CASE TAKINGCASE TAKINGCASE TAKINGCASE TAKING

General Physical ExaminationGeneral Physical Examination

Made by :Ishant Arora-19Kushagr Duggal-26Shresta Sandhu-69

ACKNOWLEDGEMENT

We would like to thank Dr. Rekha Thomas and Dr. Parul for giving us an opportunity to present our views on the most important topic of medical diagnosis “GENERAL PHYSICAL EXAMINATION”.

List of Contents• Introduction to

Case taking• GPE of patient• Built• Nutrition• Icterus • Pallor

• Clubbing • Tongue• Cyanosis • Oedema • Pigmentation • Lymphadenopathy • Temperature • Respiratory rate• Blood pressure

INTRODUCTION• Case taking is a unique art of getting into

conversation observation and collecting information from patient as well as from bystanders to define the patient as a person and the disease.

• The history obtained thus makes the basis for a physician to go further into the physical examination and laboratory studies in order to define the problem accurately.

• Each case is unique in all respects only true individualized approach can explore the true picture and help a physician to arrive at a totality in its true sense. Every individual is different in health as well as in disease and hence every case has to be examined individually giving importance to its unique expressions during health and disease.

General Physical Examination Of a

Patient

• Many patients are apprehenive about being examined, the environment is unfamiliar, they may feel exposed and are likely to have anxieties about the findings.

The examination should be done in a warm , private, quiet area.Daylight is preferable to artifical light.And give a brief explanation to the patient as to what you will do.

BUILT/ PHYSIQUE Certain observations that can be

made from the general inspection of the patients physique are-

• If the patients appearance is consistent with his chronological age

• Body proportions and obvious deformities

• The somatotype of the patient

Somatotypes• Body types, otherwise known as

somatotypes can be split into 3 different types:

1.Endomorph (Fat)2.Mesomorph (Muscular)3.Ectomorph (Thin)

A somatotype number of three digits is determined for an individual classified by the system, with the first digit referring to endomorphy, the second to mesomorphy, and the third to ectomorphy; each digit is on a scale of 1 to 7. Hence, the extreme endomorph has the somatotype 711, the extreme mesomorph 171, and the extreme ectomorph 117. In practice, extreme types (711, 171, 117) are rare or nonexistent, and the person of normal build has a somatotype approaching 444, evenly balanced between extremes.

Endomorph (711)•A pear shaped body•A rounded head•Wide hips and shoulders•Wider front to back rather than side to side.•A lot of fat on the body, upper arms and thighs

Mesomorph (171)•A wedge shaped body•A cubical head•Wide broad shoulders•Muscled arms and legs•Narrow hips•Narrow from front to back rather than side to side.•A minimum amount of fat

Ectomorph (117)•A high forehead•Receding chin•Narrow shoulders and hips•A narrow chest and abdomen•Thin arms and legs•Little muscle and fat

NUTRITION • The nutritional status of an individual is often

the result of many inter-related factors.

• It is influenced by food intake, quantity & quality, & physical health.

• The spectrum of nutritional status spread from obesity to severe malnutrition

NUTRITION ASSESSMENT

DIET HISTORY• Nutritional intake of humans is assessed by:

1. 24 hours dietary recall – All foods & beverages– Time of day eaten– Amounts consumed– Food preparation2. Food frequency questionnaire– In this method the subject is given a list of around 100 food items to

indicate his or her intake (frequency & quantity) per day, per week & per month.

3. Dietary history since early life4. Observed food consumption - The meal eaten by the individual is weighed and contents are exactly

calculated

INTERPRETATION OF DIETARY DATA

• Quantitative and qualitative analysis using the food pyramid. The amount of energy & specific nutrients in each food consumed can be calculated & then compared with the recommended daily intake.

ANTHROPOMETRY METHODS

• Anthropometry is the measurement of body height, weight & proportions.

• It is an essential component of clinical examination of infants, children & pregnant women.

• It is used to evaluate both under & over nutrition.

