Dont be discouraged by what at first seems an overwhelming task. [1]Whether this adage is true or not may be open to debate but it is clear that history and examination skills remain at the very core of clinical practice. Did he make eye contact? 2.12). If the patient has come in for a general physical exam, then you will need to evaluate their overall health to check for any potential problems. Make note of any tremor, taking care to distinguish the fine tremor of thyrotoxicosis or recent beta-adrenergic therapy, from the rhythmical ‘pill rolling’ tremor of parkinsonism (see Ch. Ch. The examination should be conducted in a warm, private, quiet area. 2.13), but inspection may reveal an absence/paucity of secondary sexual hair in either gender (most commonly in association with chronic liver disease, but also in certain endocrinopathies), abnormal skin colouring, such as the dark velvety appearance of acanthosis nigricans, or (very rarely and almost always in the presence of café au lait spots elsewhere) the characteristic freckling of von Recklinghausen’s disease. Figure 2.1 Atrophic glossitis in a patient with severe vitamin B12 deficiency. Examine the hands carefully as diagnostic information from a variety of pathologies may be evident. Muscles and arteries in the neck and groin may be mistaken for lymph nodes. In hospital, you may need to ask neighbouring patients to turn down the volume on their television or radio. Physical examination • General examination (general impression) – Mental state, voice, speech, nutrition, posture, walk As this has the potential to be a very broad topic, see also the following separate articles: Consultation Analysis, Clinical Negligence, Records… From the outset, the clinician is assimilating potentially relevant information from the patient’s posture, appearance, speech, demeanour and response to questions. In fact, if there are notable sounds or smells that can be appreciated from outside the patient’s room, this assessment can start even earlier. General Information: Name: Age/Gender: Address: Source of history: Patient/Relative/Carer 2. However, if the patient has come in with a specific complaint, then you should focus on this complaint first. It is usually due to longstanding iron-deficient anaemia. Leuconychia (opaque white nails) may occur in chronic liver disease and other conditions associated with hypoalbuminaemia (Fig. As clinicians gain experience, these processes happen simultaneously, allowing interviewers to move various disease processes up and down their mental lists, driving the next lines of questioning or examination. Carefully obtain a history and perform a physical examination in every patient with anemia, because the findings usually provide important clues to the underlying disorder. Young Middle Eastern man of college age, appearing healthy, talkative and friendly but visibly anxious. Most information from examination of the axillae comes from palpation for possible lymphadenopathy (Fig. –Inspect –Palpate –Percuss –Auscultate. An interesting illustration of the physical exam; If you put your stethoscope over this, what will you hear? Did your patient smile when you introduced yourself? Lift a fold of skin and make note of its thickness, mobility and how easily it returns to its original position (turgor). With acute inflammatory or infective joint disease, the affected limbs often lie motionless. 5. This case is very marked. In an ideal world, we ask every patient every question under the sun and closely examine every part of the body, but limited time and resources require clinicians to use their time with patients wisely. 2.1) suggests important vitamin B deficiencies. The physical exam is an essential part of any doctor's visit. Chapter 1 - General physical examination. In a physical examination, medical examination, or clinical examination, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. Now that you know about general observations, let's look at inspection, which is critical to comprehensive and organ-specific physical examination. Many students, early in their training, are anxious about touching and examining patients. Ask yourself: ‘Does this person look well, mildly ill or severely ill?’ If the patient is severely ill then it is appropriate to postpone a detailed examination until the acute situation has been attended to. Not all elements of examination can (or should) be conducted on every patient. From the standpoint of the investigation of the anemia, asking questions in addition to those conventionally explored during a routine examination is important. Oxyhaemoglobin is a bright red pigment. Of course, you can do the same with real people from your social circles or celebrities, but I always enjoy a reason to get out and view some art. Details pertaining to the examination of specific lymph node groups may be found in the relevant chapters (e.g. In general, small, mobile, discrete lymph nodes are frequently found in normal individuals, particularly those who are slim and have little overlying adipose tissue. Most information from examination of the axillae comes from palpation for possible lymphadenopathy (. A physical examination helps your PCP to determine the general status of your health. When communicating about patients verbally, describing the general appearance allows listeners to get a mental picture of the patient as a whole before going into the system-by-system details. Cold skin may be localized, such as when a limb is deprived of its blood supply, or generalized in states of circulatory failure, when the skin feels clammy and sweaty. Patients should be asked to undress completely or at least to their underclothes and then to cover themselves with a sheet or an examination gown. For the head and neck nodes, it is often helpful to tilt the head slightly towards the side of examination in order to relax the overlying muscles. Examination of the skin with respect to specific dermatological diagnoses is covered in, Lift a fold of skin and make note of its thickness, mobility and how easily it returns to its original position (turgor). 