General Physical Examination _____________________________________________________
___________________________________________ -General Physical Examination -Approach to jaundice through general physical examination -Approach to anemia through general physical examination -Examination of Rheumatoid Hands
Comprehensive Clinical Skills in Medicine 1-General Physical Examination: It is general approach to the patient’s disease through examination. In this examination we do not examine the system involved but we look for general physical signs of a disease. General physical examination can help you to find out which system of the body is involved. It is important to follow a sequence while doing examination, by doing this you will not miss any step. A sequence that is usually followed is to start examination from hands followed by head and neck and legs.
Performing examination: 1. Introduction, consent & exposure: This is important step from ethical as well as from exam point of view. You should introduce yourself to patient and ask same from patient. Then ask for permission for examination and tell briefly what you will examine. Expose the patient according to the area to be examined. 2. General Look: Look at patient before you examine different areas for signs and symptoms. Look whether patient is child, adult or aged, also guess about physical appearance of the patient like what is patient’s height? Is patient normal? Obese or thin and see whether he is looking normal or diseased overall? While looking at your patient try to assess his mental alertness, whether he/she is normal, confused or drowsy and evaluate his consciousness with Glasgow Coma Scale. Look for any restlessness or pain during examination. 3. Examine Hands: Hands may be the important clue for any systemic disease or local disease. Examine hand properly and compare it with other hand. Hands have different parts and any part can be involved in the disease. Give a general look to both hands and look for size and shape. Nails: In nails you should look for pallor, cyanosis, koilonychia, leuconychia, clubbing, splinter hemorrhages and pitting of the nails. Fingers: First look for number of fingers and morphology (any polydactyly, oligodactyly or syndactyly), note any node or swelling in the fingers, joints and pulp (Osler’s nodes, Heberden’s nodes, Pulp abscess).
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Comprehensive Clinical Skills in Medicine Assess hand function appropriately (buttoning/un-buttoning the shirt, writing, combing hair). Palm: Look palmer eminences (thenar and hypothenar), palmer erythema, dupuytren’s contracture, excessive sweating and pallor. Feel Pulse: Measure the rate of radial pulse and note the rhythm and volume of the pulse. Measure it for 15 seconds then multiply with 4 but proper method is to feel the pulse for 1 minute. Compare it with other hand’s pulse, measure any delay and compare it with femoral pulse and measure any delay. 4. Measure Blood Pressure: Though it consumes time but it is important part of general physical examination. 5. Breathing Rate: It should also be measured. 6. Look for fever: Feel and measure for increased or decreased temperature with thermometer. 7. Head & Neck examination: General Look: Look patient face for particular facies (moonlike face, mask face, puffiness of the face). Examine Hair: Look for alopecia, dandruff or scalp infection or swelling and look for hair line and eyebrows. Examine Eyes: Look patient’s eyeball, peri-orbital area and eyelids for any abnormality. Look for anemia, jaundice, color of conjunctiva and color of sclera. Try to measure visual acuity of the patient and examine extra-ocular muscle movements. Examine Nose: Look for any pathology in nose. Examine Ear: Give a look to ear for any pathology. Examine Mouth: Look peri-oral area, denture, gums, oral hygiene, tongue and its base, pharyngeal walls and tonsils. Look specifically for anemia on the dorsal surface of the tongue, jaundice at the base of the tongue, cyanosis over the tip of the tongue, tongue coating (this occurs in fever) and dehydration. Thyroid examination: Inspect, palpate, and auscultate thyroid gland for any sign.
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Comprehensive Clinical Skills in Medicine Examine the lymph node groups of the neck: these are Sub-mental lymph nodes Sub-mandibular lymph nodes Anterior chain lymph nodes Posterior chain lymph nodes Pre-auricular/parotid lymph nodes Post-auricular lymph nodes Occipital lymph nodes Supra-clavicular lymph nodes 8. Examine lymph nodes of axilla: These lymph nodes include: Anterior lymph nodes Posterior lymph nodes Medial lymph nodes Lateral lymph nodes Apical lymph nodes 9. Look for dehydration: Examine for any signs of dehydration. Dehydration signs include: Sunken eyes Dry tongue Decreased skin turgidity (if you pinch a skin fold it will go back slowly) Decreased urine output, decreased blood pressure and rapid pulse 10. Examine the feet: Like hands, feet are examined, look nails and toes. 11. Look for edema: Edema follows area where there is gravitational force (dependent areas), so the edema can be seen in Over the shin of both legs Behind medial malleolus Dorsal surface of the feet Sacrum (if patient is bedridden) 12. Cover the patient and say thanks to patient.