• The measured values reflects the current nutritional status & don’t differentiate between acute & chronic changes .

BMI Classification• BMI < 18.5 = Under Weight• BMI 18.5-24.5= Healthy weight range• BMI 25-30 = Overweight (grade 1

obesity)• BMI >30-40 = Obese (grade 2 obesity)• BMI >40 =Very obese (morbid or grade 3 obesity)

ICTERUS• Icterus is a yellowish pigmentation of the skin, the

conjunctival membranes over the sclerae (whites of the eyes), and other mucous membranes caused by hyperbilirubinemia (increased levels of bilirubin in the blood).

• This hyperbilirubinemia subsequently causes increased levels of bilirubin in the extracellular fluid.

• Concentration of bilirubin in blood plasma is normally below 1.2 mg/dL (<25µmol/L).

• A concentration higher than approx. 3 mg/dL (>50µmol/L) leads to jaundice.

Sites:•Upper bulbar conjunctiva (sclera)•Palate•Under surface of tongue•Palms and soles•General skin surface

Scleral icterus

In people with scleral icterus, the body's processing system for bilirubin breaks down. The pigment circulates in the blood, and becomes deposited in the conjunctiva, the membrane that covers the whites of the eye. It can also be present in the skin, causing it to turn yellow along with the eyes.

SHADES OF JAUNDICE• Reddish shade (Rubin jaundice): Hepatitis• Lemon yellow with a reddish hue (Flavin

jaundice): Hemolysis• Greenish yellow (Verdin

jaundice): Obstructive jaundice• Grayish or blackish green (Melas

jaundice): Prolonged obstructive jaundice

PALLOR•  Pallor is the paleness of skin and mucous

membranes, due to the reduced amount of oxyhemoglobin or decreased peripheral perfusion.

• Assessment of pallor for anaemia is an important part of general physical examination of every patient.

• To detect anaemia, pallor at sites where capillaries are superficial is looked for. The usual sites are lower eyelid conjunctiva, nailbed and palm.

A. Technique of exminaing for pallor in lower palpebral conjunctiva

B. Normal conjunctiva (Note the demarcation shown by arrow)

C. Pale conjunctiva (Loss of demarcation)

Pallor in the palm of the patient

Pallor in nailbeds: Press the nail and note the color of nailbed after releasing the digital pressure.

CAUSES OF PALLOR1) Anemia (can be appreciated clinically when

hemoglobin <8-9 g/dl)2) Pallor without anemia:• Physiologic (“fair skinned”)• Shock• Hypoglycemia and other metabolic derangements• Respiratory distress• Skin edema• Pheochromocytoma

CLINICAL GRADING OF ANAEMIA

• Mild: Pallor of conjunctiva and/or mucous membrane

• Moderate: Above + Pallor of skin• Severe: Above + Pallor of palmar

creases

CLUBBING Clubbing (also known as

drumstick fingers and watch-glass nails) is a deformity of the fingers and finger nails associated with a number of diseases, mostly of the heart and lungs.

STAGING• Clubbing may be present in one of five stages:• Fluctuation and softening of the nail bed

(increased ballotability)• Loss of the normal <165° angle ( Lovibond

angle) between the nail bed and the fold ( cuticula)

• Increased convexity of the nail fold• Thickening of the whole distal (end part of

the) finger (resembling a drumstick)• Shiny aspect and striation of the nail and skin

SCHAMROTH’S WINDOW TEST

• When the distal phalanges (bones nearest the fingertips) of corresponding fingers of opposite hands are directly opposed (place fingernails of same finger on opposite hands against each other, nail to nail), a small diamond-shaped "window" is normally apparent between the nail beds. If this window is obliterated, the test is positive and clubbing is present.

