Physical diagnosis

THE COMPREHENSIVE
PHYSICAL
EXAMINATION
Dr. Samir Lamichhane, MD Clinical Pharmacology
GENERAL EXAMINATION

PILCCOD
or
JALCyClOD
PILCCOD

 Pallor
 Icterus
 Lymphadenopathy
 Clubbing
 Cyanosis
 Oedema
 Dehydration
JALCyClOD

 Jaundice
 Anemia
 Lymphadenopathy
 Cyanosis
 Clubbing
 Oedema
 Dehydration
Pallor
Pallor

 Pale appearance of skin and mucous membrane

 A sign in a patient with anemia

Pallor

 Anemia is defined as the qualitative or quantitative

diminution of RBC and/or hemoglobin concentration
➢ in relation to standard age, sex and altitude of
residence

 Normal Hb concentration
 Male:13.8 -17.2 gm/dL
 Female: 12.1-15.1 gm/dL
Sites to be examined for pallor

 Lower palpebral conjunctiva

 Dorsum of tongue

 Soft palate

 Nail beds

 Palms, soles and general skin surfaces

Pallor
Pallor

A. Technique of
examining for
pallor in lower
palpebral
conjunctiva

B. Normal
conjunctiva

C. Pale conjunctiva
Pallor
Pallor
Pallor
Anemia
Grading of severity

 Mild
 60-80% of Hb (9-12 g/dl)

 Moderate
 40-60% of Hb (6-9 g/dl)

 Severe
< 40% of Hb (< 6 g/dl)
Anemia
Classification

 According to the size of RBC

 Microcytic
◼ MCV: < 80 fl

 Normocytic
◼ MCV: 80 - 100 fl

 Macrocytic
◼ MCV: > 100 fl
Anemia
Causes: According to MCV
 Microcytic (MCV: < 80 fl)
 Iron deficiency anemia

 Thalassemia

 Anemia of chronic disease

 Sideroblastic anemia

 Lead poisoning
Anemia
Causes: According to MCV
 Normocytic (MCV: 80-100 fl)
 Acute blood loss

 Hemolysis, sickle cell anemia

 Aplastic anemia

 Anemia of chronic renal failure

 Hematological malignancies, myelodysplasia

 Hypersplenism
Anemia
Causes: According to MCV
 Macrocytic/Megaloblastic anemia (MCV: >100 fl)
 Vitamin B12 deficiency
 Folate deficiency
 Hypothyroidism

 Liver disease
 Chronic alcohol
 Congenital metabolic diseases
 Cytotoxic drugs e.g. methotrexate
Anemia
Symptoms
 Decreased oxygen transport
 Fatigue,weakness, syncope, dyspnea, angina, lack of
concentration

 Increased cardiac output

 Palpitation, tinnitus

 Congestive cardiac failure

 Orthopnea, paroxysmal nocturnal dyspnea
History to remember
 Age/sex
 Puberty, pregnancy

 Residence
 Tropical areas

 Occupational history
 Personal history
 Past medical history
History to remember
 Family history
 Blood disorders
 Nutritional history
 Dietary deficiency of folate, vitamin B12, iron
 Drug history
 NSAIDs

 Steroids

 Menstrual history
Clinical examination
 General: jaundice, lymphadenopathy, edema

 Cardiovascular system
 Tachycardia

 Water hammer pulse

 Hyperdynamic apex beat

 Systolic murmur

 Abdominal examination: hepatosplenomegaly

Clinical examination
 Iron deficiency anemia

 Angular stomatitis

 Bald tongue: in severe IDA

 Koilonychia

 Platynychia (platonychia)
Clinical examination
Clinical examination
 Vitamin B12 def

