General Physical Examination

Dr Preamala.G
Medical Department
HTJ,Seremban.
First impressions .....

• Decide how sick is your patient?

• Is she well,sitting up and talking?
• Or ill totally not aware of her surroundings?
• DOCTORS SHOULD BE
OBSERVANT,LIKE A DETECTIVE;
• "CONAN DOYLE"
• Look at the patients general appearance...atthe face ,hands
and body
• Each examining system can be described using four
elements;
- looking/inspection
- feeling/palpation
- tapping/percussion
- listening/auscultation
- assessment of function
VITAL SIGNS

• PULSE
• BLOOD PRESSURE
• TEMPERATURE
• RESPIRATORY RATE
• Should be assessed immediately once you
discover that your patients unwell.
• They provide important basic physiological
information.
Weight,body habitus and posture

• Obesity,BMI >30.
• Any wasting of muscles?
• Tall?short?
• Always observe when the patient walks into
the examination room.
FACIES

• Specific diagnosis can be made by just

looking at a patient's face.
• Some facial characteristics are so typical of
certain diseases that they immediately
suggest the diagnosis....so called diagnostic
facies......
hydration

• Mild-2.5L deficit
-mild thirst,dry mucous membranes,concentrated urine
• Moderate - 4L deficit
-as above with moderate thirst,reduced skin turgor(especially the
arms,forehead,chest and abdomen) , tachycardia
• Severe - 6L
-great thirst,reduced skin turgor and decreased eyeball pressure
-collapsed veins,sunken eyes,postural hypotension,oligu
acromegaly
Acromegaly hands
Important diagnostic facies

• Acromegaly
• Cushingnoid
• Down syndrome
• Hippocratic
• Marfanoid
• Myxoedemetous
• Thyrotoxic
• parkinsonism
Down!
Cushing's syndrome
JAUNDICE

• It is the yellowish discolouration of a patient's

skin and sclerae that results from
hyperbilirubinemia.
• It happens when the serum bilirubin level
rises twice above the normal upper limit.
• It is deposited in the tissues of the body that
contains elastin.
jaundice

Hep A Patient with Jaundice

Causes of cyanosis

• Central cyanosis • Peripheral cyanosis

1) )Decreased arterial 1) All the causes of central
oyygen saturation. cyanos1s
-high altitude 2)Exposure to cold
-lung disease 3)Reduced cardiac output
-right to left cardiac shunt -left ventricular failure
2)Polycythaemia -shock
3)Haemoglobin 4)Arterial or venous
abnormalities; obstruction
methaemoglo
binemia,sulphaemoglobine
.,a
m
cyanos1 ■

s
CYANOSIS

• Blue discolouration of the skin and mucous membranes;it is

due to the presence of deoxygenated haemoglobin in the
superficial blood vessels.
• Occurs when there is more than 50g/L of deoxygenated
haemoglobin in the capillary blood.
• Types-central and peripheral
• Central cyanosis- abnormal amount of deoxygenated
haemoglobin in the arteries and that a blue discolouration is
present in parts of the body with good circulation.eg;tongue.
• Peripheral cyanosis-occurs when blood supply to a particular
part of body is reduced,eg;lips in cold weather becomes blue
but the tongue is spared.
Macrocytic anaemia

• Megaloblastic bone marrow

1) Vitamin B 12 defiency due to
.
-pern1c1ous anaemia
-gastrectomy
-tropical sprue
-ileal disease;crohns disease,ileal resection
-fish tapeworm
-poor diet in vegetarians
Causes of anaemia

•MICROCYTIC ANAEMIA
1)Iron deficiency anaemia
-chronic bleeding
-malabsorption
-hookworm
-pregnancy
2)Thalassemia minor
3)Sideroblastic anaemia
4)Longstanding
anaemia of chronic
blood loss
PALLOR

• Deficiency of haemoglobin can produce

pallor of the skin.
• Should be noticeable especially in the
mucous membranes of the sclerae if the
anaemia is severe- Hb of less than 7g/L.
• Facial pallor can also be seen in patients
with shock,due to the reduction of cardiac
output. These patients usually appear cold
and clammy and significantly hypotensive.
Normochromic anaemia

• Bone marrow failure

-aplastic anaemia
-ineffective haematopoiesis
-infiltration
• Anaemia of chronic disease
-chronic inflammation
-liver disease
-malignancies,chronic renal failure
• Haemolytic anaemia
2) Folate deficiency due to
-dietary defiency in alcoholics
-malabsorption
-increased cell turnover eg;pregnancy,leukemia,chronic
haemolysis
-anti folate drugs -
phenytoin,methotrexate,sulphasalazine
non megaloblastic bone marrow
-alcohol,cirrohis of the
liver,hypothyroidism,myelodysplastic syndrome
Oral cavity

