Introduction to clinical

examination
Dr Sonu Bhattarai
Physical examination

General assessment:

Demeanour and general condition: physique, nutrition, state of hydration

Posture, gait, personality and mental state

Record height and weight

Regional examination

Skull deformity, asymmetry

Exopthalmos, Endopthalmos

Facies

Scoliosis,Kyphosis, lordosis

Thyroid swelling

Abdominal asymmetry Abdominal swelling

Deformity of limbs Abnormal posture of limbs

Scrotal swelling
Cardinal signs

Anaemia Cyanosis Lymphadenopathy Jaundice Clubbing Venous engorgement

Blood pressure; Peripheral pulse; Temperature: oral; Respiration; Oedema legs,

sacrum

Skin: Abnormal pigmentation, texture, swelling, rashes

Nails: Roughness, pitting, brittleness, spooning, ridging

NICE:Namaste, Introduction, Consent, Chaperone , Examination / exposure

ABCDEFG: Appearance, Behaviour, Built, Consciousness, Chaperone, Decubitus,

Deformities: skull, chest, limb , eyes: Exophthalmos, Enophthalmos, Facies, Gestures,

Breast, thyroid, scrotal swellings

PILCCOD: Pallor, Icterus, Lymphadenopathy, Cyanosis, Clubbing, Oedema,

Dehydration/ Hydration status

PICKLE: Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy, Edema

TPPR: Temperature, Pulse, blood Pressure, Respiratory rate, Jugular venous pressure

Anthropometry : height, weight, BMI

NICE
N-Namaste

I- Introduction

C-Consent; Chaperone

E-Exposure; Examination

Chaperone: when a male doctor is examining a female patient

General assessment:
Appearance: well looking/ ill-looking

Built: lean, thin, heavily built; Nutritional status

Consciousness

Decubitus: Position of the body: stooping, forward, propped up, sitting in

recombinant position

Gestures:e.g. Pain gestures: ; gait

Facies:moon face, mask face

Other features: cannulas, catheter

Gestures: Pain
Squeezing gesture: cardiac pain

Hand position: renal colic

Rubbing the sternum: heartburn

Rubbing the buttocks and thigh: sciatica

Arms clenched around abdomen: midgut colic

Facies
Butterfly rashes: SLE
Pallor
Definition: It is the waxy appearance of the skin and mucous membrane. It
depends on the thickness, quality of skin and the amount of blood in the
capillaries.

Is seen in palpebral conjunctiva, nails, palms

Microcytic hypochromic anemia: hookworm: iron deficiency anemia

Pernicious anemia: vitamin B12 deficiency

Aplastic anemia: normocytic normochromic anemia

Causes of pallor
Anemia

Peripheral circulatory failure (shock, acute myocardial infarction)

Myxoedema

Nephrotic syndrome (dropsy, generalized edema, anasarca)

Vasovagal attack

Sheehan’s syndrome

Thick skin (obesity)

Which of the following is not a non- anemic cause of pallor?

a. Shock
b. Myxoedema
c. Thin skin
d. Nephrotic syndrome
Which of the following is not a non- anemic cause of pallor?

a. Shock
b. Myxoedema
c. Thin skin
d. Nephrotic syndrome
Anemia
It is qualitative or quantitative diminution of RBC and or hemoglobin and/ or
hemoglobin concentration in relation to standard age and sex. It is not a disease
but a manifestation of some disease.

The normal hemoglobin concentration:

Males: 14.6 to 15.5 g/dl

Females: 13.3 to 14.5 g/dl

Symptoms related to anemia
General symptoms

Cardiovascular features in severe anemia

Features in other systems in severe anemia

General symptoms
Weakness Palpitation

Fatigue Breathlessness

Lassitude Anginal pain

Lightheadedness Insomnia

Giddiness Tinnitus

Anorexia Tingling sensations in the extremities

Cardiovascular features in severe anemia
Tachycardia

Capillary pulsation

Water- hammer pulse

Cardiomegaly

Hyperdynamic apex beat

Mitral systolic murmur due to functional MI

Haemic murmur over the pulmonary area

Rarely mid-diastolic(non-rumbling) murmur in mitral area( due to relative stenosis at mitral valve) secondary to increased
blood flow
Features in other systems in severe anemia
General examination: pallor, dyspnea, ankle oedema or anasarca, koilonychia

CVS: described above

GI tract: Hepatosplenomegaly may be present

Respiratory system: basal crepitations

Nervous system: features of neuropathy, anemic retinopathy

Lymphoreticular system: sternal tenderness

Classification of anemia
Based on hemoglobin level:

Based on size of rbc:

Based on mechanism:
Classification of anemia

Based on hemoglobin level:

Mild anemia (60-80% of normal Hb) (9-12 g/dl)

Moderate anemia(40-60% of normal Hb (6-9g/dl)

Severe anemia(<40% of normal Hb (<6g/dl)

Classification of anemia

Based on size of rbc:

a. Microcytic: MCV<80 FI; iron deficiency anemia: hookworm infection

b. Macrocytic: MCV>96 Fl; folate deficiency, vitamin B12 deficiency, excess
alcohol, liver disease
c. Normocytic: MCV 80-96 Fl; aplastic anemia, blood loss, chronic kidney
disease
All of the following causes microcytic hypochromic anemia except:

a. Lead poisoning
b. Thalassemia
c. Iron deficiency
d. Fanconi’s anemia
All of the following causes microcytic hypochromic anemia except:

a. Lead poisoning
b. Thalassemia
c. Iron deficiency
d. Fanconi’s anemia
Classification of anemia
Based on mechanism:

