Physical Examination in General

OBJECTIVES
! ! ! ! ! !

To learn skills of physical examination. To assess the general condition of the patient. To assess the mental status of the patient. To assess baseline values of vital signs. To assess the clinical changes relevant to complaints. To assess the status of various groups of lymph glands.

Muhammad Shuja Tahir, FRCS (Edin), FCPS Pak (Hon)

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PHYSICAL EXAMINATION IN GENERAL

Muhammad Shuja Tahir, FRCS (Eden), FCPS Pak (Hon)

General physical examination is a series of methodical and scientific observations collected from the patient to help in finding the cause of his/her problems. Physical examination has a low sensitivity but reasonably good specificity. Inter observer variability is high. Palpation is more sensitive and specific than percussion. Combination of these examinations improve accuracy and combined specificity over 90%1. INTRODUCTION AND COUNSELING You should introduce yourself to the patient. Inform the patient about mechanics of examination so that patient understands exactly what is going to happen with him/her. Which of his/her body parts are to be uncovered and for how long. Please be polite and decent during and after the examination. Never forget to cover the uncovered parts of patient at the end of examination. Inform the patient about completion of examination. EXPOSURE AND POSITION The examination is conducted in proper day light and in privacy. A nurse or a female attendant should be present during examination of a female patient.

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The patient should wear hospital gown for convenience during examination. Adequate exposure of the patient is achieved during examination while rest of the patient remains covered. The patient is examined in standing, sitting or lying position to have maximum information. Structured examination helps in complete and uniform documentation and avoids missing of important information.

for the diagnosis and monitoring the progress or deterioration of the patient.

PULSE
The word "PULSE" is commonly used for arterial pulse.

GENERAL CONDITION
(Over view of the patient) General appearance of the patient is noted. It is clearly described whether the patient is; Child, adult or old. Male or female. Comfortable or in pain. Ill looking or well looking. Patients posture is noted. Built and nutritional status of the patient is noted. Conscious level is checked (whether the patient is conscious, semiconscious or unconscious). Attitude of the patient is noted ; Co-operative. Well oriented in time and space. Confused. Unresponsive. VITAL SIGNS Vital signs are observed and recorded. These are; Pulse. Blood pressure. Respiration. Temperature. The observation of vital signs is very important

Palpation of radial pulse

Arterial pulse is the palpable expansion of the arterial wall which follows the pressure wave in the arteries set up by the systolic ejection from the heart. It is independent of, and faster than the velocity of the blood flow. SPEED (VELOCITY) OF PULSE IN ADULTS AORTA Average LARGER ARTERIES Average SMALLER ARTERIES Average 15-35 meters/second 16 meters/second 7-10 meters/second 8 meters/second 3-5 meters/second 4 meters/second

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The radial pulse is felt only 0.1 second after the peak systolic ejection. The velocity of transmission of pulse is 15 times the velocity of blood flow in the aorta. There is progressive diminution of the pulses in the periphery. It is called damping. It is due to vessel resistance and compliance. The pulse is faster in old people due to rigidity and lower compliance caused by the atherosclerosis of the vessels. EXAMINATION OF PULSE It should be felt frequently when the patient is relaxed. The radial pulse is felt with one hand. Other pulses on the same side are felt with the other hand and synchronization of the pulses is assessed and noted. RATE (Count for the pulse rate) It is the number of vessel wall expansions per minute and should be counted for full one minute. This is the only way to estimate the pulse rate correctly. The normal pulse rate is different in different age groups. It is also different in different people. The usual normal pulse rate in an average adult is 70-80/min.

TEMPERATURE & PULSE RELATION The pulse rate increases by ten per minute with every degree Fahrenheit rise in the temperature in most of the pyrexial conditions above 100F. The pulse rate does not increase like this in enteric fever and in immuno compromised patients and temperature pulse rate ratio is disturbed. It is called relative bradycardia. TACHYCARDIA It is the condition when pulse rate is more than 100 beats per minute. Various types of increased heart rates are noticed depending upon the trigger zone for increase in heart rate. Following types are seen; ! Sinus tachycardia. ! Ventricular tachycardia. ! Supra-ventricular tachycardia. BRADYCARDIA It is a condition when pulse rate is less than 60 beats per minute. DELAYED PULSE The femoral pulse is delayed in patients having Coarctation (obstruction) of Aorta on simultaneous examination of the radial and femoral
Normal Pulse rate at various ages
160 135 120 110 90 72

