General Physical Examination- Dr.Bhakti Kharate, #medicine #mbbs

hello dear students today we are going

to talk about general examination

history taking and general examination

are an important part of any physical

examination of the patient so before you

start clinical examination a proper

history taking is important along with

that if you do a proper meticulous

general examination it gives you at

least a probable diagnosis now what are

the prerequisites before you start a

general examination are the patient has

to be put in a very comfortable position

so when you do start general examination

see to it that the surrounding is

comfortable and it is a quiet place so

you can examine the patient comfortably

now most of the times the patient are

very apprehensive about the examination

so assure the patient what is the need

and significance of doing the general

examination as it is going to help you

arrive at a diagnosis

now when you perform general examination

it has to be done in a proper light

because the skin changes can be

appreciated properly in a natural light

so as far as possible avoid artificial

light

then the third point we need to know we

need to remember is that general

examination when we have it done it has

to be done with the proper exposure of

the patient of whatever part we are

examining now at this point it is

mandatory that i tell you that whenever

you are examining a male doctor is

examine a female subject a female

attendant or a nurse should be present

that will assure or make the female

patient comfortable as well as it will

prevent you from any

accusations of immodesty so always

remember that a female attendant should

be present in whenever you examine a

female patient now another important

point i want to highlight is for any

examination clinical examination

henceforth you will be always standing

on the right side of the patient

standing on the right side of the

patient allows you to examine the

abdominal organs properly you can also

observe the jugular veins and examine

the apex beat properly when you are

standing on the right side so it is

mandatory that you stand always on the

right side of the patient now with this

points in mind we also have to

understand that whenever you are doing

examination that the you should take

into consideration the severity of the

patient's complaints if the patient is

having very acute illness see to it that

you first look at those things and if

the patient is comfortable only then

proceed for general examination or you

can postpone till you are although his

acute condition is taken care of so

these are the prerequisites which you

will do before you actually start the

general examination

now we start the general examination we

have to take the consent of the patient

so

so once you have taken the consent of

the patient now we have to start the

general examination now general

examination is usually started as soon

as a patient arrives in your clinic so

if the patient is arriving in your

clinic you have to be very observant

about the way he walks that is going to

give or how ill is the patient whether

the patient appears healthy or is ill if

the patient is ill try to cause what is

the severity of the patient now if the

patient is lying down on the bed

that the position of the patient in bed

is called as decubitus so once you know

that patient is lying down comfortably

and how much is the severity of the

illness you can proceed for your general

examination if the patient is breathless

you will know the position of the

patient will be propped up so that is

called as a decubitus or the position of

the patient in bed now once you have

seen that you start the examination from

head to toe now first coming to the head

now head examination of the head is

usually more significant when you're

examining a pediatric patient the size

and shape of the head is important if

the patient is having macro kefali or if

there's a microcephaly you will know the

significance of those things suppose

there's hydrocephalus he will have a big

head so microcephaly and macro kefali

these are the things you will observe

especially in pediatric patients when

you are talking about the size and shape

of the head

then you talk about the mental condition

of the patient whether how patient is

oriented in time in space what is a how

is the speech of the patient whether the

patient is cooperative or not now most

of the things you would have taken when

you are taking history taking you would

have asked about his uh educational

qualification his occupation and all the

history you have taken by now you know

how cooperative the patient is and

whether it is oriented in time on space

and how is this speech because that

gives you a lot of information about the

diagnosis you are going to make later on

so keep in mind about the mental state

of the patient now once you have done

that then you go and you observe the

build of the patient so you know the

what is the height and weight you have

