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General Physical Examination




          General Physical Examination :
                                        
History
Introductory information
  • Introduce, shake hands.
  • Name, age, sex, residence, occupation, DOA.
Presenting complaint
  • What is the problem lately. Alternatively: What is the problem that brought you to hospital [record in pt's own words].
History of presenting complaint
SOCRATES:
  • Site: where, local/ diffuse, "Show me where it is worst".
  • Onset: rapid/ gradual, pattern, worse/ better, what did when symptom began.
  • Character: vertigo/ lightheaded, pain: sharp/ dull/ stab/ burn/ cramp/ crushing.
  • Radiation [usually just if pain].
  • Alleviating factors, "What do you do after it comes on?"
  • Time course: when last felt well, chronic: why came now.
  • Exacerbating factors, "What are you doing when it comes on?".
  • Severity: scale of 1-10.
  • Associated symptoms.
  • Impact of symptoms on life: "Does it interrupt your life".
  • "Were you referred here by your GP, or did you come in through casualty?" 
Past medical, surgical history
  • Past illnesses, operations.
  • Childhood illness, obs/gyn.
  • Tests and treatment prescribed for these.
    • Drugs remaining relevant: corticosteroids, OCP, anti-HTN, chemotherapy, radiotherapy.
  • Checklist of dz's:
    MJ THREADS:
    MI, Jaundice, TB, HTN, Rheumatic fever, Epilepsy, Asthma, Diabetes, Stroke
  • Problems with the anesthetic in surgery.
  Gynecological history
  • Time of menarche, if periods regular, menopause.
  • Possibility of pregnant, number of children, number of miscarriages (GPAL).
  • Length of cycles, length of period, first day of your last period.
Family history
  • The current complaint in parents/ siblings: health, cause of death, age of onset, age of death [eg: heart dz,  bowel CA, breast CA].
  • Health of parents/ siblings/ children: "Are your parents still alive?" "How is the health of your..."
  • Hereditary dz suspected: do a family tree.
Social, personal history
  • Birthplace, residence.
  • Race and migration [if relevant].
  • Present occupation [and what do they do there], level of education.
  • Any others at workplace with same complaint.
  • Social habits [if relevant].
  • Smoking: "Ever smoked, how many per day, for how long, type [cigarette, pipe, chew]".
  • Alcohol: do you drink. If yes: type, how much, how often.
  • Travel: where, how lived when there, immunization/ prophylactic status when went [if relevant].
  • Marital status [and quality], health of spouse/ children, sex activity [discretely, if relevant].
  • Other household members, pets [if infections/ allergies], social support, whether patient can manage at home: "Who's with you there at home".
  • Diet, physical activity.
  • Community care: home help, meals on wheels. 
  • "Is there some things that worry you about the symptoms you are having?"
Drug history
  • Prescriptions currently on [don't trust their written doses, do your own when re-prescribe].
  • Over-the-counters.
  • OCP.
  • Supplements, HRT.
  • Alternative medications.
  • Recreational drugs.
  • Allergies: drugs [and what was reaction], dyes. Pt. often will confuse side effect with a reaction.
Systems review
  • See Systems.










Text Box: Skin Colors Reference.
Cyanotic
• COLD PALMS:
• Peripheral cyanosis:
• Cold.
• Obstruction.
• LVF and shock.
• Decreased cardiac output.
• Central cyanosis:
• Polycythemia.
• Altitude.
• Lung dz.
• Met-, sulphaemoglobinaemia.
• Shunt.
Hyperpigmented
• Addison's.
• Drugs.
• Hemochromatosis ["bronze diabetes"].
• Malabsorption.
Jaundiced
• Direct: DROP:
• Dubin-Johnson/ Diffuse hepatocellular dz [drug or viral hepatitis, cirrhosis].
• Rotor.
• Obstruction.
• Pregnant.
• Indirect: ABCDEFGHI:
• Anemia [hemolytic, pernicious].
• Breast feeding jaundice.
• Craig-Najjar.
• Diffuse hepatocellular dz [drug or viral hepatitis, cirrhosis].
• EPO insufficiency [thalassemia, etc].
• Fetus [physiologic jaundice of newborn].
• Gilbert's.
• Heart failure.
• Internal bleeding.
Pallid
• Anemia
• Shock.
Carcinoid
• Carcinoid syndrome
Cherry red
• CO poisoning
----------------------

Examination
Environment
General appearance
  • Pre-exam checklist: WIPE:
    Wash your hands
    Introduce yourself to pt
    Position pt
    Expose the area
  • Always examine from the R side of the pt.
  • Ask pt. if tenderness anywhere, before start touching them.
  • Skin colors. See Skin Colors Reference.