Age And Average Pulse Rate Relation Fetus 1 year 2 year 4 year 6 year Adult 140/min 130/min 120/min 110/min 90/min 70/min

160 140 120 100 80 60 40 20 0

Foetus 1 Year

2 Year

4 Year

9 Year

Adults

Foetus 4 Year

1 Year 9 Year

2 Year Adults

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pulses. The radial and femoral arterial pulses are not synchronized in these patients. RADIAL PULSE Radial pulse should be felt at the lower most part of the forearm over the radius in mid prone and semi flexed position of the wrist with ulnar deviation. PHYSIOLOGICAL VARIATIONS INCREASED PULSE RATE Increased left ventricular stroke volume. Reduced elasticity of the arteries. It is seen in the following conditions; Exercise and exertion. Fear and fright. Anxiety. Pregnancy. REDUCED PULSE RATE Starvation. Athletes. Certain familial conditions. PATHOLOGICAL VARIATIONS INCREASED PULSE RATE Hemorrhage. Shock. Fever. Atropine or similar drugs. Thyrotoxicosis. Pheochromocytoma. Anaemia. Beri beri. Paget's disease. Arterio venous fistula. Cardiac failure. Myocardial Infarction. Sub tentorial tumours.

Alcoholic neuropathy. REDUCED PULSE RATE Enteric fever. (Relative bradycardia). Heart blocks. Lignocaine over dosage. Opium and digitalis toxicity. Viral infections. Diphtheria and meningitis. Tetanus. Jaundice. Myxedema. Raised intra cranial pressure VOLUME The pulse volume is high in patients with raised cardiac output conditions such as anaemia, thyrotoxicosis and renal failure. It is weak and thready in low cardiac output conditions such as shock. RHYTHM The pulse rhythm is the regularity in height and frequency of the pulse wave. Normally it is regular. Detection of the abnormalities of rhythm is very significant in the diagnosis of various diseases. Irregularities of pulse rhythm may present at regular intervals (regularly irregular) or at irregular intervals (irregularly irregular). The abnormalities in rhythm are seen in the following conditions: ABSENT PULSE The pulse may be absent in the peripheral vessels on palpation. It may be absent at some

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specific site or all over. All the pulses are sluggish and of low volume when sudden hemorrhage has occurred and the patient may be in any kind of shock. The pulse may disappear after trauma to any limb due to injury or compression of the vessel. The pulse may also be absent in peripheral vessels in atherosclerosis and peripheral arterial occlusive diseases and in thromboembolic phenomenon. MISSED BEAT When a pulse beat is missed at a time when it should not, it is called missed beat. It may be noticed at regular or irregular intervals. ATRIAL FIBRILLATION The pulse is irregularly irregular in atrial fibrillation. Multiple beats are felt.

at periphery (radial artery). Thus a deficit in number of pulses and cardiac contractions is noted. It is called pulse deficit. EXTRA SYSTOLE (PREMATURE BEAT) A premature beat is felt at regular or irregular intervals in a normal cardiac cycle. This is followed by a pause and then a normal pulse pattern. It is called extra systole. SINUS ARRHYTHMIA It is a minor phasic change in the pulse during respiration. It is noted when the pulse is faster during inspiration.

Extra systoles
pre-mature strong beat followed by a pause Rythum and volume are irregularly irregular

Atrial fibrillation

PULSE DEFICIT The difference between heart rate and pulse rate is called pulse deficit. The pulse rate is counted at a peripheral vessel and heart rate is auscultated at apex simultaneously. In atrial fibrillation, the heart contracts ahead of schedule, the ventricles are not filled with blood and it leads to absent or reduced stroke volume. The pulse wave is so weak that it cannot be felt

Expiration

Inspiration Sinus arrhythmia

Faster during inspiration

PULSUS PARADOXUS The pulse is weaker during inspiration. It is due to marked decrease in the venous return. It is felt in patients suffering from;

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Expiration

Inspiration
NORMAL The Dicrotic notch is not normally palpable FLATTENDED Slow rise and fall, called anacrotic, caused by aortic stenosis ACCENTUATED Rapid rise and fall, called a water hammer pulse, caused by aortic incompetence and patent ductus arteriosus

Pulsus Paradoxus Weaker during inspiration

Constrictive pericarditis. Pericardial effusion. Pericardial temponade. Bronchial asthma. PULSUS BIGEMINUS Two beats are felt at one time on palpation of radial pulse. One of these is normal and the other is premature. There is a compensatory pause as well. It is seen in the following conditions; Digitalis poisoning. Premature beats. A. V. Block. (Atrio ventricular block) CHARACTER OF PULSE Character and shape of graphical recording of the pulse is also typical. It is felt as a single beat or wave but on recording, a small notch is seen on the descending beat. (dicrotic notch). The abnormalities in the character of pulse are seen in following conditions: PULSUS PLATEAU ANACROTIC PULSE It is seen in aortic stenosis. It is felt as a flat pulse which rises and falls slowly.

