Clinical examination Plan of Conduction & Scheme of Recording

Chiranjeevi Kumar

Department of Physiology

AIIMS Bhopal

Three sections

• Vital data.

• General examination.

• Systemic examination.

Vital Data

• Name Of The Institution :

• Name Of The Doctor:

• Ward No:

• Cot No :

• Case No :

• Date:

• Name Of The Patient :

• Age :

• Sex :

• Religion :

• Caste :

• Married Or Single :

• Children :

• Occupation :

• Income

• Address

General History

• The general history is organized into the following

sections:

• Identifying data (ID)

• Chief complaint (CC)

• History of the present illness (HPI)

• Past medical history (PMHx)

• Family history (FHx)

• Medications (MEDS) and Allergies (ALL)

• Social history (SHx)

• Review of systems or functional inquiry (ROS/FI)

History of Present Illness • Symptom characterization:• 0 =Onset and duration• P = Provoking and alleviating factors• Q = Quality of pain (e.g. sharp, dull, throbbing)• R = Does the pain radiate?• S = Severity of pain ("on a scale from 1 to 10, 10 being the

most severe")• T =Timing and progression ("Is the pain constant or

intermittent? Worse in the morning or at nighttime?")• U = "How does it affect 'U' in your daily life?“• V = Deja vu ("Has this happened before?")

• W ='What do you think it is?

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

Instruments And Equipment :

• Stethoscope

• Sphygmomanometer

• Thermometer

• Torch

• Wooden tongue depressors

• Measuring tape

• Note:-

• Exam begins the minute you first see the patient

• Exam continues throughout your patient interaction

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

General examination– General Appearance– Hands and arms– Skin– Face– Eyes– Mouth– Neck– Oedema– Lymph nodes– Vital Signs

• Temperature• Pulse• Respiration Rate• Blood Pressure

General Appearance• General state of health: Healthy/ill/comfortable/Distressed • Body Built and Nutritional status

– Height – Weight– BMI– Obese/lean– Tall/short– Muscular/Asthenic/Cachexic

• State of awareness or level of consciousness• Facial feature/expression/ Mood/Attitude• Speech（ tone/voice)• Position/posture and Gait• Personal Hygiene• Breath/Odor

• General state of health: Healthy/ill/comfortable/Distressed

• Body Built

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.

GigantismDwarfism

Malnutrition

• State of awareness or level of consciousness

Facial feature/expression/ Mood/Attitude

Acromegaly

The enlargement of the frontal and maxillary sinuses results in an prominent brow and long face

Growth of mandible leads to a jutting jaw (prognathism).

Alveolar bone growth causes the teeth to separate

Acromegaly

Macroglossia. There is also generalized visceral enlargement

Broadening and enlargement of the hands and feet due to increased periosteal growth as well as thickening of the skin

Graves’ disease

Ocular involvement is mediated by one or more distinct but still poorly characterised orbital-stimulating immunoglobulins:Proptosis, due to increased volume and edema of retrobulbar fat. Shortened extraocular muscles, because of the muscle infiltration and fibrosis result in upper lid retraction. Conjunctival erythema, and periorbital edema are evident.

Facial expressionThe stare in hyperthyroidism

Hypothyroidism

• The most common cause is the Hashimoto’s thyroiditis, affects appr. 1% of adult populationThis woman demonstrates the typical hypothyroid facies. She also had a slow, hoarse, deep voice and lassitude (state of feeling very tired in mind or body).

• Dull, puffy facies. Edema does not pit with pressure. The lateral eyebrows are thin.

Speech And Language

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

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

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

Compulsive side down positionin patients with one sided pleurisy or pleurorrhea

Orthopnea An abnormal condition in which a person must keep the head elevated (sit or stand) to breathe deeply or comfortably (orthopnea) or wakes up suddenly in the middle of the night short of breath. It can be seen in patients with lung or heart disease

Squar down position It has been seen in patients with congenital heart disease

• Compulsive rest position When patient suffers an angina attack it will force them to rest.

The heart is then able to return to it’s normal working level

• Toss & turn position (alternative position)

• Opisthotonos It is an abnormal posturing condition characterized by

rigidity and severe aching of the back, with head thrown backwards

The typical position of COPD patients

An elderly patient who looks chronically ill. He is unable to speak more than two or three words at a time due to shortness of breath. He has intercostal muscle retraction when breathing and sits upright. Hi is thin with diffuse muscle wasting.

Gait : a way or manner of walkingGait abnormalities describe unusual and uncontrollable

problem with walking

Personal Hygiene

Personal Hygiene

Breath/Odor

HANDS and ARMS• Nails

– Clubbing– Koilonychia– Leuconychia

• Palmar erythema• Dupuytren’s contractures• Hepatic flap

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

HANDS

Palmar erythema Dupuytren’s contractures

ARMS• Spider naevi (telangiectatic lesions)• Bruising• Wasting• Scratch marks (chronic cholestasis)

• Conjuctival pallor (anaemia)• Sclera: jaundice, iritis• Cornea: Kaiser Fleischer’s rings (Wilson’s disease)• Xanthelasma (primary biliary cirrhosis)• Parotid enlargement (alcohol)

FACE, EYES …

Jaundice

Pale Conjunctiva, due to severe anemia

Parotid enlargement

Xanthelasmafat builds up under

the surface of the skin.