DISEASE ASSOCIATIONS

Clubbing is associated with:• Lung disease:

– Lung cancer, mainly non-small-cell (54% of all cases), not seen frequently in small-cell lung cancer (< 5% of cases)

– Interstitial lung disease– Complicated tuberculosis– Suppurative lung disease: lung

abscess, empyema, bronchiectasis, cystic fibrosis– Mesothelioma of the pleura– Arteriovenous fistula or malformation

• Heart disease:– Any disease featuring chronic hypoxia– Congenital cyanotic heart

disease (most common cardiac cause)– Subacute bacterial endocarditis– Atrial myxoma (benign tumor)– Tetralogy of Fallot

Gastrointestinal and hepatobiliary:– Mal-Absorption– Crohn's disease and ulcerative colitis– Cirrhosis, especially in primary biliary

cirrhosis– Hepatopulmonary syndrome, a

complication of cirrhosis.

THE TONGUE• General examination involves

examination of the anterior two-thirds of the tongue (oral tongue) visible on routine examination.

On physical examination, there are several characteristics of the tongue that should be noted:Color

Pink-red on dorsal and ventral surfaces. The ventral surface may have some visible vasculature.

TextureRough dorsal surface owing to papillae, which have three types. There should be no hairs, furrows, or ulceration.

SizeShould fit comfortably in mouth, tip against lower incisors. Sublingual glands should not be displaced.

In general, the examination of the tongue should occur in the following steps:•Have the patient touch the tip of the tongue to the roof of their mouth and inspect the ventral surface.•Have the patient protrude the tongue straight out and inspect for deviation, color, texture, and masses•With gloved hands, hold the tongue with gauze in one hand while palpating the tongue between the thumb and index finger of the other, noting masses and areas of tenderness

CLINICAL FINDINGS

A classic smooth, beefy red tongue from vitamin B12 deficiency 

A black, hairy tongue consistent with aspergillus overgrowth

Geographic tongue is a benign condition in which discolored, painless patches of the tongue appear and then reappear from atrophy, often in a different distribution.

White hairs along the sides of the tongue are the classic appearance of oral hairy leukoplakia.

CYANOSIS• The name cyanosis, literally means "the blue

disease" or "the blue condition." It is derived from the color cyan, which comes from kyanos, the Greek word for blue

• Cyanosis is the appearance of a blue or purple coloration of the skin or mucous membranes due to the tissues near the skin surface having low oxygen saturation.

• The onset of cyanosis is classically described as occurring if 5.0 g/dL of deoxyhemoglobin or greater is present.

TYPES OF CYANOSIS• Cyanosis is divided into two main

types:1. Central (around the core, lips,

and tongue) 2. Peripheral (only the extremities

or fingers).

CAUSES OF CENTRAL CYANOSIS

Central cyanosis may be due to the following causes: 1. CENTRAL NERVOUS SYSTEM (impairing normal ventilation): Intracranial hemorrhage Drug overdose (e.g. Heroin) Tonic–clonic seizure (e.g. grand mal seizure) 2. RESPIRATORY SYSTEM Pneumonia Bronchiolits Bronchospasm (e.g. Asthma) Pulmonary Hypertension Pulmonary embolism Hypoventilation Chronic obstructive pulmonary disease, or COPD (emphysema)

 

3.CARDIOVASCULAR SYSTEM Congenital heart disease (e.g. Tetralogy of

Fallot, Right to left shunts in heart or great vessels) Heart failure Valvular heart disease Myocardial infarction 4. BLOOD Methemoglobinemia * Note this causes "spurious"

cyanosis, in that, since methemoglobin appears blue, the patient can appear cyanosed even in the presence of a normal arterial oxygen level.

Polycythaemia Congenital cyanosis (HbM Boston) arises from

a mutation in the α-codon which results in a change of primary sequence, H → Y. Tyrosine stabilises the Fe(III) form (oxyhaemoglobin) creating a permanent T-state of Hb.

CAUSES OF PERIPHERAL CYANOSIS

• All common causes of central cyanosis• Reduced cardiac output (e.g. heart

failure, hypovolaemia)• Cold exposure• Arterial obstruction (e.g. peripheral

vascular disease, Raynaud phenomenon)• Venous obstruction (e.g. deep vein

thrombosis)

OEDEMA• Edema (American English)

or oedema (British English) (from the Greek οἴδημα—oídēma, "swelling"), formerly known as dropsy or hydropsy, is an abnormal accumulation of fluid in the interstitium, which are locations beneath the skin or in one or more cavities of the body.