The flatness is due to diminished flow of the blood into the aorta. WATER HAMMER PULSE COLLAPSING PULSE It is felt in patients with aortic incompetence and patent ductus arteriosus (PDA). This pulse is felt and recorded as a rapid rise and fall of the beat. PULSUS ALTERNANS

Pulsus alternans
Alternating strong and weak beats

It is felt in patients with heart failure. The pulse is felt as alternating strong and weak beats. These are felt at regular intervals. PULSUS BISFERIENCE It is felt in patients having a combined lesion of

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aortic stenosis and aortic incompetence. The combination of anacrotic and water hammer pulse is felt twice in one beat.

The temperature should be noted carefully for at least three times a day. Preferably same time should be used for noting the temperature. SITES FOR TEMPERATURE OBSERVATION Oral cavity. Axilla or groin. Rectum. Skin. ORAL TEMPERATURE This is the most common site selected for temperature observation in adults. The thermometer for oral use should preferably be used for one patient only to avoid spread of different diseases such as Hepatitis B & C etc. Disposable thermometer is a better option than trying to sterilize the same thermometer. The temperature is not taken immediately after a cold or hot drink as it may lead to an incorrect observation. Oral site cannot be used in children, patients with oro pharyngeal lesions, psychiatric and unconscious patients.

TEMPERATURE
The body temperature of the human beings is constant within minor variations irrespective of the atmospheric temperature variations. This is why the mammals and human beings are also called warm blooded (homeothermic). CORE TEMPERATURE It is the temperature of the deep tissues of the body. It remains almost constant within 1F of average temperature normally. FEVER The temperature elevation or fever is the rise in temperature above the normal level. The control of temperature is maintained by the hypothalamus. The rise in temperature occurs due to the effect of endogenous pyrogen (E.P) over the pre-optic area of hypothalamus. The endogenous pyrogen (EP) is a protein of molecular weight of 13000-15000. It is produced in the body by the action of toxins from the bacteria on phagocytes (polymorphs, monocytes, macrophages, Kupffer cells). NORMAL VALUES Oral temperature 36.7O to 37.1O Centigrade 97.3O to 98.8O Fahrenheit

Assessment of the oral temperature

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The thermometer is usually kept in the antiseptic solution. It should always be washed with clean water before and after the use. METHOD The column of mercury of thermometer is brought down by shaking the thermometer. The thermometer is held from the opposite side and not the side of mercury column. The mercury bulb side of the clean and washed thermometer is kept under the tongue of the patient. The patient is asked to keep the mouth closed. The thermometer is kept in this position for at least two minutes. The thermometer is taken out gently and reading is noted against the upper level of the mercury. Oral temperature is usually one degree Fahrenheit lower than the rectal temperature. AXILLARY OR GROIN TEMPERATURE This site is usually selected for children and unconscious patients when oral route cannot be used. Active co-operation of the patient is not required while using this site. The temperature observation by this route is not always reliable as the weather alters the temperature. The temperature reading with this method is ONE degree Fahrenheit less than the oral temperature.

METHOD The thermometer is kept in the crease of axilla or groin. The shoulder or hip joint is flexed tightly to hold the thermometer for at least two minutes. The thermometer is removed and the upper level of the mercury is noted for temperature reading. RECTAL TEMPERATURE It is the representative of the temperature of the core of the body and shows minimum variations. This site is selected for the children, critically ill patients, unconscious and psychiatric patients. This site can be used in patients without their active co-operation. The temperature observation from this site is quite reliable. Only problem is that adults and conscious patients do not like this route very much. Rectal temperature above 43 degrees centigrade is almost fatal. Do not use the rectal thermometer for oral temperature observation. IT IS NOT VERY CLEAN. SKIN TEMPERATURE It is the temperature of the exposed areas of the skin. It varies with the variations in the temperature of surrounding atmosphere. These days strip thermometers are also

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available for checking the temperature in the children and unconscious patients. Observations with this thermometer are also less reliable as these are affected by the weather conditions and improper application of the strip.

Shock.