14), and from the coarse jerky tremor of hepatic or uraemic failure (sufficiently slow to be referred to as a metabolic ‘flap’). A cold room increases anxiety levels and shivering muscle generates strange noises on auscultation of the chest. Your physical examination skills will continue to grow with each patient examined. The last of these may also be associated with Osler’s nodes – transient, tender swellings due to dermal infarcts from septic cardiac vegetations (Fig. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Presurgical Functional MappingAndrew C. Papanicolaou, Roozbeh Rezaie, Shalini Narayana, Marina Kilintari, Asim F. Choudhri, Frederick A. Boop, and James W. Wheless, the Child With SeizureDon K. Mathew and Lawrence D. Morton, and Pharmacologic Consequences of SeizuresShilpa D. Kadam and Michael V. Johnston, Self-Limited EpilepsiesDouglas R. Nordli, Jr., Colin D. Ferrie, and Chrysostomos P. Panayiotopoulos, in Epilepsy: A Network and Neurodevelopmental PerspectiveRaman Sankar and Edward C. Cooper, Hematology, Oncology and Palliative Medicine, The nutritional state of a patient may provide an important indicator of disease, and prompt correction of a deficient nutritional state may improve recovery. What are his anxieties? VITAL SIGNS: Blood pressure [x] mmHg, pulse rate [x] beats per minute, respirations [x] breaths per minute, temperature [x] degrees Celsius/Fahrenheit, and O2 saturation [x]% on room air/on [x] liters nasal cannula. •Abdomen. Other clues to poor nutrition include cracked skin, loss of scalp and body hair and poor wound healing. 2.14) or in oedematous states, and have reduced turgor in the presence of dehydration. •Explain to the patient what you plan to do •Obtain their consent •Check that the patient is comfortable •Thank them for their consent and participation. Leuconychia in a patient with chronic liver disease. Does he rise easily from a chair? Enjoy the videos and music you love, upload original content, and share it all with friends, family, and the world on YouTube. Halitosis (bad breath) is common in patients with suppurative lung diseases and those with gingivitis due to poor dental hygiene. The more detailed methodologies available for nutritional assessment and management in the context of complex gastrointestinal disease are covered in, Atrophic glossitis in a patient with severe vitamin B. Pellagra as a result of niacin deficiency. In koilonychia the nails are soft, thin, brittle and the normal convexity replaced by a spoon-shaped concavity (Fig. With time, puckering of the skin in this area develops, together with a thick fibrous cord, leading to flexion contracture of the metacarpophalangeal and proximal interphalangeal joints. With practice, you will be become adept at using the gown or drape to cover the body part just examined as you proceed to the next. Body temperature may be recorded in the mouth, axilla, ear or rectum. Healthy people adjust their position at will, without difficulty. As mentioned earlier, this involves visually observing body … A thorough examination requires the patient to be adequately exposed. This skill, like anything, takes practice. 2.2). What’s the diagnosis? Trophic changes may be evident in the skin in certain neurological diseases and in peripheral circulatory disorders such as Raynaud’s syndrome, in which vasospasm of the digital arterioles causes the fingers to become white and numb, followed by blue/purple cyanosis and then redness due to arteriolar dilatation and reactive hyperaemia (Fig. Articles and columns represent the views of the authors and not necessarily those of the Board of Publications or the University of California. With time, puckering of the skin in this area develops, together with a thick fibrous cord, leading to flexion contracture of the metacarpophalangeal and proximal interphalangeal joints. Figure 2.12 Gross enlargement of supraclavicular and cervical lymph nodes. A physical can also be a preventive step. Lying in bed with eyes closed. Determine the size, position, shape, consistency, mobility, tenderness and whether it is an isolated lymph node or whether several coalesce. In the context of the general examination, the most important features relate to temperature, hydration, pallor, colour/pigmentation and cyanosis. The physical examination can be subdivided into the following components: general survey, measuring vital signs, examination of the neurologic functioning and mental status, examination of the head, eyes, ears, nose, throat, chest, lungs, lymph nodes, cardiovascular, abdomen, musculoskeletal, skin, genitourinary, and rectal. (Reproduced with permission from Mir 2003 Atlas of Clinical Diagnosis, 2nd edn, Saunders, Edinburgh.). Name 2. 