2002/2003 General Examination 1

History Taking

2002/2003 General Examination 2

• Name • Age• Sex• Occupation• Residence • Marital state, number of children • Menstrual history in some cases

• Special habits of medical importance (e.g. smoking: number of cigarettes & duration)• Social history

Personal History

2002/2003 General Examination 3

In the patient’s own words & duration

Complaint:

2002/2003 General Examination 4

Symptoms are analyzed in relation to each other and chronologically.

Onset : Sudden ,acute or gradual.Course: - Progressive - Stationary - Regressive - Fluctuating - Responce to Tx

Negative information in some cases may be important e.g. central chest pain not related to effort

Review of other systems

History of the present illness

2002/2003 General Examination 5

Previous illness

Drugs

Pregnancies.

Family history:Similar disease

DM

Hypertension

Allergy

Trauma

Surgery

Blood transfusion

Travel abroad

Radiotherapy

Past history:

2002/2003 General Examination 6

Pain : ask about

1-Site: •Midline pain arise from single structure

( heart -liver- pancrease -GIT).

•Localized or diffuse

•Diaphragmatic pleura --> tip of shoulder

•Myocardial ischemia --> retrosternal, Lt arm, Lt shoulder

3-Character of pain: aching, colicky, stabbing, burning…….

2- Radiation :

Example of a symptom’s analysis

2002/2003 General Examination 7

4-Severity of pain

5-Duration: e.g. - Trigemimd neuralgia ( seconds)

- Intestinal colic (minutes)

6-Frequency & Periodicity

7-Time of occurence: e.g.

•Morning headache in migraine & HTN

•After rising in frontal sinusits.

•At the end of the day in tension headache

Pain (cont .)

2002/2003 General Examination 8

8- Aggravating factors : e.g. swallowing in esophagitis

9- Relieving factors: e.g. stop walking in ischemic pain

10-Associated phenomena: e.g. marked swaeting in cardiac pain

Pain (cont .)

2002/2003 General Examination 9

General Examination

2002/2003 General Examination 10

Temperature

Pulse

Blood pressure

Respiratory rate

Routine Data or Vital Signs :

2002/2003 General Examination 11

Radial Artery

2002/2003 General Examination 12

Pulse Examination

2002/2003 General Examination 13

Sphygmomanometer cuff

2002/2003 General Examination 14

Length of the cuff

2002/2003 General Examination 15

Stethoscope

2002/2003 General Examination 16

Brachial Artery

2002/2003 General Examination 17

BP measurement

2002/2003 General Examination 18

Normal: 36 .5 - 37.20c

-Diurnal variation

-Age

-Menstrual cycle variation

Fever: T> 37.40c

-Infection

-Tissue injury

Temperature

2002/2003 General Examination 19

Neoplastic causes Collagen diseases Drugs Endocrine causes CNS causes

Hyperpyrexia:T> 41.50c

2002/2003 General Examination 20

Shock. Hypothyroidism Panhypopituitarism Starvation Damage to anterior hypothalamus Old age Drugs e.g. phenothiazine

Hypothermia:

2002/2003 General Examination 21

Types of fever Continuous Fever: Day & night changes < 10 C -

Pneumonia

-Meningitis

Relapsing Fever: Brucellosis- spirochaetal relapsing fever- Bel Epstein fever (Hodgkin’s disease)- charcoat fever (biliary obstruction)

Intermittent Fever: reaches base line during day

-Malaria Remittent Fever : variation > 10 C

-Septic conditions

2002/2003 General Examination 22

Color changesNormal complexion depends on:-• Thickness of skin

Edema and Myxoedema pallor• Vascularity , Hb

Reduced Hg > 5 gm cyanosis• Presence of pigments .

Bilirubin ++ --> jaundice

Caroten causes yellowish discoloration

2002/2003 General Examination 23

Pallor Look for mucous membrane in inner aspect

of lips

Hb < 6 gm/dl --> pale palmar creases

Causes of pallor: Anemia

Anxiety

Shock

Edema

2002/2003 General Examination 24

Bluish discoloration

-Central ~~~ lateral aspect of under surface

of the tongue (warm hands)

-Peripheral ~~~ extremities (cold hands)

D.D of central cyanosis: ++ methemoglobin

N.B red cyanosis is due to CO poisoning

Cyanosis

2002/2003 General Examination 25

Cyanosis

2002/2003 General Examination 26

Body Built (weight & Hight)

BMI = BW (kg) / Ht (m2)

NormalOver

weight

Obese Morbid

Obesity

20-25 25-30 30-40 >40

Body Built1

2002/2003 General Examination 27

Factors affecting the body built : Racial

Familial

Genetic

Endocrine

Malnutrition in young age

Child hood disease.