BLOOD PRESSURE
It is the estimation of pressure inside the blood vessels (arteries). It is estimated by indirect method in daily clinical practice. Arterial blood pressure is an important indicator of circulatory status and fluid balance. Correct estimation of blood pressure is essential for the management of the patient.

PHYSIOLOGICAL VARIATIONS OF TEMPERATURE The normal temperature is lowest at 6 AM. The normal temperature is highest in the evenings. It is low while sleeping. It is higher while awake. It is highest while working. It rises marginally (0.5 degree Fahrenheit) at the time of ovulation in the females and this rise continues throughout the second half of the menstrual cycle. It is higher during emotional excitement. (due to involuntary tensing of the muscles). It is low in patients with idiopathic or constitutional hypothermia. It is low due to exposure to cold weather. PATHOLOGICAL VARIATIONS Fever due to any reason. Infections. Hyperthyroidism. Malignancies. Heat stroke. Drugs (Methyldopa etc). DECREASED TEMPERATURE Myxedema. Old age. Iatrogenic body cooling. Exposure to cold weather. Drugs (phenothiazine).

Incorrect method of blood pressure assessment

Correct method of blood pressure assessment

Following points should always be re-

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membered; Always measure the blood pressure in a relaxed patient. The blood pressure is checked and rechecked in a relaxed patient at different occasions before it is accepted as correct. Single reading (specially abnormal) is not accepted for prescription of anti hypertensive therapy. It should be clearly mentioned whether blood pressure is taken in standing, sitting or lying position. Date and time of blood pressure measurement is very clearly noted down. Correct size cuff is used. The size of the cuff varies with the length and circumference of the upper arm of the patient. There are different sizes of cuff and sphygmomanometers available for use in pediatrics or obese patients. The cuff is applied smoothly and evenly over the upper arm keeping the rubber tube untangled and lower border of the cuff at least 2.5 cm above the cubital fossa. The sphygmomanometer is kept at level with the heart level of the patient. Always measure blood pressure first with palpatory method and then with auscultatory method. PALPATORY METHOD When the patient is relaxed and the cuff of the sphygmomanometer is applied correctly around the upper arm, the radial pulse is

palpated. The examiner keeps feeling the radial pulse of the same side with one hand and uses the other hand to inflate the air and distend the cuff till the radial pulse disappears completely. The cuff is further distended for 20- 30 mm of mercury above the highest level of systolic pressure. The slow deflation of the cuff is started and the reading is noted with the beginning of the reappearance of the pulse. This is the systolic pressure on palpation. AUSCULTATORY METHOD It is an indirect method. It is not 100% correct for evaluation of blood pressure but it is correct within ( 10%) when compared with direct estimation of blood pressure. It is more precise than the palpatory method. The cuff of the sphygmomano-meter is inflated approximately 20-30 mm of mercury above the blood pressure estimated with palpatory method. The stethoscope is put over the brachial artery in the cubital fossa of the same side approximately half to one cm medial to the midline in the cubital fossa. The cuff is deflated slowly and reading is noted when the tapping sounds (sounds of Korotkoff) of pulse become audible. It indicates the systolic blood pressure. The cuff deflation is continued and second reading is taken when the taping sound becomes muffled (less sharp). It is the indication of diastolic blood pressure. PULSE PRESSURE Pulse pressure is difference of systolic and diastolic pressure.

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MEAN ARTERIAL PRESSURE It is the average of all the pressures measured from millisecond to millisecond over a period of time. It is not equal to average systolic or diastolic pressure. It remains more near to diastolic pressure. Approximately the sum of diastolic pressure and 1/3rd of pulse pressure is reasonably accurate. PHYSIOLOGICAL VARIATIONS Temporary variations in blood pressure are noticed during; Meals. Change of posture. Exercise or exertion. Excitement. PATHOLOGICAL VARIATIONS HIGH PRESSURE Essential hypertension. Renal induced hypertension. Toxaemias of pregnancy (pregnancy induced hypertension). Atherosclerosis. Drugs. Over hydration. LOW PRESSURE Shock. Concealed or revealed hemorrhage. Anti hypertensive drugs. Severe diarrhoea. Fear and fright. Long hours of standing duty. Sepsis. Heart failure.

RESPIRATION
It is one of the most important vital signs. Normal respiration is essential for living. Normal adults breathe 15-20 times per minute. The type of breathing and chest expansion is variable for age and sex. RATE The respiratory rate should be counted for full one minute. NATURE Type of respiration should be noticed such as; Abdominal. Thoracic. Abdomino-thoracic. PHYSIOLOGICAL VARIATIONS IN INCREASED RATES Exercise. Food intake. Defecation. DECREASED RATE Sleep. Evening. PATHOLOGICAL VARIATIONS IN INCREASED RATE Hysteria. Respiratory distress syndrome. Adult respiratory distress syndrome. Asthma. Obstructive respiratory diseases. Chest injuries. Flail chest. Pneumothorax. Haemothorax. Haemopneumothorax.