 Glossitis: atrophic glossitis

 Painful ‘beefy’ red tongue

 Nervous system: peripheral neuropathy

➢ Glove and stocking paresthesia

Clinical examination
 Hemolytic anemia
 Chipmunk facies (thalassemia)
◼ Frontal bossing
◼ Maxillary hypertrophy
◼ Depressed nasal bridge
◼ Malocclusion of teeth
Chipmunk facies (thalassemia)
Chipmunk facies (thalassemia)
Chipmunk facies (thalassemia)
Clinical examination
 Fanconi anemia
 Microcephaly

 Micropthalmia
Clinical examination
 Fanconi anemia
 Microcephaly

 Micropthalmia

 Dangling thumb

 Short stature

 Rocker bottom foot

Clinical examination
 Fanconi anemia
 Microcephaly

 Micropthalmia

 Dangling thumb

 Short stature

 Rocker bottom foot

Clinical examination
 Plummer-Vinson syndrome
 Atrophic glossitis

 Post-cricoid esophageal web

◼ Difficulty swallowing

 Iron deficiency

 Motor palsy: lead toxicity

THANK YOU
 Physical diagnosis

THE COMPREHENSIVE
PHYSICAL
EXAMINATION
Dr. Samir Lamichhane, MD Clinical Pharmacology
GENERAL EXAMINATION

PILCCOD
or
JALCyClOD
PILCCOD

 Pallor
 Icterus
 Lymphadenopathy
 Clubbing
 Cyanosis
 Oedema
 Dehydration
JALCyClOD

 Jaundice
 Anemia
 Lymphadenopathy
 Cyanosis
 Clubbing
 Oedema
 Dehydration
Icterus
Icterus

 Sign manifesting jaundice

 Jaundice is defined as yellowish discoloration of

skin and mucus membrane due to excess amount of
bilirubin present in blood
Icterus

 Normal bilirubin level

 0.3 -1 mg/dl

 Conjugated bilirubin < 20%

 Hyperbilirubinemia
 Bilirubin level > 1 mg/dl
Icterus

 Clinical manifestation of jaundice

 Bilirubin level > 3 mg/dl

 Latent jaundice
 Clinically not evident jaundice
 Only detected by serum analysis
 Bilirubin level: 1-3 mg/dl
Icterus
Sites to be examined for icterus

➢ Always seen in daylight

 Upper bulbar conjunctiva

 Scleraexamined by retracting upper eyelids upwards
and asking the patient to look downwards
 Both eyes at a time
 Undersurface of tongue
 Soft palate
 Palms and soles, general skin surface
Fig. Sites to be examined for icterus
Macrophage

Heme
Heme
oxygenase

Biliverdin
Biliverdin
reductase

Bilirubin

Fig. Bilirubin synthesis

Blood

Fig. Bilirubin metabolism

Causes of jaundice

 Hemolytic

 Hepatocellular

 Obstructive
 Intrahepatic

 Extrahepatic
Causes of jaundice

 Hemolytic
 Thalassemia

 Sickle cell anemia

 Blood transfusion

 Malaria
Causes of jaundice
 Hepatocellular
 Viral hepatitis
 Alcoholic hepatitis
 Cirrhosis

 Drugs: paracetamol, rifampicin, isoniazid

 Hemochromatosis

 Wilson's disease
 Acute fatty liver, e.g. of pregnancy
Causes of jaundice
 Obstructive
 Intrahepatic

◼ Cholestatic viral hepatitis

◼ Pregnancy

◼ Drugs: OCPs, erythromycin, steroids

Causes of jaundice
 Obstructive
 Extrahepatic

◼ Gallstone impaction in common bile duct

◼ Carcinoma of head of pancreas
◼ Periampullary carcinoma
◼ Enlarged gland of porta hepatitis
◼ Sclerosing cholangitis
Comparison among types

Features Hemolytic Hepatocellular Obstructive

Bilirubin Unconjugated Both Conjugated
Color Lemon-yellow Orange-yellow Greenish-yellow
Urine CB -ve CB -ve CB +ve
Normal color Yellowish Deep yellow
Stool High colored High colored Clay colored
Features of + - -
hemolysis Anemia,
splenomegaly
Pruritus Absent Variable Present
History to remember