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Comprehensive Clinical Skills in Medicine 2-Approach to the patient with jaundice through general physical examination Step 1: Introduction, consent & exposure. Step 2: Note patient’s general appearance particularly for cachexia and lethargy. Also state of alertness and consciousness as it is affected in hepatic encephalopathy. Evaluate for asterixis. Step 3: Look hands & skin of the patient: Look for palmer erythema, dupuytren’s contracture, yellowish discoloration of skin, flapping tremors, bruising, clubbing and needle tracks.
Palmer Erythema
Dupuytren’s contracture
Step 4: Vital signs are reviewed for fever or signs of systemic toxicity (e.g. hypotension, tachycardia). Step 5: Head and neck examination includes inspection Sclerae for icterus and the eyes for Kayser-Fleischer rings. Mild jaundice is best seen by examining the sclerae in natural light [it is usually detectable when serum bilirubin reaches 2 to 2.5 mg/dL (34 to 43 μmol/L)].
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Kayser-Fleischer Ring (K-F Rings: Brownish-yellow ring visible around the corneo-scleral junction (limbus). Consists of copper deposits in Descemet’s membrane, extending into the trabecular meshwork). Look for jaundice under the surface of the tongue. Breath odor should be noted (e.g. for fetor hepaticus). Examine the lymph node groups. Step 6: Examine the chest: Look for gynaecomastia (in men also see testicular atrophy and breast atrophy in women) and spider naevi.
Gynaecomastia
Spider naevi
Step 7: Look for edema and bruising in the legs. Step8: Cover the patient and say thanks to patient.
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Comprehensive Clinical Skills in Medicine 3-Approach to the patient with anemia through general physical examination Step 1: Introduction, consent & exposure. Step 2: Note patient’s general appearance whether he/she is cachectic and lethargic. Assess state of alertness and consciousness. Signs of dementia, ataxia, and paresthesias suggest vitamin B12 deficiency. Step 3: Look hands & skin of the patient: Look for pallor, brittle nails, koilonychia and leuconychia. Look for jaundice which suggests hemolytic anemia.
Pallor Nails
Brittle Nails
Leuconychia Leukonychia (or leuconychia), also known as white nails, is a medical term for white discoloration of nails.
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Comprehensive Clinical Skills in Medicine Step 4: Vital signs are reviewed for fever or signs of systemic toxicity (e.g. hypotension, tachycardia). Step 5: Head and neck examination includes: Frontal bossing with prominent malar and maxillary bones suggest Chronic Hemolytic Anemia.
Note Frontal Bossing in both pictures Inspection for hair loss Pale Conjunctiva or mucous membranes Angular Cheilitis suggesting Iron Deficiency Anemia
Angular Cheilitis
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Glossitis
Leg Ulcers in Sickle Cell Disease
Note: Glossitis suggests Iron Deficiency Anemia, Vitamin B12 Deficiency and Folate Deficiency Anemia. Sickle cell ulcers usually begin as small, raised, crusting sores on the lower third of the leg. Leg sores occur more often in males than in females and usually appear between ages 20-50 years.  Look for velvety appearance of the tongue.  Examine the lymph nodes. Step 6: If anemia is due to mal-absorption then signs of mal-absorption can also be seen like muscle wasting, night blindness, bleeding gums, osteomalacia or rickets and poor wound healing. Step 7: Look for edema and bruising (in vitamin B12 deficiency) in the legs. Look for leg ulcers (in sickle cell anemia). Step 8: Cover the patient and say thanks to patient.
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Comprehensive Clinical Skills in Medicine 4-Examining a patient with Rheumatoid Arthritis (Hand examination) Step 1: Introduction, consent & exposure. Step 2: Note general appearance of the hands for any wasting, excessive sweating, palmer erythema, skin thickness, rheumatoid nodules or surgical scars. Also inspect nail changes. Step 3: Note deformities of the hand; Ulnar deviation of meta-carpo-phalangeal (MCP) joints, hyperextension of Proximal inter-phalangeal (PIP) joints and fixed flexion of distal inter-phalangeal (DIP) joints (Swan neck deformity), hyperextension of DIP joints and fixed flexion of PIP joints (Boutonniere deformity) and hyperextension of IP joints and fixed flexion and sublaxation of MCP joint (Z deformity of the thumb).
Swan Neck Deformity
Boutonniere Deformity
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Boutonniere Deformity
Hand with Rheumatoid Arthritis Findings
Step 4: Palpate each joint of the hand and then compare them with joints of other hand. Note for any tenderness. Step 5: Assess the function of hand joints, ask patient to button or unbutton, to write and comb his/her hair. Step 6: Also assess the joint movements at wrist joint, extension and flexion. Step 7: You should also comment on other signs present in patient like, anemia, ocular changes (episcleritis and scleritis), nodules at other body parts, bruising and carpel tunnel syndrome. Step8: Say thanks to patient.
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