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Sepsis. Shock. Fever. DECREASED RATE Head injuries. Barbiturate poisoning (late stages). Respiratory distress syndromes (R.D.S). A.R.D.S.

PALLOR
Pallor is clinical representation (marker) of anaemia. The red color of the circulating blood is due to the amount of oxygenated hemoglobin present in it. The color is quite obvious in the superficial vessels (Capillaries). The skin and mucosa may look pink or pale depending upon the amount of oxygenated hemoglobin passing through the capillaries. This color represents the amount of hemoglobin present in blood. ANAEMIA Anaemia is the pale discoloration of the mucosa, skin and body tissues due to reduction in the circulating hemoglobin. It leads to reduction in the oxygen carrying capacity below normal range for that age and sex. NORMAL HEMOGLOBIN VALUES At birth At one year At 10 years Adult male 13.6-19.6 g / dl 11.3-18.5 g / dl 12.0-16.4 g / dl 13.5-15.0 g / dl

Looking at the lower conjunctiva for pallor

EXAMINATION It should be performed in proper day light.

Look at the nails. Only the unpolished nails should be examined. The color of the nails is seen and compared with the color of the nails of a healthy adult. Examination of nails soon after removal of the polish is very deceptive and wrong. Look at lips. Evert the lower lip and look at the oral part of buccal mucosa; it can give good indication of pallor. The lips should not be seen in patients who have used some foods which colour the tissues because it will not give correct observation. Look at Palms Look at the color of palms and compare with normal healthy palm. The painted or soiled palms should not be examined.

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Severely anaemic patient Looking at the nails for pallor

Spoon shape nails (Chronic Iron Deficiency)

Look at the palms of hand for pallor

Looking at the lips for pallor

Spoon shape nails (koilonychia)

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Look at conjunctive. Pull the lower eye lid downwards and look at the palpebral part of the conjunctiva. It gives good indication of pallor. KOILONYCHIA Look at the nails for flattening and concavity (spoon shape). This is seen in anaemia. (Chronic iron deficiency)

JAUNDICE
It is the yellow discoloration of the sclera, mucous membranes, skin and body tissues due to increased bilirubin level in the circulation.

Looking at the sclera for jaundice

Normal Bilirubin Values

Total bilirubin Free bilirubin Indirect reacting (Unconjugated) Direct reacting (Conjugated) 17 mols/L 0.8-01 mg/dL 10 mols/L 0.5 mg/dL 07 mols/L 0.3 mg/dL
Looking at sclera from side for jaundice

The jaundice becomes clinically detectable at and above the bilirubin level of 34 mols/L (02 mg/dL). TYPES AND CAUSES OF JAUNDICE (Raised serum bilirubin level) PRE HEPATIC (HEMOLYTIC) This type of jaundice is seen due to excessive production of bilirubin. It is seen in patients having intra vascular hemolysis. It is seen in the following conditions; Malaria. Drug intoxication. Rh incompatibility. Mismatched transfusion.

Looking at under surface of tongue for jaundice

Hemolytic anaemia.

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HEPATIC (HEPATOCELLULAR) This type of jaundice occurs due to inadequate or reduced detoxification of bilirubin. It occurs due to; Decreased uptake by the liver cells. Depressed conjugation or protein binding in the liver cells. Disturbances of the secretion into the biliary canaliculi. POST HEPATIC (OBSTRUCTIVE) This type of jaundice occurs due to reduced ability or complete inability to drain the bile. It occurs due to intra or extra hepatic bile duct obstruction. It is seen in; Bile duct stones. Strictures. Malignancy and tumors of the head of pancreas. Accidental ligation of the common bile duct. EXAMINATION FOR JAUNDICE The yellow discoloration of jaundice is best seen against the white background of the sclera where it becomes obvious at the earliest. Look at the sclera in bright day light. (Never in artificial light) The upper eye lid is retracted and patient is asked to look downwards at examiners finger. It exposes the white of eye to maximum. Jaundice can also be examined by looking at the tongue & skin color of the patient.