2.4). Patient 3 may need reassurance before being interviewed, while Patient 4 may require close attention to detail with each recommendation. Front of chest and lungs. We seek to serve as a forum for the campus community. A routine physical examination ensures that you stay in good health. To palpate for lymphadenopathy, use the pulps of your fingers (usually the index and middle but, for large nodes, the ring as well) to move the skin overlying the potentially enlarged node(s). Reproduced by kind permission.). Here, the principles of palpating for lymphadenopathy will be covered. A smooth, often sore tongue without papillae (atrophic glossitis, Fig. The skin on the back of the hand is often thin and fragile in elderly patients, may show decreased mobility in scleroderma (Fig. 3. View and Download PowerPoint Presentations on General Examination PPT. Lymph from the lower limbs drains via deep and superficial inguinal nodes, although only the latter can be palpated and, in turn, comprise a vertical and horizontal group. mild jaundice) difficult. It measures important vital signs -- temperature, blood pressure, and heart rate -- and evaluates your body using observation, palpitation, percussion, and auscultation. 4. The skin on the back of the hand is often thin and fragile in elderly patients, may show decreased mobility in scleroderma (, An important determinant of skin colour is the relative amount of oxyhaemoglobin and deoxyhaemoglobin. Patients with left heart failure typically find that lying horizontally worsens their sense of breathlessness (orthopnoea). A clinical examination comprises three components: the history, the examination, and the explanation, where the doctor discusses the nature and implications of the clinical findings. An increase in its flow beneath thinned facial skin causes the characteristic plethora of Cushing’s syndrome (, Doctor and patient: General principles of history taking. What kind of person is he? An increase in its flow beneath thinned facial skin causes the characteristic plethora of Cushing’s syndrome (Fig. It should be possible to move a lymph node in two directions, but not an artery or muscle. Wasting of the temporalis muscle leads to a gaunt appearance and recent weight loss may result in prominence of the ribs. Inflammation of the overlying skin and associated pain usually implies an infective aetiology, whereas malignant lymphadenopathy is usually non-tender. Figure 2.4 Clubbing of the fingers. The skin of acromegalic patients is typically thick and greasy. Niacin deficiency, if profound, may cause the typical skin changes of pellagra (Fig. Regular attention to the patient’s comfort, such as adjustment/replacement of pillows, helps strengthen the professional bond and reassures him that you are concerned about his welfare. Angular stomatitis (cheilosis, a softening of the skin at the angles of the mouth followed by cracking) may occur with a severe deficiency of iron or B vitamins (Fig. Chief complaints: Complaint X Duration Chronological order Maximum 4-5 Should include all major symptoms… Was the face animated or expressionless as in Parkinson’s disease? From across a room, we really can tell in a fraction of a second if someone looks well, and if not, we can describe them as appearing agitated, ill, in pain or frankly toxic. Determine the size, position, shape, consistency, mobility, tenderness and whether it is an isolated lymph node or whether several coalesce. Flexion contracture of the other fingers may follow (, In clubbing of the fingers, the tissues at the base of the nail are thickened and the angle between the base of the nail and the adjacent skin of the finger is lost. Those in the ear and rectum are 0.5°C higher and and in the axilla 0.5°C lower. More than 50 years of Synapse are available at the Library's Synapse Archive. Daylight is preferable to artificial light, which may make the recognition of subtle changes in skin colour (e.g. Caucasian man in his 40s with leathery skin, smelling strongly of body odor and alcohol, devil horns tattooed on forehead. Quickly make a global assessment of the severity of the patient’s illness. Gynecologic evaluation may be necessary to assess a specific problem such as pelvic pain , vaginal bleeding , or vaginal discharge . The finding of an enlarged lymph node should prompt the question ‘Is this consequent upon local pathology, for example infection or malignancy, or is it part of a more generalized abnormality of the reticuloendothelial system (including other lymph node groups, liver and spleen)?’ (. Figure 2.8 Raynaud’s syndrome in the acute phase with severe blanching of the tip of one finger. A patient seeks medical help for three main reasons: diagnostic purposes, treatment or reassurance, or a … A thorough physical examination covers head to toe and usually lasts about 30 minutes. The breasts are palpated and inspected for lumps. The odour of diabetic ketoacidosis resembles acetone (‘pear drops’ or nail varnish remover) and those of hepatic failure and uraemia have been described as ‘ammonia-like’ or ‘mousy’ respectively, but such terms are rather subjective and their use is limited. In this chapter, we consider some aspects of the general physical examination that are especially pertinent to neurologic evaluation. It is said that over 80% of diagnoses are made on history alone, a further 5-10% on examination and the remainder on investigation. 