of the skin and mucous membranes and is due to the presence of 5g/ dL of deoxygenated haemoglobin in the blood. In central cyanosis : T he tongue appears blue due to an abnormal amount of deoxygenated blood in the arteries,(many lung disease, right to left cardiac shunts and also seen in polycythaemia and haemoglobinopathies ). Peripheral cyanosis: This occurs in the hands, feet or ears, usually when they are cold. It is also found with central cyanosis, but is most often seen with poor peripheral circulation due to shock, heart failure, peripheral vascular disease, Raynaud's phenomenon and venous obstruction, e.g. deep vein thrombosis .

91. cyanosis Central cyanosis Peripheral cyanosis

92. Jaundice Jaundice (icterus) refers to a yellow pigmentation of skin, sclerae , and mucosa and occurs due to an increase in plasma bilirubin. It is best appreciated in fair-skinned individuals in natural daylight. Expose the sclera by gently holding down the lower lid and asking the patient to look upwards. Jaundice should not be confused with carotenaemia , which also causes a yellow discolouration of the skin, but the sclerae remain white.

93. Jaundice

94. Common causes of jaundice 1. Pre hepatic cause: Unconjugated hyperbilirubinemia : a. Increased bilirubin production ( hemolysis , ineffective erythropoiesis , blood transfusion). b. Decreased hepatocellular uptake: (drugs, e.g. rifampin ). c. Decreased conjugation : Gilbert‘s syndrome. 2. Hepatocellular : V iral hepatitis A, B, C . Acute fatty liver of pregnancy. Chronic hepatocellular dysfunction. Metabolic diseases (e.g., Wilson's disease). Drugs (acetaminophen), and hepatotoxins . Autoimmune hepatitis 3. Impaired bilirubin excretion(Post Hepatic Causes) Intrahepatic cholestasis: Drugs (chlorpromazine) Primary biliary cirrhosis. Extrahepatic cholestasis : Gallstones. Cancer : pancreas, cholangiocarcinoma .

95. Other abnormalities of colouration : These include: classic slate-grey appearance of haemachromatosis silver-grey colouration in argyra (silver poisoning), increase skin-fold pigmentation seen in Addison's disease, the non-pigmented patches of vitiligo

96. vitiligo Haemochromatosis with increased skin pigmentation.

97. Temperature Record the patient's temperature using either a mercury or electronic thermometer. The recording will depend on the site of measurement. Normal oral temperature is usually considered to be 37 C, whereas rectal temperature is 0.5 C higher and axillary temperature is 0.5C lower.

98. Normal body temperature is 36.8ºC (mouth), 36.4ºC (axilla), 37.3ºC (rectum). Temperature > 37.3ºC in mouth or 37.7ºC in rectum is considered as fever. Temperature above 41.1ºC is called hyperthermia or hyperpyrexia. This may occur in severe infection, pontine hemorrhage, heat stroke, malignant hyperthermia, thyroid crisis , lobar pneumonia. Hypothermia means temperature less than 35ºC.

99. Pulse examination T he number of times the heart beats within a certain time period, usually a minute .   When taking a pulse, characterize the information according to: Rate. (beat/min) Rhythm. (interval between two beats) Volume.( low, high or normal) Character of the pulse . (normal, slow rising, collapsing) Character of the vessel. (if normal, tell, “neither thicken nor tortuous”) Palpate both radial pulses simultaneously for Radio-radial delay. ( aneurysm at the aortic arch or subclavian artery stenosis). Palpate the femoral and radial pulse simultaneously, for any delay between the two and any difference in pulse volume between them. Radio-femoral delay ( coarctation of aorta).

100. Site of pulsation: Radial artery : place the pads of three middle fingers over the right radial artery. Brachial artery : Feel at the medial side of the cubital fossa, just medial to the tendenous insertion of the biceps . Carotid artery : This is the best place to assess the pulse volume and waveform. Find the larynx, move a couple of centimeters laterally and press backwards medial to the sternomastoid muscle . Femoral artery : can be felt midway between the pubic tubercle and the anterior superior iliac spine . Popliteal artery : the patient lying flat and knees slightly flexed, press into the center of the popliteal fossa with tips of the fingers of the left hand and use the fingers of the right hand to add extra pressure to these . Posterior tibial artery : Palpate at the ankle just posterior and inferior to the medial malleolus. Dorsalis pedis : This runs lateral to the exterior hallucis longus tendon on the superior surface of the foot between the bases of the 1st and 2nd metatarsals.