● Blood loss:
○ Acute:
■ Post hemorrhagic anemia
○ Chronic
■ Gastrointestinal bleeding, gynaecological bleeding
● Increased rbc destruction:
○ Intrinsic abnormality
○ Extrinsic abnormality
○ Impaired rbc production
Increased rbc destruction:
● Intrinsic abnormality (Intracorpuscular)
○ Heredity membrane disorder: spherocytosis, elliptocytosis
○ Rbc enzyme deficiency: G6PD deficiency
○ Hb synthesis disorder: thalassemia, Hb S
● Extrinsic abnormality(Extracorpuscular)
○ Ab mediated immune hemolytic: erythroblastosis fetalis
○ Mechanical trauma
○ Infection- malaria
○ Pb poisoning
○ Splenomegaly- sequestration of RBC
● Impaired rbc production
○ Stem cell defect: Aplastic anemia
○ Disturbed proliferation and maturation of erythroblastic
■ Defective DNA synthesis: Vitamin B12, vitamin B9
■ Defective heme synthesis: Thalassemia
What is the site to see pallor?

Palpebral conjunctiva

Bulbar conjunctiva

Sclera

Ventral surface of tongue

What is the site to see pallor?

Palpebral conjunctiva

Bulbar conjunctiva

Sclera

Ventral surface of tongue

Examination: where will you look for anemia
Lower palpebral conjunctiva( retract the lower eyelids downward and ask the
patient to look upwards both eyes at a time)

Tongue: specially the tip and the dorsum

Soft palate

Nail beds:(press the pulp to see the redness of nail bed)

Palms.soles and general skin surfaces

Examination of hands in anemia
Nails: beds: anemia; Koilonychia: type: iron, capillary pulsation,

Palms give an indication of anemia

Subacute bacterial endocarditis: rare cause of anemia: Osler’s node and Janeway
lesions

Rheumatoid arthritis: finger deformities

Palmar crease: degree of anemia: if pale as compared to surrounding skin:

hemoglobin level<7 g/dl
Stool examination in anemia
Presence of occult blood: GI bleeding

Presence of hookworm ova

Investigations in anemia
❖ Reticulocyte count
➢ ↑: destruction of rbc, bleeding
➢ ↓ or normal: look for cause of bone marrow failure
❖ MCV: low: Iron/ globulin problem
➢ ↑: megaloblastic / DNA
❖ Folate, B12 level
❖ Coombs test: Direct and Indirect
❖ Osmotic fragility
❖ Peripheral blood smear
❖ Iron+TIBC+ferritin
❖ Peripheral blood smear: look for reticulocyte, hypersegmented PMN cells…..
Iron deficiency anemia(IDA)
Features

1 Hb decreased

2 Hypochromic rbc

3 MCV⋜ 50fl(microcytic RBC)

4 Serum Fe<50

5 TIBC increased

6 Serum ferritin decreased: most sensitive and specific for IDA

7 Bone marrow cellularity increased

Which of the following finding is diagnostic of iron deficiency anemia?

a. Increased TIBC, decreased serum ferritin

b. Decreased TIBC, decreased serum ferritin
c. Increased TIBC, increased serum ferritin
d. Decreased TIBC, increased serum ferritin
Which of the following finding is diagnostic of iron deficiency anemia?

a. Increased TIBC, decreased serum ferritin

b. Decreased TIBC, decreased serum ferritin
c. Increased TIBC, increased serum ferritin
d. Decreased TIBC, increased serum ferritin
Common causes
Nutritional deficiency

Bleeding peptic ulcer

Bleeding hemorrhoids

Menorrhagia

Pregnancy

Lactation

Malabsorption syndrome
Clinical diagnosis of iron deficiency anemia
Pica: eating : clay(geophagia), cornstarch(amylophagia), ice(pagophagia)

Anemia

Cheilosis,stomatitis: cracks at the corners of the mouth

Glossitis: inflammation of tongue

Dysphagia(Plummer-Vinson syndrome or Paterson- Kelly syndrome)

Icterus
The yellowish discoloration of the skin and mucous membrane due to excess
amount of bilirubin present in blood.

The normal serum bilirubin: 0.3-1.0mg/dl

Latent jaundice: 1.0-3 mg/dl

Clinical jaundice: >3 mg/dl

Fraction of normal bilirubin:

Direct / Conjugated: 0.1-0.3mg/dl

Indirect / Unconjugated: 0.2-0.7mg/dl

Types of bilirubin
Unconjugated Conjugated

Water solubility: - Water solubility:+

Affinity for lipids: + Affinity for lipids:-

Renal excretion:- Renal excretion:+

Van den Bergh reaction: indirect Van den Bergh reaction: direct
Examination
Daylight: Icterus should be examined in day light

Upper bulbar conjunctiva: sclera is examined by retracting the upper eyelids

upwards and asking the patient to look downwards- both eyes at a time: a white
background is formed by sclera, sclera, bilirubin stains elastin, more on periphery.

