Learning objectives
- Importance of taking history.
- Importance of general examination.
- Examine and elicit different signs.
- Physiological basis
- Correlate with the pathophysiology of the disease processes.
- Why? Where? How? What? Whom? When?
History taking
Preliminary data
- Name:
- Age:
- Gender:
- Educational Qualification:
- Occupation:
- Address:
Chief complaints
History of the presenting illness
- Onset, duration, progression, diurnal variations, aggravating & relieving factors Past history/injuries/operations
- Special or specific questioning about symptoms pertaining to the system involved
Drug history
Family history
Personal history - Sleep/Diet/Bowel & Bladder
General Physical Examination
- No embracement/discomfort to the patient
- Done in broad daylight
- General appearance
- Mental state and intelligence
- Consciousness and cooperation
- Build & Nutrition
- Development (Ht., Wt., Sexual)
1) General appearance
- Look weather the patient is healthy, unwell or ill.
- If looks ill assess the severity of illness
- Ill
- very ill
- In distress
2) Mental state and intelligence
- Assess mood, intelligence and emotional state
- Intelligence assessed by
- Education
- Occupation
- General knowledge
3) Conscious and cooperation
- Assess the level of consciousness
- Clear sensorium
- Drowsiness
- Stupor
- Semicoma
- Coma
4) Build & Nutrition
- Assess the skeletal structure of the person in relation to age and sex
- Tall or short
- Lean or fat
- Muscular or asthenic
- Assess nutritional status by
- Taking dietary history
- By performing
- Physical examination
- Bulk of the muscles
- Body fat (skinfold thickness)
- Anthropometric measurements (Ht., Wt.)
- Malnutrition may be due to starvation, maldigestion or malabsorption
5) Height, Weight & Sexual development
Height:
- Recorded
- Empty stomach
- Without shoes
- Minimum clothing
- Assess weight is normal for age and sex
Weight:
- To assess the average height for age and sex
- Measurement of
- Arm span (tip of middle finger of one side to other side)
- Upper segment (crown to pubic symphysis)
- Lower segment (pubic symphysis to foot)
- Normal individual
- Arm span = Height
- Upper segment = Lower segment
Sexual development:
- Assess for the development of secondary sexual characteristics
- Secondary sexual characteristics develop
- In males: 13 to 18 years
- In females: 11 to 15 years
- Pallor(Anemia)
- Icterus(Jaundice)
- Cyanosis
- Clubbing
- Lymphadenopathy
- Edema
Pallor
- Paleness of skin
- Depends on
- Thickness and quality of skin
- Amount and quality of blood in capillaries
- Detected by examining
- Lower palpebral conjunctiva
- Tip and dorsum of tongue
- Soft palate
- Palms
- Nails
Degree of Pallor
- Pallor: 0 (no anemia)
- Pallor: + (mild anemia)
- Pallor: ++ (moderate anemia)
- Pallor: +++(severe anemia)
Icterus (Jaundice)
- Yellowish discoloration of skin and mucus membrane due to presence of excess bilirubin in blood
- Normal serum bilirubin: 0.2 to 0.8 mg/100 ml
- 0.8 to 2 mg/100ml – Hyperbilirubinemia or subclincial/latent jaundice
- > 2 mg/100ml – Clinical jaundice
Types of Jaundice
- Pre-hepatic jaundice
- Hepatic jaundice
- Post-hepatic jaundice
Causes of yellow discolouration of skin
- Jaundice
- Carotenemia (excess carotene)
- Hemochromatosis (excess iron)
- Picrates
- Mephacrine
Method to assess
- Upper eyelids are retracted upwards and subject is asked to look downward to assess the yellow discoloration of sclera
Cyanosis
- Bluish discoloration of skin and mucous membrane due to presence of more than 5g% of reduced hemoglobin
- Skin and mucous membrane becomes blue due to dark colour of reduced hemoglobin
Types of Cyanosis:
- Peripheral
- Central
- Mixed
Peripheral cyanosis
- Due to slowing of blood through the tissues: more time for removal of oxygen
- Causes
- Heart failure: decreased cardiac output
- Extreme cold: local vasoconstriction
- Venous obstruction: SVC obstruction
- Polycythemia: increased viscosity of blood
Central cyanosis
- Mixture of arterial and venous blood
- Causes
- Right left shunt
- Fallot’s tetralogy
- Pulmonary arteriovenous fistula
- Patent truncus arteriosus
- Transposition of great vessles
- Inadequate oxygenation of arterial blood
- High altitude: low atmospheric oxygen
- Inadequate ventilation: airway obstruction, lung collapse
- Decreased gaseous exchange: hyaline membrane disease
Note
- Patients suffering from severe anemia with hemoglobin content less than 5 g% may not show cyanosis (as the total hemoglobin is less than 5 g%)
- Cyanosis may not be seen in carbon monoxide poisoning, because carboxyhemoglobin prevents reduction of oxyhemoglobin and the color of carboxyhemoglobin is cherry red.