Posture, weight, body shape
  • If pt. enters, examine gait.
  • Posture, stature, height..
  • Obesity [BMI = kg/m^2. Normal <25].
  • Limb amputations, deformities.
  • Physique expected for age.
Hydration
  • Sunken orbits.
  • Mucus membrane dryness.
  • Axillae.
  • Skin turgor [pinch skin: normal returns immediately].
  • Postural hypotension [less BP when sit, stand].
  • Peripheral perfusion [press nose, time capillary return].
  • Examine weight loss over hours.
Vital signs
·         Often logged on ward chart.
·         See Taking Vital Signs Reference
1.      Temperature
·         Types:
• Axillary: worst
• Oral
• Aural
• Rectal: best
·         Text Box: v Pulse Reference.
Rate
<60: bradycardia,  >100: tachycardia
Rhythm
• Regular, Regularly irregular,Irregularly irregular
Character
• Bounding pulse:
• CO2 poisoning
• Collapsing pulse, aka 'water hammer pulse':
• Aortic regurgitation
• Heart block
• PDA 
• Plateau pulse:
• Aortic stenosis
• Pulsus alterans [alternate strong, weak beats]:
• LVF
• Pulsus paradoxus [volume decreases on inspiration more than normal: by >10mm Hg]:
• Constrictive pericarditis
• Tamponade
• Severe asthma
• Small volume:
• Aortic stenosis
• Shock
• Pericardial effusion
Delays
• Radioradial delay
• Radiofemoral delay: test in pts with HTN or ejection systolic murmur:
• Coarctation of aorta
Surface anatomy of pulses
• Radial
• Palmar side of wrist, between flexor carpi radialis tendon and radius.
• Brachial
• Cubital fossa, medial to biceps tendon.
• Carotid
• Just lateral to upper border of thyroid cartilage.
• Superficial temporal:
• Abdominal aorta:
• In midline, at umbilicus pressing into abdomen.
• Use caution if large AAA, to avoid rupture.
• Femoral
• Below inguinal ligament, midway between ASIS and pubic symphysis [not pubic tubercle].
• May be reduced or absent in arteriosclerotic dz.
• Popliteal
• Flex knee before palpating.
• In midline, on popliteal side of lower end of femur.
• Most difficult one to palpate.
• Alternative method: Dr's one hand on pt's knee, other hand under knee. Push flexed knee downwards [into extension] until can feel popliteal.
• Posterior tibial
• Posterior, inferior to medial malleolus, between flexor digitorum longus and flexor hallucis longus.
• Dorsalis pedis
• Lateral to extensor hallucis longus, over tarsal bones.
• Palpate with 3 fingers along artery.
• May be reduced or absent in peripheral vascular dz.
• For JVP, See JVP Reference.................(end)


Timing:
• Continued
• Intermittent
• Remittent
• Relapsing
·         Nomenlature:.
• Hyperpyrexia: >41.6°C
• Hypothermia: <35°C
2.      Pulse
v  Shake hands: Dr's L to pt's L.
v  During handshake grip Dr's R hand takes pulse.
v  Measure for 15 seconds, then multiple by 4 to get rate/min.
v  Assess rhythm, character, delays.
3.      Respiratory rate
·         Don't announce measuring it, since under pt's control.
·         Adult normal: 14-20/min.
4.      Blood pressure
·         Pt's anticubital fossa level with heart, arm slightly bent.
·         Proper-sized cuff over brachial a. 2cm above anticubital fold.
·         Inflate cuff until pulse disappears to tell systolic
• If HTN, then need to palpate radial as inflate.
·         Stethoscope over brachial a., inflate cuff 30mmHg more.
·         Release pressure, when hear pulse, tells diastolic.
Text Box: JUGULAR VENOUS PRESSURE
• Manometer of right atrial pressure.
• Function at waveform points: ASK ME:
• Atrial filling
• Systole
• Klosed tricuspid
• Maximal atrial filling
• Emptying of atrium
• S1 occurs with 'a' and 'c' wave, S2 occur with 'v' wave.
Distinguishing JVP from carotid
• Fills from above.
• Complex, double pulsation for each arterial pulse [if pt has normal sinus rhythm].
• Usually visible, but not palpable.
• Changes with posture [decreases as sit up more vertical].
• Moves on inspiration [decreases in healthy].
• Hepatojugular reflux.
Examination of JVP
• Pt. must be at 45°. Pt's head tilted upwards and facing slightly away from Dr.
• Use the internal jugular, not external jugular. External jugular is lateral to SCM and easier to see. Internal jugular is medial/behind the clavicular head of SCM. 
• Shine a torch [light] on internal jugular vein at an oblique angle.
• Extend torch out horizontally from highest point of JVP pulsations, use ruler to measure vertical height from sternal notch to torch.
• Height >3cm above sternal angle is pathologic (raised ventricular filling pressure or volume overload often from RHF). Key is 3cm and JVP has 3 letters.
• In normal person, usu. can't see the JVP when pt is at 45°, but can see when pt is flat.
• Optionally: auscultate heart or feel carotid pulse to help identify JVP by its complex waveform.
Exam: Kussmaul's sign
• Place Pt. sitting up at 90°.
• JVP becomes more distended during inspiration (classically constrictive pericarditis, currently severe RHF). This is opposite of what happens in normal pt.
• Usually negative in cardiac tamponade.
Exam: hepatojugular reflux
• Exert pressure on liver for 15 sec.
• Venous return to right atrium increases.
• JVP will rise transiently in normal person.
• Check if remains elevated (RVF).
Causes of elevated JVP
v Too much fluid:
• Fluid overload [esp. IV infusion]