Undersurface of tongue, ventral tongue

Soft palate

Palms and soles

General skin surface

Hemolytic, obstructive and hepatocellular jaundice
Jaundice: lemon- yellow, greenish yellow, , yellow

Stool: dark brown, pale or clay/steatorrhoea/ offensive/ soft/ floats on water,

difficult to wash from the pan, high coloured/ pale

Urine: acholuric/ dark yellow/mustard yellow, yellow

Anemia, splenomegaly, reticulocytosis

Pruritus, petechiae,purpura, ecchymosis, palpable gallbladder, osteomalacia, bone

pain/ fracture, night blindness, hepatic osteodystrophy

Anorexia , nausea, vomiting, fever, chills, rigors, tender hepatomegaly

Features of hemolytic jaundice
Anemia (hemolysis)

Reticulocytosis, splenomegaly

Stool: excess stercobilinogen and stercobilin: dark brown colour

Urine: freshly passed urine is normal in colour, which turns dark yellow on
standing as it is converted from urobilinogen to urobilin (by oxidation)

Jaundice: mild; lemon yellow tinge of bulbar conjunctiva, less than 6 mg/dl,
unconjugated
Features of hepatocellular jaundice
Anorexia, nausea, vomiting, fever, chills, rigors

Tender hepatomegaly

Stool- high coloured and may become pale if there is obstructive due to cellular
(hepatocyte) edema.

Orange yellow tinge of bulbar conjunctiva.

Features of obstructive jaundice
Generalized pruritus with scratch marks and shiny nails (bile acids irritate the free nerve endings)

Sinus bradycardia: bile salts directly inhibit the sinoatrial node

Xanthelasma: hypercholesterolemia: around the eyes or in the knees, buttocks.

Petechiae, purpura or ecchymosis: vitamin K deficiency (lack of bile salts produces vitamin K
malabsorption as it is fat soluble vitamin

Gallbladder: may be palpable indicating site of obstruction: bile duct, usually due to carcinoma of
head of pancreas(Courvoisier’s law)

Fat soluble:Vitamin A,D deficiency: night blindness, osteomalacia, bone pain, bone fracture, due
to malabsorption or steatorrhoea.
Which of the following is called surgical jaundice?

a. Hemolytic jaundice
b. Obstructive jaundice
c. Hepatic jaundice
d. All
Which of the following is called surgical jaundice?

a. Hemolytic jaundice
b. Obstructive jaundice
c. Hepatic jaundice
d. All
Cyanosis
The bluish discolouration of the skin and mucous membrane due to presence of
increased amount of reduced /deoxygenated hemoglobin (>5gm/dl) in the capillary
blood.

Types

Peripheral

Central
For cyanosis; amount of deoxygenated Hb should be

a. >4 mg/dl
b. >5 mg/dl
c. >5gm/dl
d. >4gm/dl
Peripheral cyanosis Central cyanosis

Mechanism/ Sites /causes Mechanism/ Sites/ causes

Mechanism Mechanism

Reduced cardiac output Marked reduction of oxygen in arterial blood

Peripheral vasoconstriction Decreased arterial oxygen saturation

Slow speed of circulation in the extremities Arterial blood goes below 80-85%

(Venous obstruction, cold exposure, vasculitis) Detection of central cyanosis

Arterial blood is normally saturated, oxygen

saturation at venous end of the capillary

Excessive extraction of oxygen from the

peripheral blood
Peripheral cyanosis Central cyanosis

Sites Sites

Tip of nose Tongue: margins and the under surface

Ear lobules Inner aspects of the lips

Outer aspects of lips, chin, cheek Mucous membrane of gums, soft palate, cheeks

Tip of finger and toes

Nail bed of finger and toes

Palms and soles

Causes (Peripheral cyanosis) Causes(Central cyanosis)

Exposure to cold air or cold water Cardiac:

Frostbite Cyanotic heart disease(tetralogy of fallot)

Shock or peripheral circulatory failure Acute pulmonary oedema

Venous obstruction MI

Hyperviscosity syndrome (multiple myeloma, Congestive heart failure

polycythemia)
Pulmonary
Peripheral vascular disease (Atherosclerosis,
Buerger’s disease) Acute severe asthma

Mitral stenosis(lips, tip of nose and cheeks) Chronic obstructive pulmonary disease

Malar flush is due to vasodilation(vascular Pneumonia

stasis) aka malar rash due to CO2 retention
Tension pneumothorax
Central cyanosis Peripheral cyanosis

Application of oxygen : cyanosis Application of oxygen : no response

decreases
Clubbing & polycythemia: absent
Clubbing & polycythemia: usually
present

Pulse volume: may be high Pulse volume: low volume

volume( due to arteriovenous shunt)

Dyspnea: patient is breathless Dyspnea: no respiratory difficulty

Cyanosis
Is not due to

a. Fever
b. Hypovolemic shock
c. Hypoxia
d. All of the above

Central cyanosis is detected in tip of tongue

Cyanosis
Is not due to

a. Fever
b. Hypovolemic shock
c. Hypoxia
d. All of the above

Central cyanosis is detected in tip of tongue

Mixed cyanosis(central+peripheral) is seen in

Congestive cardiac failure due to left heart failure

Acute myocardial infarction

Ortho Cyanosis: cyanosis in upright position(in pulmonary arteriovenous

malformation)
Cyanosis COLD PALMS
Peripheral cyanosis Central cyanosis

Cold Polycythemia

Obstruction Altitude

Shock Lung disease

Decreased cardiac output Met- sulfhemoglobinemia

COLD Shunt

PALMS
Both cyanosis and polycythemia are commonly present in :

Cyanotic heart disease

COPD
Lymphadenopathy

Inflammatory or non- inflammatory inflammation of lymph nodes.

To be significant, enlarged cervical lymph nodes >0.5 cm, axillary>1cm, inguinal

lymph nodes> 1.5cm in size

Generalized lymphadenopathy: It is characterized by involvement of three or more

non-contiguous lymph node areas.