101. Site of pulsation Radial artery : place the pads of three middle fingers over the right radial artery. Brachial artery : Feel at the medial side of the cubital fossa, just medial to the tendenous insertion of the biceps.

102. Carotid artery : This is the best place to assess the pulse volume and waveform. Find the larynx, move a couple of centimetres laterally and press backwards medial to the sternomastoid muscle. Femoral artery : can be felt midway between the pubic tubercle and the anterior superior iliac spine.

103. Popliteal artery : the patient lying flat and knees slightly flexed, press into the center of the popliteal fossa with tips of the fingers of the left hand and use the fingers of the right hand to add extra pressure to these. Posterior tibial artery : Palpate at the ankle just posterior and inferior to the medial malleolus. Dorsalis pedis : This runs lateral to the exterior hallucis longus tendon on the superior surface of the foot between the bases of the 1st and 2nd metatarsals.

104. Pulse rate :This should be expressed in beats per minute. A rate <60bpm is called bradycardia whilst tachycardia is a pulse >100bpm. The most accurate method is to count the pulse for a full minute. In practice, people count for 15 seconds and multiply the number by 4. Rhythm : In general, the pulse can be either regular or irregular but variations exist . 1. Regular : It must be remembered that the pulse rate may be variable with respiration. 2. Irregularly irregular: this is a completely random pattern of pulsation and is found in atrial fibrillation.(should estimate the pulse deficit)

105. Character/waveform and volume This is best assessed at the carotid artery . You are feeling for the speed at which the artery expands and collapses and force with which it does so . Aortic stenosis : a slow rising pulse . Sometimes called anacrotic or aplateau phase. Aortic regurgitation : a collapsing pulse which feels it suddenly hits your fingers and falls away just as quickly. You could try feeling at the brachial artery and raising the arm above the patient's heart. Sometimes referred to as a waterhammer pulse. Pulsus bisferiens : a waveform with 2 peaks, found where aortic stenosis and regurgitation co-exist. Hypertrophic cardiomyopathy: this pulse may feel normal at first but peter out quickly. Often described as jerky . Pulsus alternans : an alternating strong and weak pulsation, synonymous with a severely impaired left ventricle in a heart failure. Pulsus paradoxus : pulse is weaker during inspiration (causes include cardiac tamponade , status asthmaticus , and constrictive pericarditis).

106. Blood pressure Blood pressure (BP) is a measure of the force that the circulating blood exerts against the arterial wall. The systolic BP is the maximal pressure that occurs during ventricular contraction (systole). During ventricular filling (diastole), arterial pressure is maintained, but at a lower level, by the elasticity and compliance of the vessel wall. The lowest value (diastolic BP) occurs immediately before the next cycle . BP is usually measured by means of a sphygmomanometer cuff . It is measured in mmHg and recorded as systolic pressure/diastolic pressure, together with where, and how, the reading was taken , e.g. BP: 146/92 mmHg, right arm, supine.

107. Korotkoff sounds These noises are produced from under the distal half of the BP cuff between systole and diastole because the artery collapses completely and reopens with each heartbeat. As the artery wall rapidly opens it causes a snapping or tapping sound. As the cuff pressure falls below the diastolic pressure, the sound disappears as the vessel wall no longer collapses. The first appearance of the sound (phase 1) indicates systole . As the pressure is reduced, the sounds muffle (phase 4) and then disappear (phase 5).

108. Examination sequence of blood pressure 1 . Rest the patient for 5 minutes. 2. Use either arm. 3 . With the patient seated or lying down, support his arm comfortably at about heart level, ensuring that no tight clothing constricts the upper arm. 4. The usual sphygmomanometer cuff has a bladder width of 12.5 cm and length of 3-35 cm. Apply the cuff to the upper arm, with the centre of the bladder over the brachial artery. 5 . Palpate the brachial pulse. 6 . Inflate the cuff until the pulse is impalpable. Note the pressure on the manometer; this is a rough estimate of systolic pressure. 7 . Inflate the cuff another 30 mmHg and listen through the diaphragm of the stethoscope placed over the brachial artery. 8 . Deflate the cuff slowly (2-3 mmHg/s) until you hear a regular tapping sound (phase 1 Korotkoff sounds). Record the reading as the systolic pressure. 9 . Continue to deflate the cuff slowly until the sounds disappear. Record the pressure at which the sounds completely disappear as the diastolic pressure.