.
Nails
Hands
  • Palms:
    • Palmar erythema (cirrhosis, polycythaemia, pregnancy).
    • Pigmentation of crease (Addison's, but normal in asians, blacks).
    • Pallor of palmar crease. Better results if hyperextend fingers, or stretch skin on either side of crease (anemia).
    • Dupuytren's contracture [fibrosis, contracture of palm's fascia] (liver dz, epilepsy, trauma, elderly).
  • Joints:
    • Herberdens, Bouchards (OA).
    • Swollen PIP, distal PIP spared (RA).
Head
  • Hair: deficiency, excess.
  • Facial hallmarks (Down's, Grave's, acromegaly, Cushing's, etc).
  • Teeth: nicotine stains.
Examination tips
  • Initial examination is from the foot of the bed.
  • Always ask if any part tender, before touching pt.
  • Watch pt's head as palpate, to look for pain flinches.
  • Percussion is R middle finger hitting middle of middle phalynx of L middle finger.
  • To measure circumference of limbs, choose the bony landmark on each, measure down the correct distance, then take the circumference at that point.
General Systems Review
Text Box: v It's clogging up before gets to heart:
• SVC obstruction
v Can't beat it out of the heart fast enough:
• RVF
• Bradycardia
• Constrictive pericarditis
• Pericardial effusion
• Tricuspid stenosis or regurgitation
v Other:
• Hyperdynamic circulation
Abnormal waveform causes
• Dominant a wave
• Pulmonary stenosis
• Pulmonary hypertension
• Tricuspid stenosis
• Cannon a wave
• Complete heart block
• Paroxysmal nodal tachycardia
• Ventricular tachycardia
• Dominant v wave [easily heard].
• Tricuspid regurgitation
• Absent x descent
• Atrial fibrillation
• Exaggerated x descent
• Cardiac tamponade
• Constrictive pericarditis
• Sharp y descent
• Constrictive pericarditis
• Tricuspid regurgitation
• Slow y descent
• Right atrial myxoma...............(end)
• -----_____________


Cardiovascular
  • Chest pain, pressure
  • Shortness of breath, exertion required
  • Lie flat or use pillows, how many pillows
  • Awoke breathless at night
  • Noticed heart racing, aware of heartbeat
  • Ankle swelling
  • Cold/ blue hands, feet
Pulmonary
  • Cough: sputum, blood
  • Shortness of breath, wheeze
  • Snore loudly, apnea
  • Fever, night sweats
  • Recent chest X-ray
  • Breast: lumps, bleeding, masses, discharge
Text Box: 4: Drumstick shaped fingertip.
5: Pt has wrist pain and wrist onion skinning.
6: Hypertrophic osteopathy.
Koilonychia
• What: misshapen, spoon-shaped nails.
• DDx:
• Iron deficiency
• Birth abnormality, rarely
Onycholysis
• What: distal nail separation.
• DDx:
• Trauma
• Psoriasis
• Thyrotoxicosis
Pitting
• DDx:
• Psoriasis
• Atopic eczema
• Allopeica areata
Thickening
• What: extremely thickened nail, esp. great toe
• DDx:
• Geriatric pt: onychogryphosis
• Psoriasis
• Local fungal infection 
Nail color: leuconychia
• What: leuco- means white, like a leucocyte.
• DDx:
• Hypoalbuminemia
Nail color: yellow
• DDx:
• Nicotine stains
• Yellow nail syndrome [peripheral edema, bronchiectasis, pleural effusion] 
Nail color: blue
• DDx:
• Cyanosis
• Ochonosis
• Wilson's [esp. lulunae of nails]
• Blue-red: polycythemia
Nail colour: red
• DDx:
• Cherry red: CO poisoning
Nail color: melanonychia
• What: multiple, brownish, longitudinal streaks
• DDx:
• Black pt: normal
• White pt: melanoma under fingernails 
Nail bed pallor
• What: pallor of the flesh underneath the nails.
• DDx:
• Anemia. See Anemias Reference.
Nail bed erythema/ telangiectasia
• What: flushed skin or distended blood capillaries below and around nail, esp at nail base. See Skin Lesion Terminology Reference.
• DDx:
• SLE
Splinter hemorrhages
• What: small, linear hemorrhages under the nail.
• DDx: SPLINT:
• Sepsis elsewhere
• PAN/SLE/RA
• Limey [vitamin C deficiency]
• IE
• Neoplasm [hematologic]
• Trauma**
Alimentary
  • Weight, appetite changes
  • Abdominal pain or discomfort
  • Bloating, distention
  • Indigestion
  • Nausea, vomiting: contents
  • Bowel habits: change, number
  • Incontinence, constipation/ diarrhea
  • Stool: colour, blood/ black, consistency, mucous
Text Box: NAIL EXAMINATION