CYANOSIS
It is the bluish discoloration of the mucosa, skin and body tissues due to presence of reduced hemoglobin in concentrations more than 5 grams / dl. It is also seen in patients who have oxygen saturation of hemoglobin less than 85% (Normal oxygen saturation of hemoglobin is

Looking for color of hands (peripheral cyanosis)

Looking at tongue for cyanosis

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97%). Similar discoloration of the skin is also seen with raised circulating met hemoglobin in the blood. It is produced due to action of certain drugs and oxidizing agents on blood when ferrous iron is changed into ferric iron. Normally this process is reversed by a red cell enzyme, NADH Met hemoglobin reductase. The absence of this enzyme from red cells leads to rising concentrations of the met hemoglobin in the blood and blue discoloration of the skin. CENTRAL CYANOSIS This is seen in patients with arterial hypoxia when arterial oxygen saturation falls below 85 % in patients with normal hemoglobin level. The discoloration is seen all over the body. It is seen in following conditions; Cyanotic diseases of the heart. Respiratory deficit problems. Consolidation of lungs. Foreign body in respiratory passages. Obstructive respiratory diseases. PERIPHERAL CYANOSIS This is seen in patients with stagnation of the blood at periphery or when the blood flow is slow and takes longer time in peripheral capillaries leading to greater extraction of oxygen by the tissues. This is seen in low cardiac output states and conditions with local vaso constriction. The discoloration is not seen in the warmer parts of

the body and mucosa. It is seen in following conditions; Cold weather. Peripheral vascular diseases. EXAMINATION FOR CYANOSIS Look for both peripheral and central types of cyanosis. Look at the finger tips and toes. Look at the lips, tip of the nose, ear lobule and tongue.

HYDRATION
It is the presence of the fluid in the intra and extra-cellular compartments of the body within normal range for that age and sex. DEHYDRATION Dehydration is the presence of extracellular or intracellular fluid in less than normal quantity. It is seen in patients who are having; Diarrhoea. Vomiting. Enteric fistulas.

Looking at lips for dryness (normal hydration)

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Nasogastric aspiration without fluid replacement. Renal failure (diuretic phase). Dry and cracked lips make the diagnosis of dehydration very obvious. Wet tongue indicates the state of hydration very clearly. Dry, cracked and fissured tongue is seen in patients with dehydration. Dry skin is loose, lusterless and cracked. The fontanelle are checked in infants, these are depressed in dehydration and are bulging out in Over hydration or in conditions of raised intra

cranial pressure. OVER HYDRATION Over hydration is the presence of fluid in the intra and extra cellular compartments of body in more than normal values. It is seen in patients who have been over infused or in patients with renal failure and conditions of hypo proteinemia and malabsorption syndromes. EDEMA It is the accumulation of interstitial fluid in abnormally large amounts. EXAMINATION FOR EDEMA Look at the shin (subcutaneous part of the tibia just above the ankle) and compare both sides. Press the swollen part for 30 sec. and note the pitting.

Looking at the skin for dehydration

Looking at the patient for over hydration (Nephrotic Syndrome)

Look at the sacral region in bed ridden patients and press to check the pitting. PATHOGENESIS OF EDEMA Following changes lead to edema formation;

Looking at the skin for dehydration

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Looking for edema (press the shin with thumb)

Looking at pre sacral area for pitting edema

Reduced plasma proteins. Accumulation of osmotically active substances in the interstitial space. Increased vascular permeability. Histamine or similar drugs. Kinins and cytokines. PHYSIOLOGICAL CONDITIONS LEADING TO OEDEMA Standing still for longer periods. (guard duties). Long distance traveling and driving. Bank managers and cashiers sitting with legs dependent for long hours. Obesity. PATHOLOGICAL CONDITIONS LEADING TO OEDEMA Heart failure. Nephritis. Renal failure. Over hydration.(intravenous infusion) Allergic or Angio-neurotic oedema. Varicose veins. Hypo-proteinemia. Carcinoma. Myxedema. Pressure due to tumor on large veins. Starvation.

Looking at pressed shin for pitting edema

Pressing the sacral area with thumb

Increased filtration pressure. Arteriolar dilatation. Venous constriction. Increased venous pressure. Improper lymphatic flow. Decreased osmotic pressure.

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Lymph-adenopathy. Filariasis. Phlebothrombosis. Beri-beri. Vit B-1 deficiency. Duodenal fistula. MilRoy's disease. (hereditary edema) SPIDER NEVI These are red spots which disappear on pressure but reappear on removal of the pressure (vascular in nature). These are seen in patients with liver diseases. These are present in the distribution of superior vena cava. Look at the palm of hand and trunk for red spots with these features. CLUBBING Look at the nails for their shape. There is loss of nail bed angle. Drum stick appearance is seen in clubbing. It is usually seen in patients with chronic respiratory diseases such as bronchiactasis and carcinoma lung. It is seen in right to left shunt at the intra-cardiac or intrapulmonary level. It is associated with cyanosis as well.