Virchow’s nodes: Medial group of left sided supraclavicular lymph nodes which lie
in between two heads of sternocleidomastoid muscles.

Troisier’s sign: Palpable Virchow’s nodes in carcinoma of stomach.

Troisier’s sign is seen in

a. carcinoma of stomach
b. carcinoma of bladder
c. carcinoma of pancreas
d. carcinoma of rectum
Troisier’s sign is seen in

a. carcinoma of stomach
b. carcinoma of bladder
c. carcinoma of pancreas
d. carcinoma of rectum
Examination of lymph nodes
Neck

Axillary

Epitrochlear

Inguinal

Popliteal
Neck

Submental, submandibular, digastric, tonsillar, anterior cervical, posterior cervical,

preauricular, postauricular, occipital

Palpation is done from behind when the patient is sitting the head bend forward ( to relax
the muscles in the anterior part of neck).Submental, submandibular, digastric, tonsillar,
supraclavicular and deep cervical

Upper circular group: palpated symmetrically by both hands using the right hand for the
right side and left hand for the left side, order from front to back:

Scalene, above and behind the head of clavicles on both sides of neck by placing index
finger in between the sternocleidomastoid and clavicle

From the front, palpate the posterior triangle, up the back of the neck and the posterior
auricular and occipital nodes
Axillary lymph nodes examination

The patient sits on a stool and the examiner sits in front of the patient.

5 groups: central, apical, pectoral(anterior), brachial(lateral), subscapular(posterior)

To palpate the right axilla, support the patient’s right arm with your right arm to relax
shoulder muscles and explore the axilla with your left hand.

Gently place your fingertips into the apex of the axilla and then draw them
downwards, feeling the medial, anterior, posterior axillary walls in turn.
Epitrochlear nodes
Palpated in the anterior- medial region of the lower part of the arm (in between the
biceps and brachialis)

Support the patient’s right wrist with your left hand, and use your thumb to feel for
the epitrochlear node.

Examine the left epitrochlear node with your left thumb.

Examine the right epitrochlear node with your right thumb.

Inguinal nodes
Examine for the inguinal and popliteal nodes with the patient lying down.

Inguinal lymph node are palpated with thigh extended. Palpate over the horizontal
chain, which lies just below the inguinal ligament, and then over the vertical chain
along the line of the saphenous vein.

Popliteal lymph nodes felt with the fingertips of both hands, curled into the
popliteal fossa.
General principles
Inspect for visible lymphadenopathy

Palpation is done symmetrically on both sides from above downwards.

Assess: Site, size,consistency(normal:soft, rubbery: Hodgkin’s lymphoma, matted:

tuberculosis, metastatic: hard),infection:tenderness, nontender: malignancy,
tuberculosis, HIV

Determine whether the node is fixed to: Skin, surrounding and deep structures

Examine for enlargement of liver and spleen

Hematological features: purpura(bruising under the skin), which can be

large(ecchymosis) or pinpoint (petechiae)
Generalized lymphadenopathy
Lymphoma

Tuberculosis

HIV

Systemic inflammatory disorders: sarcoidosis

Generalized enlargement of lymph nodes are seen in
Tuberculosis

Typhoid

Myeloma

Hookworm
Generalized enlargement of lymph nodes are seen in
Tuberculosis

Typhoid

Myeloma

Hookworm
Clubbing
The painless bulbous swelling of the terminal phalanges and the toes with an
increase in the soft tissue mass, and increased anterior posterior as well as
transverse diameter of the nails due to proliferation of subungual connective tissue
and increased convexity of the nails .

Also known as Hippocratic fingers

Drumstick clubbing: Bronchiectasis; cyanotic congenital heart disease

Parrot-beak clubbing: bronchogenic carcinoma

Causes of clubbing
Congenital or familial (5-10%), acquired , thoracic (about 70%)

Cirrhosis, coeliac disease, inflammatory bowel disease: gastrointestinal

Cardiovascular: cyanotic congenital heart disease, infective endocarditis,

arteriovenous shunts and aneurysms

Lung cancer, lung abscess, pulmonary tuberculosis, bronchiectasis, empyema,

cystic fibrosis, mesothelioma, fibroma, pulmonary fibrosis

Thyrotoxicosis (thyroid acropachy)

Primary hypertrophic osteoarthropathy

Examination(clubbing)
1. Look across the nail bed from the side of each finger.

Assessment of nail-bed(hyponychial/ onychodermal) angle

The angle formed between the nail and adjacent skin fold.

Normal 160 degree, > 190 degrees, clubbing is likely

Examination(clubbing)
2. Look across the nail bed from the side of each finger.

Estimate the interphalangeal depth at the level of the distal interphalangeal joint
(this is the anteroposterior thickness of the digit rather than the width).

Repeat at the level of the nail bed.

Finger clubbing is likely if

The interphalangeal depth ratio>1(that is, the digit is thicker at the level of the nail
bed that the level of the distal interphalangeal joint)
Examination(clubbing)
3. Ask the patient to place the nails of corresponding (ring) fingers back to back
and look for the normal ‘diamond-shaped’ gap between the nail beds (Schamroth’s
window sign)

In clubbing, the diamond shaped area is obliterated.

Examination(clubbing)
3. Place your thumb under the pulp of the distal phalanx and use your fingers
alternately to see if there is fluctuant movement of the nail on the nail bed.

In clubbing, the increased fluctuation may be present.