Clubbing
• What: when view fingernail from side, angle of base of nail is >160°.
• DDx: CLUBBING:
• Cyanotic heart dz
• Lung dz: hypoxia, lung CA, bronchiectasis, CF
• UC, Crohn's
• Biliary cirrhosis
• Birth defect [harmless]
• IE
• Neoplasm [esp. Hodgkins]
• GI malabsorption
• Staging:
1: Loss of normal 160° angle at base of nail. Schamroth's window test: pt's holds 2 index finger nails touching each together: if normal, will show a diamond-shaped window.
2: AP curvature increased.
3: Bouncy, spongy nail when examiner presses down on nail.


Nervous
  • Headaches
  • Vision, hearing, speech troubles
  • Dizziness, vertigo
  • Faints, seizures, blackouts
  • Weakness, numbness
  • Sleep disturbances
  • Ataxia, tremors
  • Concentration, memory
Genitourinary
  • Incontinence
  • Frequency, dysuria, nocturia
  • Genitourinary pain, discomfort
  • Hesitancy, dribbling
  • Changes to quantity, colour
  • Blood in urine
  • Genital rashes, lumps
  • Sex life problems
  • Pain, bleeding in periods
Endocrine
  • Prefer hot or cold weather
  • Sweating
  • Fatigue
  • Hand trembling
  • Neck swelling
  • Skin, hair, voice changes
  • Thirst
Integumental
  • Itchiness
  • Rashes
  • Bruising
  • Swelling
  • Colour changes
Hematological
  • Bruise easily, difficulty stopping bleeds
  • Lumps under arms, neck, loin
  • Clots in legs, lungs
  • Fevers, shakes, shivers
Rheumatoid
Text Box: 4: Drumstick shaped fingertip.
5: Pt has wrist pain and wrist onion skinning.
6: Hypertrophic osteopathy.
Koilonychia
• What: misshapen, spoon-shaped nails.
• DDx:
• Iron deficiency
• Birth abnormality, rarely
Onycholysis
• What: distal nail separation.
• DDx:
• Trauma
• Psoriasis
• Thyrotoxicosis
Pitting
• DDx:
• Psoriasis
• Atopic eczema
• Allopeica areata
Thickening
• What: extremely thickened nail, esp. great toe
• DDx:
• Geriatric pt: onychogryphosis
• Psoriasis
• Local fungal infection 
Nail color: leuconychia
• What: leuco- means white, like a leucocyte.
• DDx:
• Hypoalbuminemia
Nail color: yellow
• DDx:
• Nicotine stains
• Yellow nail syndrome [peripheral edema, bronchiectasis, pleural effusion] 
Nail color: blue
• DDx:
• Cyanosis
• Ochonosis
• Wilson's [esp. lulunae of nails]
• Blue-red: polycythemia
Nail colour: red
• DDx:
• Cherry red: CO poisoning
Nail color: melanonychia
• What: multiple, brownish, longitudinal streaks
• DDx:
• Black pt: normal
• White pt: melanoma under fingernails 
Nail bed pallor
• What: pallor of the flesh underneath the nails.
• DDx:
• Anemia. See Anemias Reference.
Nail bed erythema/ telangiectasia
• What: flushed skin or distended blood capillaries below and around nail, esp at nail base. See Skin Lesion Terminology Reference.
• DDx:
• SLE
Splinter hemorrhages
• What: small, linear hemorrhages under the nail.
• DDx: SPLINT:
• Sepsis elsewhere
• PAN/SLE/RA
• Limey [vitamin C deficiency]
• IE
• Neoplasm [hematologic]
• Trauma**
  • Joints: pain, stiffness, swollen
  • Variation in joint pain during day
  • Fingers painful/ blue in cold
  • Dry mouth, red eyes
  • Skin rash
  • B
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  • ackSource: www.doctorshangout.com, neck pain

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