It is also seen in infective endocarditis. It is associated with splenomegaly in this condition. LYMPH GLANDS All groups of the lymph glands are palpated and noted. Both sides are examined and compared. Number of lymph glands and their consistency is noted. Whether these are palpable individually or are matted together should be noted. Various groups of lymph glands are described in levels during surgery due to their level fo drainage in relation to spread of neoplastic lesions for assessment of prognosis. CERVICAL LYMPH GLAND EXAMINATION The examination is conducted in privacy. Female attendant or nurse should be present when female patient is being examined. The shirt is removed The patient is examined in hospital gown, which allows adequate exposure. INSPECTION Look around the neck, Anteriorly, laterally and posteriorly. The glands in the anterior triangle and posterior triangle is noted. Skin color, redness, discharging sinus and fistula is noted. Adjacent structures and carotid pulsation is seen.

Drum stick appearance of clubbing

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Looking for enlarged lymph glands in the anterior triangles of the neck

Palpating the sub mental lymph glands

These glands are included in level-I glands during surgery. Submental group of lymph glands lies between anterior bellies of diagastric muscles and hyoid bone. Submandibular glands lie between posterior belly of diagastric muscle and body of mandible.
Looking for enlarged lymph glands in the posterior triangles of the neck

Draining glands of mouth, nose, ear, pharynx, scalp and neck (cervical lymph glands) are inspected. PALPATION Palpate all around the neck anteriorly, laterally and posteriorly. Feel for temperature and tenderness. Check fixation of glands to; ! Skin. ! Underlying structures. ! Other lymph glands. ! Palpate all cervical lymph glands: SUBMENTAL AND SUBMANDIBULAR GROUPS

SUBMENTAL LYMPH GLAND Inspection of the submental glands should be done from the front by extending the neck. The palpation is better performed by standing behind the patient. SUB-MANDIBULAR LYMPH GLANDS Submandibular glands are best seen from the lateral aspect and these are palpated by standing behind the patient. Both sides are palpated simultaneously. JUGULO DIAGASTRIC LYMPH GLANDS Jugulo diagastric lymph glands are felt on deep palpation between the angle of the mandible and

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anterior border of the sterno mastoid muscle. UPPER JUGULAR GROUP It is included in level-II glands during surgery. It includes following glands; Lymph nodes located around upper third of internal jugular vein extending upwards from carotid bifurcation. MIDDLE JUGULAR It is included in level-III glands during surgery.
Levels of cervical lymph glands noted during surgery

It includes following glands; Lymph nodes located around middle third of internal jugular vein extending downwards from carotid bifurcation to crico thyroid notch. LOWER JUGULAR GROUP It is included in level-IV glands during surgery. It includes following glands; Lymph nodes located around lower third of jugular vein between crico thyroid notch and clavicle.

Palpation of sub mandibular lymph glands

POSTERIOR TRIANGLE GROUP

Palpation of the Jugulo digastric lymph glands

Palpation of the posterior triangle of the neck for lymph glands

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It is included in level -V glands during surgery. It includes following glands; Lymph glands located along lower half of spine near accessory nerve and transverse cervical artery. The supra clavicular glands are also included. POSTERIOR TRIANGLE CERVICAL LYMPH GLANDS Posterior triangle cervical lymph glands are felt behind the sterno mastoid muscles. These are best palpated by standing behind the patient and palpating with both hands. OCCIPITAL GROUP OF LYMPH GLANDS These are palpable from the back at the hairline over the occipital area. SUPRA CLAVICULAR LYMPH GLANDS Supra clavicular lymph glands are palpated in the hollow area just above the clavicle. Supra clavicular lymph glands palpation from the lateral aspect is easy.

Palpation of the supra clavicular lymph glands from the side

ANTERIOR COMPARTMENT GROUP OF GLANDS It is included in level VI glands during surgery.

Palpation of the anterior triangle lymph glands

Palpation of the supra clavicular lymph glands from the back

It includes following glands; Lymph glands surrounding the midline structures, between hyoid bone and supra sternal notch; Parathyroid glands. Para-tracheal glands. Peri laryngeal glands. Peri cricoid glands. In cases of the enlargement of lymph glands, their area of drainage is also examined.