Degree of clubbing
1st degree: increased fluctuation of the nail bed with loss of onychodermal angle

2nd degree: 1+increased anteroposterior and transverse diameter of the nails as

nails become smooth and glossy with loss of longitudinal ridges

3rd degree: 2 degrees increased pulp tissue

4th degree: 3 degree+ wrist and ankle swelling due to HOA (hypertrophic
osteoarthropathy)
Hypertrophic osteoarthropathy occurs in which grade of clubbing

a. Grade 1
b. Grade 2
c. Grade 3
d. Grade 4
Hypertrophic osteoarthropathy occurs in which grade of clubbing

a. Grade 1
b. Grade 2
c. Grade 3
d. Grade 4
Cyanosis with clubbing

Cyanotic congenital heart disease

Bronchiectasis

Pulmonary arteriovenous fistula

Oedema
Accumulation of excessive amount of tissue fluid in the interstitial space.

Types: pitting, non pitting

Medial malleolus, bony portion of tibia, dorsum of foot. It is gravity dependent:

sacral region in bed ridden patient.

Apply firm pressure for few seconds.

In bed ridden patient; look for oedema?

a. Leg
b. Scrotum
c. Eyelid
d. Sacrum
In bed ridden patient; look for oedema?

a. Leg
b. Scrotum
c. Eyelid
d. Sacrum
Mechanisms of oedema
Low plasma oncotic pressure: e.g. hypoproteinemia, hepatic disease

High capillary pressure: e.g. congestive cardiac failure, hepatic disease

Increased capillary permeability: acute inflammation

Obstruction: lymphatic drainage: Filariasis, radiation

Reduced protein synthesis:malabsorption/ malnutrition

Causes of pitting oedema
Congestive cardiac failure

Cirrhosis of liver

Nephrotic syndrome

Hypoproteinemia: nutritional, protein losing enteropathy

Venous obstruction: varicose veins, venous thrombosis, abdominal mass

Drug induced: amlodipine, NSAIDs, corticosteroids

Obstructive sleep apnea

Angioneurotic oedema: due to allergy

Causes of non pitting oedema
Myxoedema

Lymphatic oedema (Filariasis)

Angioneurotic edema

Scleroderma
Dehydration
The excessive loss of water and electrolytes from the body.

Seen in skin, mouth, activity, mental status, eyes

Sunken eyes

Parched lips

Dry tongue

Irritability, decreased activity

BMI
Weight in kgs divided by square of height in meters
Skin: Abnormal pigmentation, texture, swelling, rashes

On examination

Telangiectasia: dilated blood vessels

Papules are raised and palpable

Ecchymosis: large purpuric lesion

Bullae: large vesicle > 0.5 cm filled with fluid

Macule is a non palpable area of altered colour

Hematoma is a large extravasation of blood in skin.

Nails: Roughness, pitting, brittleness, spooning, ridging

Koilonychia: spoon shaped nails: thin concaves with raised surfaces

Abnormalities of nail
Shape: Koilonychia, clubbing, pincer nail, dolichonychia, bradypsychia, parrot
beak nail, macro/micronychia, platonychia

Nail surface:Beau’s line/onychomadesis, longitudinal ridging, nail pitting/

trachyonychia, onychoschizia

Nail attachment: Onycholysis, Pterygium

Nail colour: leukonychia, melanonychia, splinter hemorrhages, white nails, HIV-

associated dyschromia, yellow nail syndrome, red nails

lunula
Causes of koilonychia
Iron deficiency anemia

Idiopathic

Familial

Onycholysis

Overuse of solvent (detergents, nail)

Stages of koilonychia

First stage: stage of brittleness

Second stage: stage of flattening (platonychia)

Third stage: stage of spooning

Vitals (pulse)
Throbbing caused by regular contraction and alternate expansion pulse wave
generated in an artery as the waves of blood passes through the artery generated
by the ejection of blood into the circulation from the left ventricle.

Normal: 50-95 bpm. Resting heart rate. Taking into context. 40 bpm can be normal
in a fit young adult.
Examination of pulse
Rate: the number of pulses occurring per minute. Radial artery

Rhythm: the pattern or regularity of pulses. Radial artery

Volume: the perceived degree of pulsation. Brachial, carotid, femoral

Character: an impression of the pulse waveform or shape. Brachial, carotid, femoral

Condition of the arterial wall

Radioradial delay

Radiofemoral delay

Palpation of other peripheral arteries

Radial pulse
Place the pads of your index and middle fingers over the right wrist, just lateral to
the flexor carpi radialis tendon

Assess the rhythm of the pulse and count the number over 15 seconds, multiply
by 4 to obtain the rate in beats per minute(bpm).

To detect a collapsing pulse, first, check the patient has no shoulder and arm pain
or restriction on movement; next feel the pulse with the base of your fingers, then
raise the patient’s arm vertically above your head

Palpate both radial pulse simultaneously;assessing any delay between the two
Brachial pulse

Use your index and middle fingers to palpate the pulse in the antecubital fossa,
just medial to the biceps tendon

Assess the character and volume of the pulse

Posterior tibial pulse

1 cm behind the medial malleolus or midway between medial malleolus and

Achilles tendon.

Dorsalis pedis

Against the tarsal bone lateral to the tendon of extensor hallucis longus.
Carotid pulse
With patient semirecumbent, place the tips of your fingers between the larynx and
the anterior border of sternocleidomastoid muscle.

Palpate the pulse gently to avoid a vagal reflex, and never assess both carotid
simultaneously.

Listen for bruits over both carotid arteries, using the diaphragm of your
stethoscope in held inspiration.
Femoral pulse

At the midpoint of the inguinal ligament. (anterior superior iliac spine) to pubic
tubercle) against the femoral head.