 Age/ Sex
 Residence
 History of travel
 History of blood transfusion
 History of gallstone
 History of alcohol intake
 Drug history: OCP, Isoniazid, Rifampicin, PCM
“Medicine is learned at the bedside and
not in the classroom”.
➢ (Sir William Osler 1849 – 1919)

THANK YOU
 Physical diagnosis

THE COMPREHENSIVE
PHYSICAL
EXAMINATION
Dr. Samir Lamichhane, MD Clinical Pharmacology
GENERAL EXAMINATION

PILCCOD
or
JALCyClOD
PILCCOD

 Pallor
 Icterus
 Lymphadenopathy
 Clubbing
 Cyanosis
 Oedema
 Dehydration
JALCyClOD

 Jaundice
 Anemia
 Lymphadenopathy
 Cyanosis
 Clubbing
 Oedema
 Dehydration
Lymphadenopathy
Lymphadenopathy

 Enlargement of lymph nodes

 Inflammatory or non-inflammatory

 Groups of lymph nodes

Lymphadenopathy

 Groups of lymph nodes

 Cervical

 Axillary

 Inguinal

 Mediastinal

 Abdominal

 Popliteal

 Epitrochlear
Fig. groups
of lymph
nodes in the
body
Cervical group

 Submental
 Submandibular
 Anterior cervical chain
 Posterior cervical chain
 Preauricular
 Postauricular
 Occipital
Fig. cervical
lymph nodes
Cervical group

 Examination
 Patient on sitting position
 Always palpated from behind
 Patient’shead bending forward to relax the muscles in
the anterior part of the neck
 One side of the neck is palpated at a time
 If one side of the neck is palpated, the neck should be
flexed to that side
Cervical group
Axillary group

 Sub-groups
 Central

 Apical

 Anterior or
pectoral
 Posterior

 Lateral
Inguinal group

 Horizontal chain: lies below the inguinal ligament

 Vertical chain: lies along the saphenous vein

➢ Both sides are palpated one after another in supine

position extending the thighs.
Inguinal group
Description of lymph node

 Position, situation or extent

 Number

 Size

 Discrete or matted

 Tenderness

 Consistency: soft, rubbery, firm, hard

Description of lymph node

 Surface
 Mobility: fixity to overlying skin or surrounding
structures
 Rise of local temperature
 Skin changes: sinus, orange skin appearance
 Lymphangitis
 Draining area
Significant lymphadenopathy

 Cervical or axillary >1cm

 Inguinal >1.5cm

 Supraclavicular and epitrochlear lymph nodes are

significant if they are palpable
Causes of lymphadenopathy

 Cervical lymphadenopathy
 Infection

◼ Tonsillitis, pharyngitis, oral ulcers

◼ Miliary tuberculosis
◼ Infectious mononucleosis
◼ HIV infection
Causes of lymphadenopathy

 Cervical lymphadenopathy
 Malignancy of oral cavity and throat

 Lymphoma

 Leukemia

 Metastasis in lymph nodes from head, neck, breast,

throat, stomach and lung malignancy
Causes of lymphadenopathy

 Axillary lymphadenopathy
 Breast carcinoma

 Infection of upper extremity

 Lymphoma

 Leukemia

 Tuberculosis
Causes of lymphadenopathy

 Inguinal lymphadenopathy
 Infection or cellulitis of lower limb
 Filariasis

 Metastasis from genital malignancy, pelvic carcinoma

 Syphilis

 Chancroid

 Lymphogranuloma venereum
 Lymphoma, leukemia
Virchow’s node

 Palpable left supraclavicular lymph node

 In carcinoma of
 Stomach

 GI tract

 Lungs
Virchow’s node
Virchow’s node
Generalized lymphadenopathy

 Characterized by the involvement of three or more

noncontiguous lymph node areas

Generalized lymphadenopathy

 Causes
 Lymphoma

 Acute lymphoblastic leukemia (ALL)