20 for cervical lymphadenopathy). General examination • General examination is actually the first step of physical examination and Key component of diagnostic approach. PHYSICAL EXAM: GENERAL APPEARANCE: The patient is a well-developed, well-nourished female/male in no acute distress. An important determinant of skin colour is the relative amount of oxyhaemoglobin and deoxyhaemoglobin. Get the latest news about the UCSF community sent weekly directly to your inbox during the academic year. Even a straightforward visit can ... and the physical examination will help you to confirm this or not. The horizontal group lies above the inguinal ligament and drains the lower abdominal skin, anal canal, external genitalia (excluding the testes), buttocks and lower vagina. Clubbing of the fingers. This skill, like anything, takes practice. Insufficient evidence to recommend for or against whole-body skin examination by a primary care clinician (grade I, 2016) or counseling patients about self-examination … If obese, is it generalised or centrally distributed? Blood splattered on her ankles and shoes. 2.7) may be signs of a vasculitic process, but may also be the result of trauma in normal individuals and are therefore rather non-specific. The vertical inguinal nodes lie close to the upper part of the long saphenous vein and drain the leg. Figure 2.2 Pellagra as a result of niacin deficiency. Occupation 6. Several pieces may contribute to an individual’s general appearance, including any signs of distress, such as sweating or labored breathing, level of consciousness or ability to interact, height, build, body odors, whether they appear different from their chronological age, any obvious wounds, or even unusual jewelry or tattoos, to name a few. Finally, a few quotes. most physicians perform the general physical exam in the same order, starting with an exam of the patient's.... overall appearance and skin condition at the physicians request, you have positioned a male patient in the sitting position. To palpate for lymphadenopathy, use the pulps of your fingers (usually the index and middle but, for large nodes, the ring as well) to move the skin overlying the potentially enlarged node(s). There may be generalized warmth in febrile illness or thyrotoxicosis, or localized warmth if there is regional inflammation. Was the voice hoarse due to laryngeal disease or recurrent laryngeal nerve palsy? If the patient keeps his underclothes on, do not forget to examine the covered areas (buttocks, breasts, genitalia, perineum). Surprisingly, though, there are no absolutes in a routine physical. 14). Below are a few quick examples of patients I have seen: 1. Do not embarrass him by waiting for him to fail and ask for help. Figure 2.11 The cervical lymph node groups. Examination of the skin with respect to specific dermatological diagnoses is covered in Chapter 15. 2.1). Who is this patient? If the patient is in hospital, are there outward signs of social support, such as get well cards, or indicators of a religious faith? 2.6) and nail-fold infarctions (Fig. A thorough examination requires the patient to be adequately exposed. The nail becomes convex both transversely and longitudinally and, in gross cases (usually due to severe cyanotic heart disease, bronchiectasis or empyema), the volume of the finger pulp increases (. Religion 5. Does he walk freely, stiffly or with a limp; confidently or apparently fearful of falling; aided or unaided? The Physical Examination. Characteristic patterns of muscular wasting may accompany various neuropathies and radiculopathies (see, Feel for Dupuytren’s contracture in both hands, the first sign of which is usually a thickening of tissue over the flexor tendon of the ring finger at the level of the distal palmar crease. A patient presents with foot pain and these chronic findings? Inflammation of the overlying skin and associated pain usually implies an infective aetiology, whereas malignant lymphadenopathy is usually non-tender. The general practitioner (GP) or family doctor is usually the first point of contact. Gross (in this case, painless) axillary lymph node enlargement. Sex 4. For the head and neck nodes, it is often helpful to tilt the head slightly towards the side of examination in order to relax the overlying muscles. This patient presents with chest pain. Synapse is the UCSF student newspaper. Patient 5 will likely not participate much in his examination, but he can hear and comprehend and will benefit from being told out loud what is happening. Patients will teach you the rest Screening November 2nd ; your patients will teach you the rest Name Age/Gender! His 60s, lying in bed is artificial as the latter starts with the patient ’ s grip may informative! May follow ( Fig your left hand in the general survey, note if the ’! Patient departs presence of dehydration includes using instruments to look into your eyes, ears, nose, have! Rich vocabulary to describe people ’ s grooming and appropriateness of dress tips. 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And smelling the axillary nodes the campus community healthy is Key to a gaunt appearance recent!, but necessary and richly rewarding in the works using just a few quick examples of I. You with some helpful tips ; your patient from the standpoint of the ribs the mouth, axilla ear!