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ANTERIOR TRIANGLE CERVICAL LYMPH GLANDS Cervical lymph glands, anterior triangle of the neck are seen from the front and palpated from back of the of neck within the boundaries of both sternomastoid muscles. PRE AURICULAR LYMPH GLANDS Pre auricular lymph glands are felt in front of the pinna of the ear.

INFRA CLAVICULAR LYMPH GLANDS These are palpated in the hollow just below the clavicle.

Palpation of infra clavicular lymph glands

AXILLARY LYMPH GLANDS

Palpation of preauricular lymph glands

Palpation of axillary lymph glands (Step-1)

Palpation of posterior auricular lymph glands

POST AURICULAR LYMPH GLANDS Post auricular lymph glands are palpated behind the pinna of the ear along its lower level.
Palpation of axillary lymph glands (Step-2)

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Adequate exposure is essential for examination of axillary lymph glands. The patient should remove the shirt. Vest may be kept on leaving both axillae well exposed. Do not palpate the axilla with clothes on. Palpation of axilla with clothes on may lead to incorrect observations. The clinical evaluation of axillary lymph glands is not 100% correct even if these are palpable. There is about 33% difference in clinical and pathological evaluation of nodes for their involvement in malignancy. Inspection is performed with both arms in abducted position. Palpation of axillary lymph glands is performed as follows; Abduct the arm and place the hand in the axilla of (to be examined) the patient. Palpate the axillary lymph glands after flexion of the arm. Size of the glands is measured and noted. Number of palpated lymph glands is counted and noted. Consistency of the lymph glands is noted. Presence or absence of fluctuation is noted. Nature of the lymph glands is noted (whether the glands are separate or matted together). The central group is palpated deep in the center of the axilla. The lateral axillary group of lymph glands are palpated under the pectoralis major muscle insertion.

The subscapular group of lymph glands are felt under the posterior axillary fold. The lymph glands of pectoral group are palpated under the pectoralis major muscle anteriorly. The axillary lymph glands are graded into three levels in relation to spread of carcinoma of the breast. The prognosis & prediction of prognosis is better done by adequate assessment of the glands. The per-operative examination of axillary glands is performed according to its levels of involvement assessed during surgery. LEVEL-I These are the axillary glands present inferior & lateral to the pectoralis minor muscle. LEVEL-II These are the axillary glands present behind the pectoralis minor muscle. LEVEL-III These are the glands present superior & medial to the pectoralis minor muscle. EPITROCHEAR LYMPH GLANDS

Palpating epitrochlear glands

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These are palpated at the dorsal aspect of the elbow joint. These glands are enlarged in patients suffering from leprosy. INGUINAL LYMPH GLANDS Inguinal lymph glands are palpated in the patients after both groins are properly exposed. History and physical examination are the most impor tant components of preoperative evaluation2.

Palpation of the inguinal lymph glands

Physical examination is most important part of diagnosis and adequate care of medical inpatients. It is important to medical students 3 and teachers .

The physical diagnosis curriculum is more interactive, participatory, repetitive and on job. It was found to be very successful in improving students knowledge, skill and self confidence 4 in physical diagnosis .

REFERENCE 1. Godfried MH, Briet E. Physical diagnosis[Percussion and palpation of spleen. Med Tydschr Geneskd 2000 Jan 29; 144(5):216-9. 2. Michota FA, Frost SD. The pre operative evaluation use of history and physical examination rather than routine testing. clev clin J Med 2004 Jan; 71(1): 63-70.

3.

Relly BM, Physical examination in the care of medical in patients. An observational study. Lancet 2003 Oct4; 362(9390): 1100-5 Fagan MJ, Griffith RA, Oblard L, OConnor CJ. Improving physical diagnosis skills of third year medical students. A controlled trial of literatureBased curriculum. J.Gen Intern Med 2003 Aug; 18(8): 652-5.

4.

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PHYSICAL EXAMINATION IN GENERAL

General Condition What is the general condition of patient? (fully conscious or otherwise) Alert, Verbal, Pain, Unresponsive Blood pressure Pulse (rate / rhythm / volume / character) Temperature (oral, axillary, rectal, skin Respiratory rate What abnormalities of vital signs are present?
Nails, Lips, Palms, Conjunctiva Sclera, Tongue, Skin Central or peripheral Dehydration Edema (pre tibial and sacral)

Vital signs

Pallor Jaundice Cyanosis Hydration Lymph glands

Cervical Axillary Inguinal

Hands Neck

Nails, Joints Goiter

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