Popliteal pulse

Examine with the patient knees flexed at 120 degree and the fingertips of both
hands are placed in the popliteal fossa with the thumb resting on the patella.
Haemodynamic effects of inspiration
pulse/ heart rate: accelerates

Systolic blood pressure: falls (up to 10 mmHg)

Jugular venous pressure: falls

Second heart sound: splits

Haemodynamic effects of expiration
pulse/ heart rate: slows

Systolic blood pressure: rises

Jugular venous pressure: rises

Second heart sound: fuses

Bradycardia<60 bpm
Sinus rhythm Arrhythmia

Sleep Sinoatrial or atrioventricular node dysfunction

Medication: beta blockers, digoxin, verapamil, Carotid sinus

diltiazem
Sick sinus syndrome
Athletic training
Second degree heart block
Hypothyroidism
Complete heart block
Relative bradycardia(Faget sign)
Liebermeister rule: Increase in pulse rate is more than 8-10 bpm with each celsius
grade of body temperature.

Viral fever (yellow fever)

First week of enteric fever

Tularaemia

Brucellosis, psittacosis

Weil’s disease

Drugs beta blockers

Tachycardia>100bpm
Sinus tachycardia(most common cause) Arrhythmia

Pain Atrial fibrillation

Excitement Atrial flutter

Exercise Supraventricular tachycardia

Anxiety Ventricular tachycardia

Hyperthyroidism

Fever

Medication: sympathomimetics: salbutamol,

vasodilators
Irregular pulse
Sinus arrhythmia Arrhythmia

Atrial extrasystoles Atrial fibrillation

Ventricular extrasystoles Atrial flutter with variable response

Second -degree heart block with variable

response
Common causes atrial fibrillation
Hypertension

Heart failure

Myocardial infarction

Thyrotoxicosis

Alcohol- related heart disease

Mitral valve disease

Infection: respiratory, urinary

Following surgery: especially cardiothoracic

Characteristics of atrial fibrillation:

1. Pulse deficit >10

2. Irregularly irregular pulse
3. Both
4. None

Pulse deficit can be calculated by counting the radial pulse and subtracting this
from the apical heart rate, assessed by auscultation.
Characteristics of atrial fibrillation:

1. Pulse deficit >10

2. Irregularly irregular pulse
3. Both
4. None

In atrial fibrillation the pulse deficit > 10

In multiple ectopics, the pulse deficit<10

Volume of pulse: high
A. Hyperkinetic circulatory state( Pulse B. Atherosclerosis
pressure> 60 mm of Hg)
C. Complete heart block
After exercise

Severe anemia

Pyrexia

Pregnancy

Aortic incompetence/ Thyrotoxicosis

Arteriovenous communications like PDA

Volume of pulse: low
Shock

Severe aortic stenosis

Tight mitral stenosis

Pericardial effusion

Constrictive pericarditis

Congestive cardiac failure

Causes of absent radial pulse
Anatomical abnormality

Takayasu’s disease

Embolism in the radial artery

Death
Causes of radioradial delay

Normal anatomical variations

Thoracic inlet syndrome, e.g. cervical rib, scalene syndrome

Aneurysm of aorta

Pre- subclavian coarctation

Supraventricular aortic stenosis

Pulseless disease (Takayasu’s disease)

Peripheral embolism

Atherosclerosis of aorta

Pressure over axillary artery by tumour , lymph node

Causes of radiofemoral delay are:
Coarctation of aorta

Atherosclerosis of aorta

Thrombosis or embolism of aorta

Aortoarteritis
Variations in character of pulse
Catacrotic pulse: The normal character of pulse

Anacrotic pulse: It is a low volume pulse with an upstroke felt in the ascending
limb of the wave. It is found in severe valvular aortic stenosis.

Dicrotic pulse: When an upstroke is felt in the descending limb of the wave, it is
called dicrotic pulse. It is found in hypovolemic shock, endotoxic shock.

Water hammer pulse: This is characterized by high volume pulse sharp rise, ill-
sustained and sharp fall. It is seen in aortic incompetence, severe anemia,
atherosclerosis, complete heart block.
Variations in character of pulse
Pulsus paradoxus:

Here the pulse volume decreases with inspiration and increases with expiration.

The paradox is that the heart sounds mat still be heard on auscultation over the
apex at time when no pulse is palpable at the radial artery, it is commonly seen in
acute severe asthma, cardiac tamponade.

Pulsus bisferiens: a high volume double beating pulse. The first lift is due to
percussion wave and second is due to tidal wave. It is found in combined aortic
stenosis and aortic incompetence.
Variations in character in pulse
Pulsus alternans

When the alternate pulse waves are weak. I.e. of low volume ( the rhythm remain
regular in contrast to ectopic). Seen in left ventricular failure.

Pulsus bigeminus

Here, two beats and a pulse thereafter recur repeatedly in a regularly fashion.

It is found in digitalis toxicity.

Temperature
Normal: 37 degree C(98.6 degree F)

Range: 36.6 degree C-37.2 degree C)

Pyrexia: above 99 degree F/ 37 degree C

Hyperpyrexia: above 107 degree F/ 41.6 degree C

Hypothermia: below 95 degree F/ 35 degree C : rectal temperature

Methods of taking body temperature:
The thermometer is kept for duration recommended in its manual. Varies

Sites:

Oral: the thermometer is placed under tongue and the patient breathes through
the nose with lips firmly closed.

Axillary/ groin: Placed in the armpit or folded groin; generally 0.5-1 degree F lower
than oral temperature.