109. T ypes of H TN Essential hypertension , in which there is no identifiable cause, occurs in >90% of patients with hypertension. Secondary hypertension is rare, occurring in <1% of the hypertensive population. Causes of secondary hypertension include: 1. Renal artery stenosis: suspect if there is other evidence of peripheral vascular disease 2. Phaeochromocytoma : a tumour of the adrenal medulla that secretes catecholamines . 3 . Coarctation of the aorta. 4 . Polycystic kidney disease.

110. The face and neck Face: Examine the patient's face at rest. It is starting with an overview , moving to the eyes, nose, the mouth, then the neck. Look up whilst you gently pull down one lower eyelid, exposing the conjunctiva. Open wide and look inside their mouth. Protrude their tongue . you should be looking especially for : Jaundice : seen as a yellow discolouration of the sclera. Anaemia : seen as an unusually pale conjunctiva. Xanthelasma : yellow, raised lesions found particularly around the eyes, indicative of a high serum cholesterol. Corneal arcus : a yellow ring seen overlying the iris. Significant in patients <40 years but not in older persons. Mitral faces: rosy cheeks suggestive of mitral stenosis. Cyanosis : seen as a bluish discolouration of the lips and tongue . Dental hygiene: a common source of organisms causing endocarditis.

111. Xanthelasma

112. Corneal arcus

113. Mitral faces

114. Neck examination Neck examination: include the examination of the following: 1. Carotid pulse examination. 2. Jugular venous pressure. 3. Thyroid gland. 4. Cervical lymph nodes. 5. Neck movement to exclude neck stiffness.

115. Jugular venous pressure The jugular veins connect to the SVC and the right atrium without any intervening valves. Therefore, changes in pressure in the right atrium will transmit a pressure wave up these veins which can be seen in the neck . It is often the JVP must be measured in the internal jugular vein (IJV). T he EJV had tortuous course means that impulses are not transmitted as readily or as reliably. It is for this reason that the IJV is used. The centre of the right atrium lies ~5cm below the sternal angle which is used as the reference point. The normal JVP is ~8cm of blood (therefore 3cm above the sternal angle).

116. Examination sequel 1.The patient lying back at 45 °, and expose the neck. With the patient tilted back to 45°the upper border of the pulse is just hidden at the base of the neck. This, therefore, is used as the standard position for JVP measurement . 2. Ask the patient to turn their head away from you (their left) and ensure that the neck muscles are relaxed . 3. Look for the JVP and measure the vertical distance from the top of the pulsation to the sternal angle. 4. adding an extra 5cm.

117. It can sometimes be difficult to distinguish the jugular venous pulse from the carotid pulse

118. Aids to differentiate the jugular venous waveform from arterial pulsation Jugular Pulsation Carotid Pulsation visible but not palpable Palpable Obliterated by pressure not obliterate by pressure Moves with respiration Normally the JVP falls with inspiration Little movement with respiration Hepato-jugular reflux is positive Not affected by HJR

119. Findings Raised JVP : 1. right ventricular failure. 2. tricuspid stenosis and tricuspid regurgitation. 3. superior vena cava obstruction. 4. pulmonary embolus. 5. fluid overload .

120. Kussmaul's sign The JVP will decrease during inspiration in the normal state. The JVP will rise during inspiration (Kussmaul's sign) in the presence of pericardial constriction, right ventricular infarction or, rarely, cardiac tamponade .

121. Lymph nodes Inspection Large nodes are often clearly visible on inspection, particularly if the enlargement is asymmetrical. If nodes are infected, the overlying skin may be red and inflamed. Palpation Lymph nodes should be palpated using the most sensitive part of your hands (the fingertips).

122. Head and neck: the nodes should be palpated with the patient in an upright position and the examiner standing behind (similar to the examination of the thyroid gland)

123. Axillae: To examine the nodes at the right axilla: 1. The patient should be sitting comfortably and you should stand at their right-hand side. 2. Support their right arm abducted to 90 with your right hand. 3. Examine the axilla with your left hand. To examine the nodes at the left axilla, perform the opposite manoeuvre to the above.