 Chronic lymphoblastic leukemia (CLL)
 Miliary tuberculosis
 AIDS

 Secondary metastases to lymph nodes

 Sarcoidosis

 CMV, EBV
THANK YOU
 Physical diagnosis

THE COMPREHENSIVE
PHYSICAL
EXAMINATION
Dr. Samir Lamichhane, MD Clinical Pharmacology
GENERAL EXAMINATION

PILCCOD
or
JALCyClOD
PILCCOD

 Pallor
 Icterus
 Lymphadenopathy
 Clubbing
 Cyanosis
 Oedema
 Dehydration
JALCyClOD

 Jaundice
 Anemia
 Lymphadenopathy
 Cyanosis
 Clubbing
 Oedema
 Dehydration
Clubbing
Clubbing

 Bulbous swelling of the terminal part of the fingers

and the toes with

 An increase in the soft tissue mass, and

 Increased anteroposterior as well as transverse

diameter of the nails
◼ Due to proliferation of the subungual connective
tissue
Clubbing
Clubbing
Clubbing
Clubbing
Clubbing
Causes

 Pulmonary

 Bronchogenic carcinoma

 Lung abscess

 Bronchiectasis

 Empyema thoracis
Clubbing
Causes

 Cardiac
 Infective endocarditis

 Cyanotic congenital heart disease

 Alimentary
 Ulcerative colitis

 Hepatoma

 Idiopathic
Clubbing
Causes: remember as ‘CLUBBING’

 Congenital heart disease

 Lung abscess
 Ulcerative colitis
 Bronchogenic carcinoma
 Bronchiectasis
 Infective endocarditis
 Normal
 Genetic
Clubbing
Examination

 Lovibond’s angle

 Fluctuation test

 Schamroth’s window
Clubbing
Examination
 Lovibond’s angle
 Angle between nail bed and proximal nail fold
➢ Also onychodermal angle or hyponychial angle

➢ ~ 160◦
Clubbing
Examination
 Fluctuation test
Clubbing
Examination
 Fluctuation test
 Extend the patient’s finger
 Support the pulp of patient’s finger with your thumb
 Fix the patient’s proximal interphalangeal joint with
your middle fingers
 Place your index fingers on the base of the nailbed
 Press with one of your index finger and feel for the
fluctuation with other index finger
Clubbing
Examination
 Fluctuation test
Clubbing
Examination
 Schamroth’s sign/window
Clubbing
Examination
 Schamroth’s sign/window

Normal Clubbing
Cyanosis
Cyanosis

 Blueish discoloration of skin and mucous membrane

 due to excess accumulation of reduced

hemoglobin in blood (>5 g/dL)
Cyanosis

 Sites
 Margins of tongue
 Inner aspects of lips
 Mucous membrane of gums, palate and cheeks
 Tip of nose
 Ear lobules
 Outer aspects of cheeks, lips and chin
 Tip of finger and toes and nail bed
 Palm and soles
Cyanosis
Cyanosis
Cyanosis
Cyanosis
Cyanosis
Types

 Central cyanosis

 Peripheral cyanosis
Cyanosis
Types

 Central cyanosis

 Due to marked decrease in oxygen tension in arterial

blood because of either poor oxygenation in the lungs
or mixing of venous blood

 Usually detected when PaO2 < 80-85%

Cyanosis
Types

 Central cyanosis
 Causes

◼ Cyanotic heart diseases

◼ Tetralogy of Fallot
◼ TGA

◼ Eisenmenger syndrome
◼ Acute pulmonary edema
◼ Pulmonary disorders
◼ COPD, asthma, pneumonia, etc
Cyanosis
Types