Rectal: most reliable as well as accurate, and it is 0.5-1 degree F higher than the
oral temperature
Definition
Fever: elevation of hypothalamic set point that exceeds the normal diurnal
variation and occurs in conjunction with elevation of hypothalamic set point.

Hyperthermia: Uncontrolled increase in body temperature that exceeds the body’s

ability to lose heat and is not associated with elevation of hypothalamic set point.
Types of fever
Continuous : fever does not fluctuate more than 1 degree C during the day and
never touches the baseline.

Causes

Lobar pneumonia

Enteric fever

Dengue fever

Rheumatic fever

Meningococcal meningitis
Types of fever
Intermittent: fever is present only for several hours and always touches the
baseline.

Quotidian: The paroxysm of fever occurs daily. Found in kala azar.

Tertian: The paroxysm of fever occurs on alternate day. P. vivax, P falciparum

Quartan: When two days intervene between consecutive paroxysmal attacks of

fever. P. malariae.
Types of fever
Remittent: daily fluctuation of fever is more than 2 degree Celsius during the day
and never touches the baseline.

Amoebic liver abscess

Acute bronchopneumonia

Acute tonsillitis
Appearance of rash in febrile patient:
Very sick people must take double tablet

1st day: Varicella

2nd day:Scarlet fever

3rd day:Small pox

4th day: Measles

5th day: Typhus

6th day: Dengue fever

7th day: Typhoid fever(rose spot)

Mechanism of fever
Endotoxin released by damaged tissue or infectious agent-

Activates monocytes and macrophages-

Produce cytokines, interleukin-1, (pyrogen)-

IL-1 acts on anterior hypothalamus-

Increase in release of PGE2

Increased in thermostat set point

Increase in heat producing mechanism

Fever with chills and rigors
Malaria

UTI

Septicaemia

Acute lobar pneumonia

Fever
Fluctuates < 1 degree C in continuous

Fluctuates > 2 degree C in remittent

Hyperthermia
temperature> 41.6 degree C
When does not fluctuate more than 1 degree and at no time touches the baseline
throughout the day, it is

Intermittent fever

Remittent fever

Continuous fever

Step ladder fever

When does not fluctuate more than 1 degree and at no time touches the baseline
throughout the day, it is

Intermittent fever

Remittent fever

Continuous fever

Step ladder fever

Blood pressure(mm of Hg)
The pressure exerted by the blood on the wall of the blood vessels

Unless indicated otherwise, blood pressure refers to systemic arterial blood

pressure

The systolic pressure is defined as the peak pressure in the arteries during the
cardiac cycle. The diastolic pressure is the lowest pressure (at the resting phase
of the cardiac cycle)

Variations: BP varies from one heartbeat to another, throughout the day (in a
circadian rhythm). They also change in response to stress, nutrition, drugs,
disease.
Measurement of blood pressure
Patient should be sitting or lying at ease. The arterial pressure is affected by
anxiety, excitement, exertion and change in posture.

The manometer is placed at the same level of the cuff on the patient’s arm and the
observer’s eye.

All clothing should be removed from the arm.

Check that the width of the cough is correct (normally 12 cm). If narrower cuff is
used, recorded pressure will be high.

The cuff should be closely applied to the upper arm, with the lower border more
than 2.5cm above the cubital fossa.
Measurement of blood pressure
Palpate the radial pulse while the cuff is being inflated, at a certain level, the pulse
will no longer be palpable, this pressure gives the systolic pressure. Then pump a
little more so as to raise the pressure to 30 mm of Hg above the level at which the
radial pulsation was lost.

Place the stethoscope lightly over the brachial artery little above the cubital fossa.

Reduce the pressure of the cuff 5 mm of Hg at a time until the first sound is
heard(systolic BP).

Accordingly notice the level of complete disappearance of sound, record this as

diastolic pressure.
Korotkoff sounds
Auscultation over the brachial artery reveals five phases of Korotkoff sounds as
the cuff is deflated.

Phase 1: the first appearances of the sound marking systolic pressure.

Phase 2 and 3: increasing loud sounds

Phase 4: abrupt muffling of the sounds

Phase 5: Disappearance of the sounds marking the diastolic pressure

Factors determining the arterial blood pressure
Directly proportional to Inversely proportional to

Cardiac output Elasticity of blood vessels

Heart rate Diameter of blood vessels

Peripheral resistance

Blood volume

Velocity of blood

Viscosity of blood
 Physiologic variation of BP
Age: increases with age due to loss of Windkessel effect

Sex: BP is more in male than female

Sleep: BP is less during sleep than in awake condition

Meal: BP increases after meals

Emotion: Rage, anxiety, panic increases BP

Exercise: Slight rise of BP in isotonic exercise but sharp rise in isometric exercise

Posture: in erect posture SBP is slightly lower than DBP. In supine posture, SBP is
slightly higher than DBP.
Use of sphygmomanometer
To measure blood pressure

Hess’ capillary fragility test

To elicit Trousseau’s sign to detect latent tetany

To assess the respiratory reserve

To draw venous blood

To diagnose aortic incompetence and coarctation of aorta

Hypertension
When the BP is elevated to any value more than 140/90 mm of Hg under basal
condition.

Essential hypertension: without any definable cause

Secondary hypertension: rise in blood pressure due to some identifiable cause

E.g. endocrine: Cushing syndrome, pheochromocytoma

Hypertension of pregnancy
Hypotension
Fall in BP than normal value is called hypotension.