CLASSIFICATIONA.GENERALISED-It is often due to

disorder of heart,kidneys,liver,gut or diet.

B.LOCAL- It is due to lymphatic or venous obstruction,allergy or inflammation.

GRADING OEDEMAGRADE DEFINITIONAbsent UnilateralGrade + MildGrade ++ ModerateGrade +++ Severe

MECHANISM OF OEDEMA

Six factors can contribute to the formation of edema:• increased hydrostatic pressure;• reduced oncotic pressure within blood vessels;• increased tissue oncotic pressure;• increased blood vessel wall permeability

e.g. inflammation;• obstruction of fluid clearance in the lymphatic

system;• changes in the water retaining properties of the

tissues themselves. Raised hydrostatic pressure often reflects retention of water and sodium by the kidney.

Pitting oedema

PIGMENTATION• Normal skin contains varying amounts

of brown melanin pigment. Brown pigmenation due to deposited haemosiderin is always pathological.

• Albinism is an inherited generalised absence of pigment in the skin.

• Patches of white and darkly pigmented skin are due to local and complete absence of melanocytes.

HYPERPIGMENTATIONFacial Acanthosis Nigricans

Butterfly patches-Systemic Lupus erythematous

LYMPHADENOPATHY• Lymphadenopathy refers to lymph

nodes which are abnormal in size, number or consistency and is often used as a synonym for swollen or enlarged lymph nodes. Common causes of lymphadenopathy are infection,autoimmune disease, or malignancy.

TYPES OF LYMPHADENOPATHY

• Localized lymphadenopathy: due to localized spot of infection e.g., an infected spot on the scalp will cause lymph nodes in the neck on that same side to swell up

• Generalized lymphadenopathy: due to a systemic infection of the body e.g., influenza or secondary syphilis

•Dermatopathic lymphadenopathy:

• lymphadenopathy associated with skin disease.–Persistent generalized lymphadenopathy (PGL): persisting for a long time, possibly without an apparent cause

Cervical enlargement

CAUSES

• Lymph node enlargement is recognized as a common sign of infectious, autoimmune, or malignant disease. Examples may include:

• Reactive: acute infection (e.g., bacterial, or viral), or chronic infections (tuberculous lymphadenitis cat-scratch disease– The most distinctive sign of bubonic plague is

extreme swelling of one or more lymph nodes that bulge out of the skin as "buboes." The buboes often become necrotic and may even rupture.

– Infectious mononucleosis is an acute viral infection caused by Epstein-Barr virus and may be characterized by a marked enlargement of the cervical lymph nodes

• It is also a sign of cutaneous anthrax and Human African trypanosomiasis– Toxoplasmosis, a parasitic disease,

gives a generalized lymphadenopathy (Piringer-Kuchinka lymphadenopathy).

– Plasma cell variant of Castleman's disease - associated with HVV8  infection and HIV infection

– Mesenteric lymphadenitis after viral systemic infection (particularly in the SALT in the appendix) can commonly present like appendicitis.

• Tumoral:– Primary: Hodgkin lymphoma and non-

Hodgkin lymphoma  give lymphadenopathy in all or a few lymph nodes.

– Secondary: metastasis, Virchow's Node, neuroblastoma  and chronic lymphocytic leukemia.

• Autoimmune etiology: systemic lupus erythematosus  and rheumatoid arthritis may have a generalized lymphadenopathy.

• Immunocompromised etiology: AIDS. Generalized lymphadenopathy is an early sign of infection with human immunodeficiency virus (HIV), the virus that causes acquired immunodeficiency syndrome (AIDS). "Lymphadenopathy syndrome" has been used to describe the first symptomatic stage of HIV progression, preceding a diagnosis of AIDS.