Body BuiltBody Built2

2002/2003 General Examination 28

Rigid dorsal decubitusLateral decubitus Coild upOpisthotonusOrthopnea prayers posture SquattingTri Pod position

Decubitus :

2002/2003 General Examination 29

Patient with emphysema bending over in Tri-Pod Position

Tri Pod position

2002/2003 General Examination 30

Examination of the HEAD & FACE

2002/2003 General Examination 31

Head:

Face :

•Size•Shape•Localized swelling

•Expression

•Edema and swelling

•Complexion

•Color change ( pallor - cyanosis - jaundice)

•Individual organs

•Asymmetry

•Malar flush ------

HEAD & FACE

2002/2003 General Examination 32

Facialswelling

Facial swelling causing asymmetry

2002/2003 General Examination 33Facial swelling:Rt periorbital

2002/2003 General Examination 34

Normal Eye

2002/2003 General Examination 35

Jaundice

2002/2003 General Examination 36

Jaundice2

2002/2003 General Examination 37

Edema

Xanthelasma

Dark ring

Ptosis 3rd nerve paralysis - Horner’s syndrome

Myathenia gravis

Congenital retraction

Thyrotoxicosis

Eye Lids

2002/2003 General Examination 38Edema of the eye lids

2002/2003 General Examination 39

Exophthalmus:Congenital

Local condition

Cavernous sinus

A.V aneurysm

Thyrotoxicosis

Enophthalmus: dehydration -----

Eye ball

2002/2003 General Examination 40

Pupils : size – equality - light reaction

Small pinpoint pupils

Mid position fixed pupil: (4-6mm) slightly dilated with no light reaction Mid brain damage

Bilateral small pupils Unilateral( 1- 2.5 nm ) < 1mm

•Sympath. Damage

•Hypothalamic

• Metabolic

•pontine Hge

•Drugs: morphine, heroin , narcoti

•Horner syndrome

Pupils

2002/2003 General Examination 41

Horner syndrome

2002/2003 General Examination 42

“Large” dilated pupils anoxia

Bilaterally dilated pupils

(fixed): drugs (atropine - phenothiazine- tricyclic

antidepressants)

(Reactive)

Unilaterally dilated pupil

( Fixed dilated) Oculomotor paralysis

Temporal lobe herniation ---Mid brain.

•Cocaine•Amphetamine,• LSD• (Sympath. Agonists)

Pupils2

2002/2003 General Examination 43

Hemorrhage Subconjunctivl haemorrage with severe cough

Hypertension

Septicaemia

Bleeding tendency

Conjunctiva

Chemosis: edema

2002/2003 General Examination 44

Conjunctivitis

2002/2003 General Examination 45

ScleraScleritis

Episcleritis

2002/2003 General Examination 46

Scleritis

2002/2003 General Examination 47Nodular Episcleritis in a patient with CD

2002/2003 General Examination 48

Nose

Ear

Cornea

Tophi

Discoloration

Cyanosis

Ochronosis

Dischrge

2002/2003 General Examination 49

Unilateral enlargement as in acute parotitis

Bilateral enlargement as in Sjogren Syndrome

Parotid glands

2002/2003 General Examination 50Unilaterally enlarged parotid

2002/2003 General Examination 51

Color Angular stomatitis Chelitis Hypertrophy Herpes labialis AcromegalyTelangiectasia MyxoedemaTrauma Angioedema

Mouth: Lips

2002/2003 General Examination 52

Fetid breath (Fetor oris)

Breath

AlcoholAcetone : D.K.A Ammonia ---> uraemia

Fetor hepaticus

•Local oral condition •pyorrhea•Suppurative lung syndrome•Pyloric obstruction

2002/2003 General Examination 53

•Dehydration

•Mouth breathing

•Anxiety

•Drugs, e.g. anticholinergics

•Sjögren syndrome

Causes of Dry Mouth

Ptyalism: increased salivation

Mouth : Dryness and increased salivation

2002/2003 General Examination 54

Normal oral cavity

2002/2003 General Examination 55

Left peritonsillar abscess

2002/2003 General Examination 56

Loose teeth: - D.M - Hyperparathyroidism

Wide spaced teeth: acromegaly

Discoloration:

Teeth

•Tobacco •Poor oral hygiene •Flourosis

xxxxx

2002/2003 General Examination 57Tooth AbscessTooth abscess

2002/2003 General Examination 58

Pyorrhea

Bleeding as in:

Gums

Hypertrophy as in:

•Addison

•Heavy metal ( lead and bisthmus) poisoning

•Drugs like epanutin

•Monocytic leukemia

Pigmentation as in:

•Chronic liver disease•Thrombocytopenia

2002/2003 General Examination 59

color Tongue1

pale

Bright red ( firy tongue- pellagra)

Atrophic glossitis ( iron , B12 , riboflavin - pellagra)

Black --> iron mixture

coated --> dehydration

Strawberry tongue scarlet feve

Leukoplakia: precancerous

Pigment : Addison’s disease

2002/2003 General Examination 60

Dry tongue (see causes of dry mouth)

Scrotal tongue (mongolism)

Tremors

Tongue2

Large tongue (macroglossia) as in acromegaly

Anxiety

Smoking

Parkinsonism

Chronic Alcoholism

2002/2003 General Examination 61

Buccal mucosa1

Stomatitis

(Red, swollen& tender)

Catarrhal

Ulcerative

Monilia

Aphthous

Vincent’s angina

Pigmentation

Dark skinned

Addison disease

Intestinal polyposis

Arsenic

Hemochromatosis

2002/2003 General Examination 62

Buccal mucosa2

Enanthema :Koplik’s spots

Petechial Hge: Infective endocarditis - leukaemia

Palate:

Tonsils

•Deformity

•Paralysis

•Vesicles

2002/2003 General Examination 63

Neck Insepction

Palpation Lymph NodesSalivary glandsThyroid other swellings

DeformityAsymmetryPositionLimitation of movementPulsations

2002/2003 General Examination 64

Isthmus

Thyroid gland:anatomy

2002/2003 General Examination 65

Palpation of the thyroid gland:posterior approach

2002/2003 General Examination 66

Palpation of the thyroid gland:anterior approach

2002/2003 General Examination 67

Jugular Vein Carotid Artery

No pulsations palpable. Palpable pulsations.

Pulsations obliterated by pressure above the clavicle.

Pulsations not obliterated by pressure above the clavicle.

Level of pulse wave decreased on inspiration; increased on expiration.

No effects of respiration on pulse.

Usually two pulsations per systole (x and y descents).

One pulsation per systole.

Prominent descents. Descents not prominent.

Pulsations sometimes more prominent with abnominal pressure.

No effect of abdominal pressure on pulsations

Neck veins

2002/2003 General Examination 68Cervical lymph nodes

2002/2003 General Examination 69

Examination of Axillae

Lymph nodes Any swelling

2002/2003 General Examination 70

Examination of the axilla1

2002/2003 General Examination 71

Axillary lymphadenopathy

2002/2003 General Examination 72

Examination of the axilla2

2002/2003 General Examination 73

Examination of the Breast Gynecomastia:Physialogicl

Drugs

Liver cell failure

Klinefelter

Testiculr atrophy and tumors

Adrenal tumors

•Estrogen•Spironolactone •Chloropromazine

2002/2003 General Examination 74

Epitrochlear LN

2002/2003 General Examination 75

Examination of the Upper Limbs:Edema

2002/2003 General Examination 76

DVT of the right arm

2002/2003 General Examination 77

Examination of upper limbs:Cellulitis

Cellulitis of the upper limb

2002/2003 General Examination 78

Cellulitis of the upper limb 2

2002/2003 General Examination 79

Examination of Hands

Shape & Size

Wasting of the muscles

Signs of peripheral vascular disease

Staining of nails: as in heavy cig smokers

White nails uraemia - liver cell failure

Splinter Hg S.A.B.E

See also joint examination

2002/2003 General Examination 80

Acromegaly

2002/2003 General Examination 81

Peripheral Vascular Disease of the UL

2002/2003 General Examination 82

Wasting of the thenar eminance

2002/2003 General Examination 83

Nicotine staining

2002/2003 General Examination 84

Wrist: Ganglion

2002/2003 General Examination 85

Skin1

1. Pigmentation

2. Texture

3. Elasticity

4. Thickness

5. Striae

6. Eruption

2002/2003 General Examination 86

Skin2

1. Pigmentation

Generalized Locaalized

•Addison’s disease•Pellagra•Hemochromatosis•Ochronosis•Arsenic

•Cloasma•Sun burn •Post- inflammatory •X-ray •Neurofibromatosis

Leucoderma: -Vitiligo -leprosy - SLE

- Pityriasis versicolor

2002/2003 General Examination 87

Skin3

2-Texture:Dryness

Sweating

•Dehydration

•Myxedema

•Anxiety •Thyrotoxicosis•Respiratory failure•Hyroglycaemia•Toxemia

2002/2003 General Examination 88

3.Elasticity : cutis loxa - old age - progeria

4.Thickness : -Acromegaly

- Elephantiasis

- Occupational

5.Striae:

•Pregnancy•Obesity•Cushing’s syndrome

Skin4

2002/2003 General Examination 89

6-Eruption:Skin5

Distribution: distribution of sensory nerveHZArrangement:

Morphology:

•Linear lymphangitis •Annular psoriasis•Serpiginous Syphilis •Irregular urticria

•Monomorphic •Pleomorphic

Type:Macule- papule- nodule- plaque- vesicles- bullae- pustule - wheals - scales - crust – erosion - fissure- ulcers –scar - atrophy - sclerosis.

2002/2003 General Examination 90

Dilated Blood vessels

Skin6

•Petechie 1-2 mm (Hess test)

•Purpura: e.g. thrombocytopenia , Senile purpura

•Ecchymosis > 5 mm

•Collaterals

•Telangiectsia.

•Haemangioma

•Vascular spiders

•Campbell de Morgan spots

2002/2003 General Examination 91

Telangiectasia

2002/2003 General Examination 92

Fall of hair :

Look for Distribution: {head, face, axillae, and pubis)

Skin-Hair

Hirsutism: excessive growth of body hair of a female•Idiopathic•Racial•Endocrine: Cushing- adrenogenital syndrome- polycystic ovary.

•Endocrine: Myxoedem - Addison’s disease - Sheehan’s syndrome- Eunchiadism•Infection•Localized fall of hair: Alopecia areata

2002/2003 General Examination 93

Lymph nodes1

•Group {cervical (superfacial and deep) , scalene (Lt virchow), axillary, epitrochlear, inguinal }.

•Size

•Consistency

•Tenderness

•Matting

•Mobility

•Relation to surrounding structures.

2002/2003 General Examination 94

Lymph nodes2

Lymphadenopathy:

Localized :•Acute lymphadenitis•T.B •Hodgkin’ disease

Generalized:•Viral : glandulr fever•Leukemia . Lymphoma•Syphilis •Sarcoidosis

2002/2003 General Examination 95

Examination of the Lower Limbs

2002/2003 General Examination 96

Peripheral pulsation :Dorsalis pedis

2002/2003 General Examination 97

Peripheral pulsations :Dorsalis pedis 2

2002/2003 General Examination 98

Peripheral pulsations :post tibial artery

2002/2003 General Examination 99Peripheral pulsations :posterior tibial artery2

2002/2003 General Examination 100

Popliteal artery

2002/2003 General Examination 101

Acute vascular insufficiency:mottled appearance

2002/2003 General Examination 102

Chronic arterial insufficiency

2002/2003 General Examination 103

Digital gangrene

2002/2003 General Examination 104

Chronic Venous Insufficiency

2002/2003 General Examination 105

Neuropathic ulcer in a diabetic patient

2002/2003 General Examination 106

Inspection

Pressure over bony prominance for 5 to 30 sec just behind and below medial malleoli and sacrum

For soft tissue edema:

Lower limbs: edema1

• pinching dimpling of skin ( Peou’d ‘orange)

• press with the stethoscope

2002/2003 General Examination 107

Edema may be:Lower limbs:Edema2

Hard as in chronic. lymphatic obstruction.

SoftCauses of Soft Edema:

Localized edema: Inflammtory (hot, red, tender)- Angioneurotic - DVT- Paralysis --> paralyzed side

Generlized edema:•Renal•Cardiac•Nutritional•Hepatic

2002/2003 General Examination 108

LL edema

2002/2003 General Examination 109

Pitting edema of the lower limb

2002/2003 General Examination 110

Erythema nodosum

2002/2003 General Examination 111Onychomycosis

2002/2003 General Examination 112

Genitalia

Joints : •Swelling •Deformity•Overlying skin•Tenderness•Atrophy of muscles•Limitation of movement•Hypermobility•Eruption

Genitalia and Joints

2002/2003 General Examination 113

Rheumatoid arthritis

2002/2003 General Examination 114

RA: boutonniere finger

2002/2003 General Examination 115

Rheumatoid arthritis 2

2002/2003 General Examination 116

Heberdens nodesHeberdens nodes

2002/2003 General Examination 117

Gout: MCP joints

2002/2003 General Examination 118

Leprosy