Postural hypotension: drop in SBP by>20 mm of Hg and DBP>10 mm of Hg within

3 minutes of standing up.
Respiratory rate
Normal:14-16 per min

Examination of respiration

Examine the patient with the chest and upper abdomen fully exposed and evenly
illuminated.

Examine the rate, rhythm and type of respiration and symmetry of chest
movement.
Variation in rate of respiration

Tachypnoea is an increased respiratory rate.

Dyspnea is the symptom of breathlessness experienced by the patient.

Apnea is cessation of respiration.

Variation in rhythm of respiration

E.g. Abnormal: Cheyne-stokes breathing: cyclical deepening and quickening of

respiration followed by diminishing effort and rate.
Type of breathing

Thoracoabdominal type: common seen among children.

Abdomino-thoracic type: commonly seen among males.

Symmetry of chest movement

Bilaterally symmetrical

Asymmetrical movements
Jugular venous pressure
Normally, JVP: 5-8 cm.

Always examine internal jugular vein.

External jugular vein is less reliable because it is:

Superficial: prone to kinking

Does not directly drain into SVC

May have valves, may pierce fascia

Engorged, if patient wears a tight collar.

Not a direct reflector of central venous pressure.

Examination of jugular venous pressure
The patient should recline at 45 degree angle, and neck muscles should be
relaxed.

Good light is necessary for visualization of neck vein. A light source is illuminated
from behind tangentially.

Right internal jugular vein, left jugular vein: innominate vein may be compressed
by the aortic knob which damps and elevates the venous pressure in the left
jugular vein.
Examination of jugular venous pressure
Look in between two heads of sternocleidomastoid, if it is full, observe the
uppermost point of distension.

The JVP is measured by placing a scale vertically over the sternal angle and the
other is placed horizontally from the top of the oscillating venous column.

The junctional point between the two scales is marked and the vertical distance
from the point to the sternal angle is measured, 5cm is added to the values as it is
the distance from the sternal angle to the center of the right atrium.
Difference between venous and arterial pulsation in the neck

Venous pulsation(JVP) Arterial pulsation (Carotid pulse)

Wavy or undulating Jerky or abrupt

Better seen than felt Better felt than seen

Prominent movement is inward Prominent movement is outward

Two positive waves are seen One positive wave is seen

It has definite upper level No such level

Abolished by gentle pressure over the clavicle Does Not affect arterial pulsation

Becomes prominent on expiration, lying down, No change

on application of abdominal pressure
Mechanism of different waves in neck vein:
a wave: right atrial contraction

c wave: closure of tricuspid valve

x descent: atrial relaxation with downward descent of tricuspid valve

v wave: passive right atrial filling during ventricular systole

y descent: right ventricular filling with atrial emptying

Causes of raised JVP
Congestive cardiac failure

Constrictive pericarditis

Cardiac tamponade- pericardial effusion

Tricuspid incompetence

Restrictive cardiomyopathy
Abnormalities of raised JVP
Complete heart block ‘Canon’ waves

Tricuspid regurgitation Giant v waves

Tricuspid stenosis Giant a waves

Atrial fibrillation Absent a waves

Superior vena cava obstruction Elevation, loss of pulsation

Constrictive pericarditis Kussmaul’s sign

Heart failure Elevation, sustained abdominojugular

reflux
Systemic examination

Inspection-

Palpation-

Percussion-

Auscultation-
Cardiovascular system
Skin and temperature colour

Venous: abnormal vessels, signs of inflammation

Arterial: pulse, pressure, jugular venous pulse and pressure

Heart: Inspection: pulsations and deformities of anterior chest wall

Palpation: apex beat

Auscultation: first and second heart sounds

The respiratory system examination
Upper respiratory tract: nose, tonsils, pharynx

Chest-

Inspection- Pulsations and deformities of anterior chest wall, Respiration- rate

and depth; chest expansion and mode of breathing

Palpation- Position of trachea and range of movement

Percussion- Anterior, lateral and posterior chest wall; hepatic dullness

Auscultation- breath sounds; vocal resonance and added sounds

The gastrointestinal system examination:
Mouth: lips, tongue, teeth, gums, and other mucosae

Abdomen: Inspection: scars, abdominal wall, shape, dilated veins, general and
local changes

Palpation: tenderness, guarding, individual organs, abdominal masses.

Hernial orifices and inguinal lymph nodes

Percussion: fluid, gas and individual organs

Auscultation: frequency and character of bowel sounds

The genitourinary system
Genitalia:

Male: Inspection: swelling and skin changes

Palpation: penis, testis, epididymis, vas deferens

Female: breast examination

Inspection of external genitalia

Pelvic examination by speculum; bimanual vagino-abdominal examination

Rectal examination
Nervous system
Higher functions(place, person, time)

Motor

Reflexes

Cranial nerves

Sensory

Gait

Coordination
Presentation of a normal case(general examination)
My patient is conscious, cooperative, well looking, lying comfortably in bed, with no particular
facies or deformities. The skin, breast, thyroid are normal.

There is no pallor, icterus, leukonychia, lymphadenopathy, clubbing, cyanosis, koilonychia,

oedema, dehydration.

Pulse is 70/ min, in right radial artery, regular in rhythm, normal in character, fair in volume.
The arterial wall are just palpable and there is no radio-radial and radio femoral delay. All
peripheral pulses are palpable.JVP is normal

BP: 120/ 80mm of Hg. In the right upper arm in the sitting position. No postural drop.

Respiratory rate is 16 per minute in supine position, normal in depth and is abdomino-
thoracic.

Temperature is 98 degree F in the right axillae.