124. Inguinal : with the patient lying supine, palpate their inguinal region along the inguinal ligament. There are 2 chains of superficial inguinal lymph nodes (a horizontal chain which runs just below the inguinal ligament and a vertical chain which runs along the saphenous vein). Epitrochlear nodes : place the palm of the 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 : best examined by passively flexing the knee and exploring the fossa with the fingers of both hands.

125. A xilla Epitrochlear nodes Inguinal

126. Findings: Similar to the considerations to make when examining a lump, during palpation of lymph nodes, the following features should be assessed: Site : It is often helpful to draw a diagram detailing exactly where the enlarged node is. Number : how many nodes are enlarged ? Size : normal nodes are not palpable. Palpable nodes, therefore, are enlarged. You should measure their length and width. Consistency : ( firm , hard,rubbery and irregular). Enlarged nodes secondary to infection may feel tenderness and painful, tender nodes. Fixation : nodes that are fixed to surrounding tissue are highly suspicious of malignancy. Matted glands may occur in tuberculous lymphadenopathy. Overlying skin : inflamed nodes may cause redness and swelling in the overlying skin.

127. Hydration When assessing hydration status, you may already have obtained clues from the history. For example, a patient may have been admitted with poor fluid intake and may feel thirsty. Sepsis, bleeding, or bowel obstruction and vomiting can also cause a person to become dehydrated.

128. Examination of hydration Begin with looking around the patient for any obvious clues including fluid restriction signs, catheter bag or nutritional supplements. Inspect the face for sunken orbits (a sign of moderate-severe dehydration). 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. This sign is unreliable in elderly patients whose skin may have lost its normal elasticity.

129. 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 colour to return. Normal capillary refill time should be <2 seconds; a prolongation is indicative of a poor blood supply to the peripheries. Pulse rate : a compensatory tachycardia may occur in dehydration or in fluid overload . Blood pressure : check lying and standing blood pressure readings and look for a low blood pressure on standing which may suggest dehydration (along with many other diagnoses). JVP : Assess the height of the JVP which is one of the most sensitive ways of judging intravascular volume. The JVP is low in dehydration, but raised in fluid overload. Oedema : another useful sign of fluid overload (think right heart failure, constrictive pericarditis, hypoalbuminaemia ). Remember to test for both ankle and sacral oedema

130. Oedema Oedema refers to fluid accumulation in the subcutaneous tissues and implies an imbalance of the Starling forces (increase of intravascular pressure or reduced intravascular oncotic pressure) causing fluid to seep into the interstitial space. Oedema will occur in hypoproteinaemic states (especially nephrotic syndrome, malnutrition and malabsorption ) and severe cardiac and renal failure.

131. Examination In ambulant patients , palpate the distal shaft of the tibia for oedema by gently compressing the area for up to 10 seconds with the thumb. If the oedema is pitting, the skin will show an indention where pressure was applied which refills slowly. If oedema is present, note its upper level. Oedema may also involve the anterior abdominal wall and external genitalia. When lying down , fluid moves to the new dependent area causing a sacral pad. This can be checked for by asking the patient to sit forwards, exposing the lower back and sacral region, and again applying gentle pressure with your finger-tips.

132. NON P itting Edema

133. causes of leg swelling Local causes Cellulitis (usually unilateral). Ruptured baker's cyst (usually unilateral). Occlusion of a large vein i.e . thrombophlebitis, DVT, extrinsic venous compression. Chronic venous insufficiency : pigmentation induration, inflammation , and lipodermatosclerosis . Lipomatosis . Gastrocnemius rupture swelling and bruising around the ankle joint and foot. Systemic causes Congestive cardiac failure. Hypoproteinaemia ( nephrotic syndrome, liver cirrhosis, protein-losing enteropathy , kwashiorkor ). Hypothyroidism . Hyperthyroidism . Drugs (e.g. corticosteroids, NSAIDs, vasodilators).

134. Nutritional status The nutritional status of the patient may be an important marker of disease and is often overlooked in physical examination. The following are simple clinical measures with can easily be undertaken to assess a patient's overall nutritional status: General physical appearance Note the patient's overall body habitus ; are they fat or thin? Do they appear to have recently lost or gained weight? Weight loss can lead to muscle wasting seen as skeletal prominence, especially cheek bones and heads of humerus and major joints, rib cage, and the bony landmarks of the pelvis.

