general examination
TRANSCRIPT
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