taken is age so it has to be compatible

with this age and according to the

gender the height and weight have to be

there now two things can be the either

patient is a small nourish is starved so

you know it could be a chronic illness

or if the patient is obese which is a

very risk factor for many of our

cardiovascular diseases so keep in mind

the build of the patient also you have a

rough idea when you start general

examination you look at the build of the

patient

so now we will start the general

examination proper now there are six

things which are most important when you

are doing the general examination so we

have this acronym pickle what does p

stand for p stands for pallor

pallar is the painless of the skin so we

have to examine the subject for parallel

we'll talk about it in detail when we

see the patient so right now i'm just

going to tell you what are the the

stands for so p stands for palla i

stands for actress

actress is the yellowish discoloration

of the skin which we have to examine c

stands for cyanosis

cyanosis is bluish discoloration of the

skin which is seen when the reduced

hemoglobin is more than 5 grams per

deciliter then another c stands for

clumping

clubbing is a spelling of the

soft tissues of the fingernails then l

stands for lymphadenopathy

that is enlargement and palpable lymph

nodes and lastly e stands for edema that

is collection of fluid in the

interstitial spaces so these are the six

important most important parameters

which you should do when you're doing

general examination the acronym is

pickle p stands for pallor i stands for

actress c stands for cyanosis another c

stands for clubbing alpha

lymphadenopathy and e for edema now we

will go and examine all these things on

a subject now we are going to examine

the subject for pallor what do you mean

by pala paler is the paleness of the

skin it is usually due to reduce

hemoglobin content in the blood or there

is various amount of blood for example

when the patient is in shock then the

palate will be visible or the patient is

having anemia because of reduced

hemoglobin content so what are the areas

which you are going to examine for palla

balance usually seen in the lower

palpable conjunctiva so to examine the

lower palpable conjunctiva instruct the

subject to look up

and just retract the lower eyelids to

look for

upper dick okay

so then

look for palla at the tip of the tongue

and the soft palate akarna okay

then examine the palms

of both the hands for palla and the

nails

so these are the areas which you will

assess to look for pallow

now palla can be graded from 0 to 3 when

there is the sign 0 is no anemia so if

there is grade 1 there is mild anemia if

the parallel is grade 2 it is moderate

and grade 3 is severe anemia so those

are the things which you will do when

you want to look for palette so the next

point is now we have to look for ictress

ictress is the yellow is the

discoloration of the skin which is

usually seen in jaundice so you examine

the sclera the skin and the mucous

membrane to look for actress now when

you want to look for actress it instruct

the subject to niche now and retract the

upper eyelid

instruct the subject to look down and

detract apple id to look for actress you

can also look on the nail bed and this

if the skin appears yellow or not

so you check for actress

okay

so these are the areas now ictress is

because as i told you it is because of

the yellows discoloration of the skin

now why does the skin appear yellow the

actresses as i told you jaundice is a

major cause for uterus and whenever the

bilirubin level in the blood increases

that causes yellows escalation normal

serum bilirubin levels are 0.2 to 0.8

milligram per deciliter when bilirubin

level increase more than 2 milligram per

deciliter that appears as ah clinically

it will appear as yellow is

discoloration of the skin apart from

jaundice keratinemia is the other

condition where you will get the uh john

yellow is describation of the skin now

jaundice can be because of there could

be different causes of jaundice one

could be hemolytic jaundice which occurs

because of excessive destruction of the

red cells or it could be a hepatic

jaundice where the liver cells are

damaged increasing the bilirubin

concentration on a post hepatic jaundice

where it is an obstructive jaundice

where is obstruction to the flow of bile

and that also increases the bilirubin

count and that appears as a yellowish

discoloration of the skin the next point

is now we are look going to look for

cyanosis now what is cyanosis cyanosis

is a bluish discoloration of the skin

which is and the mucous membrane which

is seen as seen because of increase in

the reduced hemoglobin contain more than

5 grams per deciliter now cyanosis can

be of two types peripheral cyanosis and

central sinuses peripheral sinuses you

see usually in the dependent parts of

the body for example in the nail beds or

on the ear lobule central cyanosis is

usually seen on the central part of the