• Bites from certain venomous snakes such as the pit viper

• Unknown etiology: Kikuchi disease, progressive transformation of germinal centers, sarcoidosis, hyaline-vascular variant of Castleman's disease, Rosai-Dorfman disease Kawasaki disease Kimura disease

TEMPERATURE

• Normal human body temperature, also known as normothermia or euthermia, depends upon the place in the body at which the measurement is made, the time of day, as well as the activity level of the person.

• Different parts of the body have different temperatures. Rectal and vaginal measurements, or measurements taken directly inside the body cavity, are typically slightly higher than oral measurements, and oral measurements are somewhat higher than skin temperature.

• The commonly accepted average core body temperature (taken internally) is 37.0 °C (98.6 °F). The typical oral (under the tongue) measurement is slightly cooler, at 36.8° ± 0.4 °C (98.2° ± 0.7 °F), and temperatures taken in other places (such as under the arm or in the ear) produce different typical numbers.

Methods Of Measurement

• Taking a person's temperature is an initial part of a full clinical examination. Sites used for measurement include:

• In the anus (rectal temperature)• In the mouth (oral temperature)• Under the arm (axillary temperature)• In the ear (tympanic temperature)• In the vagina (vaginal temperature)• In the bladder• On the skin of the forehead over the temporal

artery

MEDICAL THERMOMETER

RESPIRATORY RATE• The respiration rate is the number of breaths

a person takes per minute. The rate is usually measured when a person is at rest and simply involves counting the number of breaths for one minute by counting how many times the chest rises. Respiration rates may increase with fever, illness, and with other medical conditions. When checking respiration, it is important to also note whether a person has any difficulty breathing.

• Normal respiration rates for an adult person at rest range from 12 to 16 breaths per minute.

PULSE• The pulse rate is a measurement of the heart

rate, or the number of times the heart beats per minute. As the heart pushes blood through the arteries, the arteries expand and contract with the flow of the blood. Taking a pulse not only measures the heart rate, but also can indicate the following:

Heart rhythm Strength of the pulse

• The normal pulse for healthy adults ranges from 60 to 100 beats per minute. The pulse rate may fluctuate and increase with exercise, illness, injury, and emotions. Females ages 12 and older, in general, tend to have faster heart rates than do males. Athletes, such as runners, who do a lot of cardiovascular conditioning, may have heart rates near 40 beats per minute and experience no problems.

How to check pulse ?• As the heart forces blood through the arteries,

you feel the beats by firmly pressing on the arteries, which are located close to the surface of the skin at certain points of the body. The pulse can be found on the side of the neck, on the inside of the elbow, or at the wrist. For most people, it is easiest to take the pulse at the wrist. If you use the lower neck, be sure not to press too hard, and never press on the pulses on both sides of the lower neck at the same time to prevent blocking blood flow to the brain. When taking your pulse:

• Using the first and second fingertips, press firmly but gently on the arteries until you feel a pulse.

• Begin counting the pulse when the clock's second hand is on the 12.

• Count your pulse for 60 seconds (or for 15 seconds and then multiply by four to calculate beats per minute).

• When counting, do not watch the clock continuously, but concentrate on the beats of the pulse.

• If unsure about your results, ask another person to count for you.

• If your doctor has ordered you to check your own pulse and you are having difficulty finding it, consult your doctor or nurse for additional instruction.

BLOOD PRESSURE• Blood pressure (BP), sometimes

referred to as arterial blood pressure, is the pressure exerted by circulating blood upon the walls of blood vessels, and is one of the principal vital signs.

• Blood pressure varies depending on situation, activity, and disease states, and is regulated by the nervous and endocrine systems. Blood pressure that is pathologically low is called hypotension, and pressure that is pathologically high is hypertension.

CLASSIFICATIONSystolic The top number, which is also the higher of

the two numbers, measures the pressure in the arteries when the heart beats (when the heart muscle contracts)

 DiastolicThe bottom number, which is also the lower of

the two numbers, measures the pressure in the arteries between heartbeats (when the heart muscle is resting between beats and refilling with blood).