135. Body weight and height All patients should be weighed using accurate scales and have their height recorded. Body mass index The body mass index (BMI) is a useful estimate of body fatness . The WHO has classified BMI as follows: 19-25 = normal. 25-30 = overweight. 30-40 = obese. >40 = extreme or morbid obesity.

136. Skin fold thickness Skin fold thickness is usually measured at the triceps halfway between the olecranon and acromial processes, by using specialist calipers. (normal values are 20mm in men and 30mm in women). Mid-arm circumference Measure mid-arm muscle circumference by use the midpoint between the tip of the olecranon and acromial processes as your standard measurement point. With the arm in a flexed right-angle position, take 3 tape measurements at this point before calculating the average. Standard age/sex charts are available

137. Hands Examination of the hands is an important part of all examination routines and may provide a huge number of diagnostic clues . Set-up Begin by exposing the forearms up to the elbows and asking the patient to place their hands on a pillow on their lap with you sitting opposite. Inspection Dorsum : ask the patient to hold their hands out flat, palms down. Palm : next, ask the patient to turn their hands over. It is often possible to make a spot diagnosis with inspection of the palmar and dorsal surfaces as many diseases cause characteristic hand changes (e.g. rheumatoid arthritis, systemic sclerosis, psoriasis, ulnar nerve palsy).

138. Skin colour : take note of the colour (e.g. palmar erythema, vasculitis , digital ischaemia , purpura ) and consistency of the skin. Muscles : look at the small muscles of the hand and the larger muscles of the forearm and make note of any wasting or fasciculation. Joints: make a point of looking at each joint in turn: ( DIP ).( PIP ). (MCP ).Wrist . Bony deformities : look for evidence of swelling or deformities. Nails: the nails should be inspected carefully.

139. Some finger joint deformities Swan neck : fixed flexion at the DIP and extension at the PIP joints. Boutonniere : fixed extension at the DIP and flexion at the PIP joints. Z-shaped thumb : flexion at the MCP joint of the thumb with hyperextension at the interphalangeal joint. Ulnar deviation : the fingers are deviated medially (toward the ulnar aspect of the forearm) at the MCP joints. Wrist subluxation : deviation (either ulnar or radial) at the wrist. Heberden's nodes : swelling (due to osteophytes) at the DIP joints(a feature of osteoarthritis). Bouchard's nodes : similar to Heberden's nodes but at the PIP joints (feature of osteoarthritis).

140. U lnar deviation S wan neck deformity

141. Important nail disorders/signs Splinter haemorrhages : tiny, longitudinal streak haemorrhages under the nails caused by micro-emboli or trauma. Pitting : tiny indentations in the surface of the nail. A feature of psoriasis. Onycholysis : premature lifting of the nail. Leukonychia : white discolouration of the nail. A sign of low albumin or chronic ill-health. Beau's lines : transverse depressions in the nail. Coincide with arrested nail growth during a period of acute severe illness. Paronychia : infection of the skin adjacent to the nail (causing pain, swelling, redness, and tenderness. Koilonychia : spooning (concave indentation) of the nail. Associated with severe iron-deficiency. Clubbing : This is increase of curvature of the nails. Progression leads to a loss of the angle at the base of the nail and eventually to gross curvature and deformity. Objectively check for clubbing by putting the patients nails back-to-back as Clubbing leads to a loss of the diamond-shaped gap ( Schamroth's sign). Onychomycosis : fungal nail infection causing the nail to become thickened, opaque, crumbly and yellow.

142. Clubbing of fingers

143. Onycholysis psoriasis

144. Onychomycosis Splinter haemorrhages

145. Koilonychia : spooning (concave indentation) of the nail. Associated with severe iron-deficiency.

146. Examining the skin Inspecting a lesion: Grouped or solitary? Distribution/location: Symmetrical/asymmetrical ? In only light exposed areas ? Colour . Shape. Size. Surface. Edge. Nature of the surrounding skin.

147. Palpation: Each lesion should be felt. For each lesion, note: Tenderness (watch the patient's face). Consistency . Temperature: Use the back of your hand. Depth/height . Mobility : Is it attached to any underlying or nearby structures? Can it be moved in all directions or only in one or two? Does it move with movement of underlying muscle or tendons?