General examination

2002/2003 General Examination 1

History Taking


• 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


In the patient’s own words & duration

Complaint:


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


Previous illness

Drugs

Pregnancies.

Family history:Similar disease

DM

Hypertension

Allergy

Trauma

Surgery

Blood transfusion

Travel abroad

Radiotherapy

Past history:


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


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 .)


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 .)


General Examination


Temperature

Pulse

Blood pressure

Respiratory rate

Routine Data or Vital Signs :


Radial Artery


Pulse Examination


Sphygmomanometer cuff


Length of the cuff


Stethoscope


Brachial Artery


BP measurement


Normal: 36 .5 - 37.20c

-Diurnal variation

-Age

-Menstrual cycle variation

Fever: T> 37.40c

-Infection

-Tissue injury

Temperature


Neoplastic causes Collagen diseases Drugs Endocrine causes CNS causes

Hyperpyrexia:T> 41.50c


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

Hypothermia:


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


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


Pallor Look for mucous membrane in inner aspect

of lips

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

Causes of pallor: Anemia

Anxiety

Shock

Edema


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


Cyanosis


Body Built (weight & Hight)

BMI = BW (kg) / Ht (m2)

NormalOver

weight

Obese Morbid

Obesity

20-25 25-30 30-40 >40

Body Built1


Factors affecting the body built : Racial

Familial

Genetic

Endocrine

Malnutrition in young age

Child hood disease.

Body BuiltBody Built2


Rigid dorsal decubitusLateral decubitus Coild upOpisthotonusOrthopnea prayers posture SquattingTri Pod position

Decubitus :


Patient with emphysema bending over in Tri-Pod Position

Tri Pod position


Examination of the HEAD & FACE


Head:

Face :

•Size•Shape•Localized swelling

•Expression

•Edema and swelling

•Complexion

•Color change ( pallor - cyanosis - jaundice)

•Individual organs

•Asymmetry

•Malar flush ------

HEAD & FACE


Facialswelling

Facial swelling causing asymmetry

2002/2003 General Examination 33Facial swelling:Rt periorbital


Normal Eye


Jaundice


Jaundice2


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


Exophthalmus:Congenital

Local condition

Cavernous sinus

A.V aneurysm

Thyrotoxicosis

Enophthalmus: dehydration -----

Eye ball


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


Horner syndrome


“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


Hemorrhage Subconjunctivl haemorrage with severe cough

Hypertension

Septicaemia

Bleeding tendency

Conjunctiva

Chemosis: edema


Conjunctivitis


ScleraScleritis

Episcleritis


Scleritis

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


Nose

Ear

Cornea

Tophi

Discoloration

Cyanosis

Ochronosis

Dischrge


Unilateral enlargement as in acute parotitis

Bilateral enlargement as in Sjogren Syndrome

Parotid glands

2002/2003 General Examination 50Unilaterally enlarged parotid


Color Angular stomatitis Chelitis Hypertrophy Herpes labialis AcromegalyTelangiectasia MyxoedemaTrauma Angioedema

Mouth: Lips


Fetid breath (Fetor oris)

Breath

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

Fetor hepaticus

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


•Dehydration

•Mouth breathing

•Anxiety

•Drugs, e.g. anticholinergics

•Sjögren syndrome

Causes of Dry Mouth

Ptyalism: increased salivation

Mouth : Dryness and increased salivation


Normal oral cavity


Left peritonsillar abscess


Loose teeth: - D.M - Hyperparathyroidism

Wide spaced teeth: acromegaly

Discoloration:

Teeth

•Tobacco •Poor oral hygiene •Flourosis

xxxxx

2002/2003 General Examination 57Tooth AbscessTooth abscess


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


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


Dry tongue (see causes of dry mouth)

Scrotal tongue (mongolism)

Tremors

Tongue2

Large tongue (macroglossia) as in acromegaly

Anxiety

Smoking

Parkinsonism

Chronic Alcoholism


Buccal mucosa1

Stomatitis

(Red, swollen& tender)

Catarrhal

Ulcerative

Monilia

Aphthous

Vincent’s angina

Pigmentation

Dark skinned

Addison disease

Intestinal polyposis

Arsenic

Hemochromatosis


Buccal mucosa2

Enanthema :Koplik’s spots

Petechial Hge: Infective endocarditis - leukaemia

Palate:

Tonsils

•Deformity

•Paralysis

•Vesicles


Neck Insepction

Palpation Lymph NodesSalivary glandsThyroid other swellings

DeformityAsymmetryPositionLimitation of movementPulsations


Isthmus

Thyroid gland:anatomy


Palpation of the thyroid gland:posterior approach


Palpation of the thyroid gland:anterior approach


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


Examination of Axillae

Lymph nodes Any swelling


Examination of the axilla1


Axillary lymphadenopathy


Examination of the axilla2


Examination of the Breast Gynecomastia:Physialogicl

Drugs

Liver cell failure

Klinefelter

Testiculr atrophy and tumors

Adrenal tumors

•Estrogen•Spironolactone •Chloropromazine


Epitrochlear LN


Examination of the Upper Limbs:Edema


DVT of the right arm


Examination of upper limbs:Cellulitis

Cellulitis of the upper limb


Cellulitis of the upper limb 2


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


Acromegaly


Peripheral Vascular Disease of the UL


Wasting of the thenar eminance


Nicotine staining


Wrist: Ganglion


Skin1

1. Pigmentation

2. Texture

3. Elasticity

4. Thickness

5. Striae

6. Eruption


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


Skin3

2-Texture:Dryness

Sweating

•Dehydration

•Myxedema

•Anxiety •Thyrotoxicosis•Respiratory failure•Hyroglycaemia•Toxemia


3.Elasticity : cutis loxa - old age - progeria

4.Thickness : -Acromegaly

- Elephantiasis

- Occupational

5.Striae:

•Pregnancy•Obesity•Cushing’s syndrome

Skin4


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.


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


Telangiectasia


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


Lymph nodes1

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

•Size

•Consistency

•Tenderness

•Matting

•Mobility

•Relation to surrounding structures.


Lymph nodes2

Lymphadenopathy:

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

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


Examination of the Lower Limbs


Peripheral pulsation :Dorsalis pedis


Peripheral pulsations :Dorsalis pedis 2


Peripheral pulsations :post tibial artery

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


Popliteal artery


Acute vascular insufficiency:mottled appearance


Chronic arterial insufficiency


Digital gangrene


Chronic Venous Insufficiency


Neuropathic ulcer in a diabetic patient


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


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


LL edema


Pitting edema of the lower limb


Erythema nodosum

2002/2003 General Examination 111Onychomycosis


Genitalia

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

Genitalia and Joints


Rheumatoid arthritis


RA: boutonniere finger


Rheumatoid arthritis 2


Heberdens nodesHeberdens nodes


Gout: MCP joints


Leprosy

General examination

Health & Medicine

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