Clubbing
- Bulbous enlargement of soft parts of the terminal phalanges with overcurving of the nails both transversely and longitudinally
- Detection
- Nail bed fluctuation
- Curving of nails
- Profile sign
- Schamroth’s sign
- Base angle
1) Nail bed fluctuation
Increased fluctuation in clubbing
2) Curving of nails
Hypertrophy of nail bed tissue
3) Profile sign
Presence of transverse ridge
4) Schamroth’s sign
Schamroth’s sign positive: loss of space
5) Base angle
Physiological Basis
- Dilatation of AV anastomosis: hypertrophy of tissues in the nail bed
- Increased pressure gradient: oedema
- Capillary stasis
- Vitamin deficiency and hormonal disorders
Causes
- Bronchopulmonary diseases
- Bronchiectasis
- Lung absess
- Bronchoenic carcinoma
- Emphysema
- Cardiac diseases
- Congenital cyanotic heart disease
- Subacute bacterial endocarditis
- GI diseases
- Ulcerative colitis
- Biliary cirrhosis of liver
- Endocrine disorders
- Thyrotoxicosis
- Acromegaly
- Hereditary
Degrees of Clubbing
- First degree
- Increased fluctuation of nail bed
- Second degree
- Increased fluctuation
- Curving of nails
- Third degree
- Increased fluctuation
- Curving of nails
- Base angle
- Fourth degree
- Increased fluctuation
- Curving of nails
- Base angle
- Subperiosteal thickening of wrist and ankle bones
Lymphadenopathy
- Neck, axillary, inguinal region and supratrochelar areas of both sides
- Neck: stand behind with patients head slightly flexed
- Axillary: stand behind with patients hand slightly abducted
- Inguinal region: supine position with thighs extended
Lymph nodes are palpated to check their
- Size and shape
- Longest diameter in cm, surface may be smooth, irregular or lobulated
- Consistency
- Often elastic and ruberry
- TB: firm, Syphilis: shotty, Carcinoma: hard
- Mobility
- Mobile or fixed
- Tenderness
- Tender or non-tender
Causes of Lymphadenopathy:
- Neoplastic
- Hematologic
- Lymphomas (Hodgkin and non-Hodgkin)
- Acute Leukemia,
- Chronic lymphocytic leukemia
- Non Hematologic
- Ca. breast
- Ca. lungs
- Inflammatory
- Infections
- Tuberculosis
- Syphilis
- Filariasis
- Infectious mononucleosis
- Connective tissue diseases
- Systemic lupus erythematosus
- Sarcoidosis
- Endocrine
- Hyper thyroidism
- Addison’s disease
- Drugs
- Carbamazepine
- Cephaloridine
- Meprobamate
- Phenylbutazone
- Phenytoin
Oedema
- Swelling of skin and subcuteneous tissues due to accumulation of free fluid in excess in the interstitial tissue space
- Types
- Localised or Generalised
- Pitting or Non pitting (Filariasis)
- Detection
- Pressing against the dependent parts (pits)
Causes of oedema:
- Cardiac causes
- Congestive Heart Failure
- Constrictive pericarditis
- Hepatic causes
- Cirrhosis of liver
- Carcinoma of liver
- Renal causes
- Nephrotic syndrome
- Acute nephritis
- Anemia and hypoproteinemia
Special features:
- Cardiac oedema
- Usually seen in dependent parts
- Dyspnea at rest
- Hepatic oedema
- Prominent on the abdomen
- Ascites
- Renal oedema
- First appears in the face
- Puffiness of lower eye lid in the morning
- Anemia and hypoproteinemia
- Generalised oedema - Anasarca
- Severe pallor
Skin
Daylight, maximum surface of body exposed
- Colour of skin
- Pallor: Anemia
- Yellow: Jaundice
- Blue: Cyanosis
- Pigmentation
- White: Albinism
- White and Black patches: Vitiligo
- Dark: Addison’s disease
Eruptions
- Macules
- Papules
- Vesicles
- Pustules
- Petechiae
Secondary lesions
- Scales
- Crusts
- Exoriations
- Fissures
- Ulcers
- scars
Vital Signs
- Pulse
- Blood Pressure
- Respiration
- Temperature
Temperature
- Recorded by clinical thermometer
- Mouth/axilla: 1 minute, Rectum in Infants
- Normal value (36.6 to 37.2 deg C/98-99 deg F)
- Febrile
- Mild fever
- Moderate fever
- High fever
- Hyperpyrexia
- Subnormal
- Hypothermia
Fever
- Increase in the diurnal variation of body temperature of more than 1 deg C (1.5 deg F)
- Types
- Continuous fever
- Remittent fever
- Intermittent fever
Continuous fever
- Temperature remains high throughout the day, diurnal variation not more than 1 deg C
- Seen in
- Typhoid
- Subacute bacterial endocarditis
- Urinary tract infection
- Brucellosis
- Glandular fever
Remittent fever
- Temperature remains raised throughout the day, diurnal variation > 2 deg C
Intermittent fever
- Temperature remains raised only for several hours during the day and remits to normal for the rest of the day
Causes of Fever
- Infections
- Bacterial
- Viral
- Rickettsial
- Fungal
- Parasitic
- Immunologic
- Rheumatic fever
- Rheumatoid arthritis
- Other collagen diseases
- Neoplastic
- Ca of any organ
- Leukemia
- Metabolic
- Gout
- Porphyria
- Addisons’s disease
- Physical agents
- Heat stroke
- Radiation sickness
- Drug induced
Hypothermia
- Condition in which body temperature decreases below the normal range
- Causes
- Prolonged exposure to cold
- Myxedema
- Hypopituitarism
- Hypoglycemia
- Hypnosedative poisoning
- Physiological effects
- Bradycardia, hypotension, shallow respiration, confusion, stupor and coma
Systemic Examination
- Inspection
- Palpation
- Percussion
- Auscultation