Evaluation of Frontal and Maxillary Sinuses

MOUTH• Breath (fetor hepaticus)• Lips

– Angular stomatitis– Cheilitis– Ulceration– Peutz-Jeghers syndrome

• Gums– Gingivitis, bleeding– Candida albicans– Pigmentation

• Tongue– Atrophic glossitis– Leicoplakia– Furring

Atrophic glossitis Thrush

NECK AND CHEST• Cervical lymphadenopathy• Left supraclavicular fossa (Virchov’s node)• Gynaecomastia• Symmetry of the chest

Skin

• The skin is the largest organ of the body

• One of the best indicators of general health

• The examination of the skin is dependent on inspection, but palpation of a skin lesion must also be performed

• The color changes include

– Pallor

– Cyanosis

– Yellow skin (Icterus)

– Redness

– Pigmentation

– Discoloration

Cyanosis

Discoloration Vitiligo • It is a skin condition in which there is loss of pigment

from areas of skin resulting in irregular white patches with normal skin texture

• Associated with pernicious anemia, hyperthyroidism, Addison’s disease

Discoloration Leukoplakia• A precancerous lesion that develops on the tongue or

the inside of the cheek as a response to chronic irritation• Occasionaly, leukoplakia patches develop on the female

external genitalia

Rashes • Skin rashes are frequently one of the manifestation of systemic

diseases, and hence, they are important for the diagnosis of some

special diseases

• The different rashes may occur in infectious disease, dermentological

disease, drug or other allergic materials

• The rashes have some special regular patterns and sharps

• Types of rashes

– Macule

– Roseola

– Papules

– Maculopapulae

– Urticaria

Macule

• A macule is small, flat, distinct colored area of skin • Does not include a change in skin texture or thickness

Rosela • Rosela is a skin lesion that is small, solid, and

raised. It may be seen in measles, drug rashes, eczema

Papule

• A papule is defined as a small (5 millimeters or less), solid lesion slightly elevated above the surface of the skin.

Maculopapulae • It is plate lesion with redness around the

papules• It can be seen in scarlet fever and drug-

induced rashes

Urticaria • Urticaria (hive) are raised red welts of variuos

size on the surface of the skin, often itchy, which come and go. It is associated with allergic reaction

Herpes zoster

• Vesicles in a unilateral dermatomal pattern are typical of herpes zoster

Subcutaneous hemorrhage • Bleeding into the skin & subcutaneous tissues• According to the size of bleeding, it may be subdivided

as follows: petechia <2mm purpura 3~5 mm ecchymosis >5mm

• A hematoma is a large collection that forms a lump

Spider angioma

• Spider angioma is a group of abnormal blood vessel that produces the appearance of a spider-web on the surface of the skin

• A spider angioma lesion typically has a red dot in the center with reddish extensions radiating out for some distance around it

• Liver palms

Spider angioma

From very small to 2 cm; pulsatility is often demonstrable, when pressure with a glass slide is applied. Distribution: upper trunk, face, arms.

Edema

• Excessive build up of fluid in the tissues

• Either occurs throughout the body (generalized swelling)

or limited to a specific part of the body (localized swelling)

• It can be either pitting edema or non-pitting edema

• Mild : facial edema, peripheral edema

• Moderate: generalized edema

• Severe: generalized severe edema

Grading Edema

Protruded eyeballs and periorbital edema

Lymph nodes• The lymph nodes are distributed all over the body• The general physical examination can only palpate the

superficial lymph notes

Palpating Anterior Cervical Lymph Nodes

Lymph nodes of the head and neck

Cervical adenopathy

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

Palpation of Epitrochlear Lymph Nodes

Palpation of the Axilla

Left Axillary Adenopathy

Lymph nodes

• Lymph node enlargement either localized or systemically

• Localized : lymphadenitis

tuberculosis

malignant metastasis

(gradually and painless)

• Systemically: lymphadenitis

lymphoma

leukemia

Vital signs---pulse

60~100 /minChildhood EmotionAgedNight

Vital signs---blood pressure

• Clinical Examination• Personal information• Name: Age: Sex: Address:• 1. General Findings• • General appearance - Normal/ Healthy• • Mental state/ intelligence/ consciousness–Patient conscious, co-operative, well oriented in time,

place and person • • Body Build• o Height - • o Weight - • o BMI - • o Nutritional Status– Normal or average• • Gait - Normal• • Pallor - Absent• • Icterus - Absent• • Cyanosis - Absent• • Clubbing - Absent• • Edema(foot)- Absent• • Lymph nodes – Not palpable• • JVP– Not visible• • Vitals• o Temperature– ….measured/febrile/afebrile• o Pulse - • o Respiration - • o BP -

The systemic examination

• The various systems to be examined are :

• 1. Cardio - vascular system.

• 2. Respiratory system.

• 3. Digestive system .

• 4. Hemopoietic system .

• 5. Excretory system.

• 6. Reproductive system .

• 7. Endocrine system .

• 8. Nervous system .

• 9. Special senses.

Thank You