• The teeth and breath

• Check the oral cavity looking for
• MOUTH ULCERS
-Aphtous,drugs and trauma
-gastrointestinal disease;inflammatory bowel
disease,coeliac disease
-rheumatological;Behcets syndrome,reiter
-erythema multiforme
-infections;herpes
zoster,simplex,syphilis,tuberculosis
Photo courtesy of CDC - Sol Silverman, Jr,, DDS
Behcets ulcers
Gum hypertrophy

• Phenytoin
• Pregnancy
• Scurvy(vitamin C deficiency;gums become
swollen,spongy,red and bleeds easily)
• Gingivitis;smoking
• leukemia
Figure 20 Figw·e
21
Pigmentation in the mouth

• Heavy metals-
lead,bismuth,iron;haemochromatosis there is
blue grey pigmentation in the hard palate
• Drugs-antimalarials,OCPs(brown/black
pigmentation anywhere in the mouth)
• Addisons disease
• Peutz-jeghers syndrome
• Malignant melanoma
HAIR

• ALOPECIA
• Non-scarring
-alopecia areta
-scalp ring worm
-traction alopecia
• Scarring
-burns,radiation,lupoid erythema,sarcoidosis
Alopecia areata
Traction alopecia
Alopecia totalis
NECK;lymphadenopathy,goitre

• During palpation of lymph nodes the

following features should be considered;
• SITE
-Localised or generalised?
-palpable lymph node areas are;
Epitrochlear,axillary,cervical and
occipital,supraclavicu lar,para-aortic,inguinal
and popliteal.
• SIZE
• CONSISTENCY
-hard are suggestive of carcinoma
-soft may be normal
-rubbery may be due to lymphoma
TENDERNESS
-Acute infection of inflammation
FIXATION
-If fixed to the underlying structures its most likely malignant
OVERLYING SKIN
-if inflar:1med then its suggestive of infection,teethered suggests
carcinoma.
Cervical lymphadenopathy
When)'Ou<ktca anenlarjlC(I lyrnphnode, paIp.ate the entirelymph node sy,;tcm to deter­
mine the extent or lyrnpharlenopathy. lndudc the 1)1 >h nodesIndicated below in your
as, scssmenL

'lf'!..-¼ - - - - - O ( d p l U I I
-.;,..;'- ---- st•rlor am\
culal
Subrn.1xUlruy - - - - - - - ' q : , . _ : ...,._....,. 1'>st<rlor "'l"'rtldal
Subrnental - - - - - - - - - ' ,..-rvtcal
Ntlcrlo, supcmcl.d i - - - - l st•rlorctlVlcal
C C I V k d l - ------'"7""---.....J • • - • - - - - - spinal ncnie clmln
Deep«:tvl.al _,, _ , S1tpri1Clavk"11la.r

Brachlal ax!Wuy - - - - - + - - - - - - - - - - , r
u.eral11><IU..ry ----i + - ------....,..q,.;.
Pectorala n;uy ------l-.----------.
Sub>wpuli,tor oll.tl)' --+- --'t-'f!,1--r---''t--- !!!i'-+i

f.l>llrodtlear - - - - - + - - 1 - - - - - - - - - + - - - - + -

Sup<:tlor s14>ert1clal
I n g u i n a l - ----+ - + + - --.
lnfe"°rsuperbelal
Inguinal1fcmorab - - f . - - 1 ' - - - - I

\
NAILS
• CLUBBING
• -Increase in the soft tissue of the distal part of the fingers or toes.
•CAUSES
1)Cardiovascular
-cyanotic
congenital
heart
disease,IE
2) Respiratory
-lung
carcinoma
-
bronchiectas
is,lung
abscess,em
phyema
localised

• Local or acute infection

• Metastasis from carcinoma or other solid
tumour
• Lymphoma especially hodgkin's disease
CAUSES OF LYMPHADENOPATHY

• GENERALISED
-lymphoma
-leukemia
-infections
-viral;infectious mononucleosis,CMV,HIV
-bacterial;tuberculosis,syphilis
-protozoa!;toxoplasmosis
-connective tissue disease
-infitration;sarcoidosis
-drugs;phenytoin
clubbing
Plummer wilson
psor1 as1
• •

s
• Blue nails-cyanosis,wilson ds
• Red nails-polycythaemia,CO poisoning
• Yellow nails- yellow nail syndrome
• Splinter haemorrhages-lE,vasculitis
• Koilonychia-iron def anaemia,fungal
infection,raynauds
• Onycholysis-thyrotoxicosis,psoriasis
• Leuconychia-hypoalbuminemia
• Nailfold erythema-SLE
• Terry's nails-CRF,cirrohis
Thank you.