MEASUREMENT OF BLOOD PRESSURE

Sphygmomanometer

• Position: supine, seated, standing.• In seated position, the subject's arm

should be flexed.• The flexed elbow should be at the level

of the heart.• If the subject is anxious, wait a few

minutes before taking the pressure.

Procedures• To begin blood pressure measurement, use a

properly sized blood pressure cuff. The length of the cuff's bladder should be at least equal to 80% of the circumference of the upper arm.

• Wrap the cuff around the upper arm with the cuff's lower edge one inch above the antecubital fossa.

• Lightly press the stethoscope's bell over the brachial artery just below the cuff's edge. Some health care workers have difficulty using the bell in the antecubital fossa, so we suggest using the bell or the diaphragm to measure the blood pressure.

• Rapidly inflate the cuff to 180mmHg. Release air from the cuff at a moderate rate (3mm/sec).

• Listen with the stethoscope and simultaneously observe the sphygmomanometer. The first knocking sound (Korotkoff) is the subject's systolic pressure. When the knocking sound disappears, that is the diastolic pressure (such as 120/80).

• Record the pressure in both arms and note the difference; also record the subject's position (supine), which arm was used, and the cuff size (small, standard or large adult cuff).

• If the subject's pressure is elevated, measure blood pressure two additional times, waiting a few minutes between measurements.

• A BLOOD PRESSURE OF 180/120mmHg OR MORE REQUIRES IMMEDIATE ATTENTION!

PRECAUTIONS-

> Don't place the cuff over clothing.• Flex and support the subject's arm.

• In some patients the Korotkoff sounds disappear as the systolic pressure is bled down. After an interval, the Korotkoff sounds reappear. This interval is referred to as the "auscultatory gap." This pathophysiologic occurrence can lead to a marked under-estimation of systolic pressure if the cuff pressure is not elevated enough. It is for this reason that the rapid inflation of the blood pressure cuff to 180mmHg was Aneroid and digital manometers may require periodic calibration.

• Use a larger cuff on obese or heavily muscled subjects.

• Use a smaller cuff for pediatric patients.• For pediatric patients a lower blood

pressure may indicate the presence of hypertension.

• recommended above. The "auscultatory gap" is felt to be associated with carotid atherosclerosis and a decrease in arterial compliance in patients with increased blood pressure.

PALPATORY METHOD

-The relaxed subject sits on a chair.  The cuff of the sphygmomanometer is wrapped firmly around the right arm above the elbow. The lower arm should be resting on a table-top or bench.

- The radial pulse (the pulse at the radial artery in the wrist) is palpated with the fingers of the left hand.  The number of beats in 30 seconds is counted, and the heart rate in beats per minute is recorded

- The valve on the inflating bulb of the sphygmomanometer is turned fully clockwise so that it is closed.  The cuff is inflated slowly (10 mm Hg/sec) by pumping the inflating bulb until the radial pulse is no longer felt.  The cuff is inflated further until the pressure is about 30 mm Hg higher. 

- The valve on the inflating bulb is opened slightly by turning it in the counter clockwise direction, allowing the pressure to drop slowly by about 5 mm Hg/sec.  At some point, one will be able to feel the radial pulse once again. 

- The pressure indicated on the gauge when the pulse reappears is noted.  This is the systolic pressure.  Now the pressure in the cuff is quickly released, so as not to cause undue discomfort to the subject.

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BIBLIOGRAPHY

• http://www.hopkinsmedicine.org/healthlibrary/conditions/cardiovascular_diseases/vital_signs_body_temperature_pulse_rate_respiration_rate_blood_pressure_85,P00866/ dated on 20.9.2014

• www.wikipedia.com dated on 21.9.2014• Hutchison’s clinical methods dated on 24.5.2014• www.ncbi.nlm.nih.gov dated on 25.9.2014• www.onlinelibrary.wiley.com dated on 25.9.2014• www.wisegeek.org dated on 25.9.2014• www.epomedicine.com dated on 25.9.2014