 Peripheral Cyanosis

 PaO2 is normal but there is oxygen unsaturation at the

venous end of the capillary

 Occurs due to excessive extraction of oxygen from

normally saturated arterial blood
Cyanosis
Types

 Peripheral Cyanosis

 Mechanisms

◼ Decreased cardiac output

◼ Peripheral vasoconstriction

◼ Stasis of blood in the extremities

Cyanosis
Types

 Peripheral Cyanosis
 Causes

◼ Exposure to cold water or environment (most common)

◼ Frost bite
◼ Raynaud’s phenomenon
◼ CCF

◼ Shock

◼ Hyperviscosity syndromes
◼ Polycythemia, multiple myeloma
THANK YOU
 Physical diagnosis

THE COMPREHENSIVE
PHYSICAL
EXAMINATION
Dr. Samir Lamichhane, MD Clinical Pharmacology
GENERAL EXAMINATION

PILCCOD
or
JALCyClOD
PILCCOD

 Pallor
 Icterus
 Lymphadenopathy
 Clubbing
 Cyanosis
 Oedema
 Dehydration
JALCyClOD

 Jaundice
 Anemia
 Lymphadenopathy
 Cyanosis
 Clubbing
 Oedema
 Dehydration
Edema
Edema

 Definition: Abnormal and excessive accumulation of

fluid in the subcutaneous tissue due to increase in
interstitial fluid collection.

 If involves the peritoneal cavity: Ascites

 If generalized: Anasarca
Edema

 Causes
 Increased capillary hydrostatic pressure
 Decreased plasma oncotic pressure
 Decreased interstitial hydrostatic pressure
 Increased interstitial oncotic pressure

 Increased blood vessel wall permeability

 Lymphatic obstruction
 Increased water retaining capacity of the body
Edema
Demonstration

 Site: Lower end of tibia slightly above the medial

malleolus

 Procedure
 Gently press with your thumb
 Apply pressure for 15-30 seconds
 Release pressure
 Observe pitting
 Feel with the pulp of the thumb for pitting
Edema
Types and causes

 Pitting edema
 CCF, DCM

 Nephrotic syndrome

 Cirrhosis of liver

 Hypoproteinemias: protein losing enteropathies

 Kwashiorkor (PEM)

 Drugs: Amlodipine, steroids

Edema
Types and causes

 Non pitting edema

 Myxedema

 Lymphatic obstruction: Filariasis

 Angioneurotic edema: ACE inhibitors

 Scleroderma
Pitting edema
Edema
Types and causes

 Localized

 Generalized (anasarca)
 Fluid accumulation in tissues and body cavities
Edema
Types and causes

 Some common pathologies

 Localized
◼ Trauma
◼ Localized inflammation
◼ Local lymphatic obstruction
◼ [[

 Generalized (anasarca)
◼ Congestive cardiac failure
◼ Renal failure
◼ Nephrotic syndrome
◼ Liver cirrhosis
Edema
Cardiac vs renal edema

 Cardiac edema
 Dependent edema: starts from
◼ Legs in ambulatory patient

◼ Sacral region in bed ridden patients

 Renal edema
 Non-dependent edema
 Starts from face
Edema due to renal cause
Nephrotic syndrome
Ascites
Anasarca
Dehydration
Dehydration

 Refers to a state of volume depletion of the body

Dehydration
Causes

 Decreased intake
 Fasting

 Increased loss
 Diarrhea

 Dysentery

 Vomiting

 Excessive sweating
Dehydration

 Site

 Adults
◼ Dorsum of tongue
Dehydration

 Site

 Adults
◼ Dorsum of tongue

 Children
◼ Abdomen skin pinch
Dehydration
Dehydration
Dehydration
Dehydration

 Symptoms/Signs
 Lethargy/irritability

 Eagerness to drink

 Sunken eyes

 Dry tongue

 Skin pinch goes back slowly

Dehydration
Dehydration
Dehydration
“Medicine is learned at the bedside and
not in the classroom”.
➢ (Sir William Osler 1849 – 1919)

THANK YOU