tip of the nose or g bhayanikala so on

the lips and on the tongue now what are

the causes of cyanosis now peripheral

cyanosis is usually caused when there is

slowing of the blood to the tissue that

allows more amount of oxygen to be

removed from the tissue and that causes

cyanosis usually so person is having a

cardiac is in cardiac failure where the

cardiac output decreases the cyanosis

will be visible or if there is a local

vasoconstriction because of extreme cold

you will the cyanosis appears now

sinuses can also occur when the

viscosity of the blood is more for

example in polycythemia so these are the

causes of peripheral cyanosis now what

are the causes of central cyanosis in

central cyanosis the as a there is

increase in the deoxygenated hemoglobin

more than 5 gram percentage usually you

see when there is a shunt here so in av

shunt uh av a shunt is there when the

venous blood bypasses the pulmonary

circulation and mixes with the arterial

blood that increases the amount of

deoxygenated hemoglobin and that appears

as cyanosis other causes of cyanosis

could be at high altitude where there is

decrease in the oxygen content of the

blood that causes cyanosis or if there

is any lung abnormality for example

there is a lung collapse that can lead

to cyanosis or there is defective gas

exchange across the respiratory membrane

that can also lead to increase in the

deoxygenated hemoglobin in the blood

so the next point we are going to look

for clubbing what do you mean by

clubbing clubbing is the bulbous

enlargement of the soft part of the nail

bed or there is increase in the

curvature of the nail but excessive

curvature of the nail bed that leads to

clubbing now clubbing has to be observed

on the nails now what how do you what

are tests you will absorb do for the

accessing the clubbing so first you

check for the fluctuation in the nail

bed now for testing the fluctuation

first hold the nail bed and with the

finger you just have to

palpate the nail bed normally there is

no fluctuation but if there is excessive

fluctuation it can be made out and that

will be

tested as clubbing then secondly you

also look for the angle between the nail

bed and the adjacent skin normally it is

an obtuse angle when there is

obliteration of this angle you it

denotes clubbing then the third sign

which is important which can be done is

the shabrod sign in this you tell the

subject to approximate his nail beds and

you look for the space between the nail

beds

normally there is some space when there

is approximation of the nail bits

obliteration of the space indicates

clubbing

okay now what are the physiological

causes of clubbing now there is no

no specific reason given given behind

why clubbing occurs but there are some

theories which have been there reason

given is that the increase in number of

av channels in the fingers which it

causes hyper pressure of the skin around

the nail bed and that causes clubbing

other causes could be there is capillary

stresses and black flow of blood which

causes edema of the finger and that

appears as clubbing or it could be

because of any uh increasing number of

growth factors which is a reason behind

clubbing or a vitamin or endocrine

abnormality which could cause clubbing

as clubbing is seen acromegaly and

thyrotoxicosis too so those could be

those factors which are implicated in

clubbing what are the causes of clubbing

clubbing can be seen in bronchitis in

lung abscess and carcinoma of the lung

or in cardiac abnormalities like uh it

can

cyanotic heart disease or subendocardial

pericarditis it is also seen it could be

a healthier tree caused by the tree or

as i told in endocrine disorders like in

thyrotoxicosis or acromegaly or whether

liver is involved whether cirrhosis of

liver or ulcerative colitis

so now we have to examine the lymph

nodes so lymph nodes have to be examined

in the neck and in the axillary region

so it has to be done in a systematic

manner you stand behind when you want to

examine the nymph stand behind the

subject and tell the subject to slightly

flex her neck and you have to examine

the lymph nodes starting from the

submental region

then the submandibular region

then in the in the preoricular area

the posterior area

cervical lymph nodes

and the occipital lymph nodes

then once you are examining the lymph

nodes in the neck we are also examining

the lymph nodes in the axilla so tell

the subject to abduct her arms now in

the axilla you have to examine remember

the acronym apical apical stands for

anterior posterior inferior central

alpical and the lateral lymph nodes so

you have to examine the lymph nodes in

all these areas anterior posterior

inferior

central

apical

and lateral

so these are the areas in the neck and

the axilla where you will examine for

the lymph nodes number lymph nodes what

you are supposed to look for you look

for the size and shape of the lymph

nodes now normally you have to measure

the

size of the lymph nodes

along the longest diameter of the lymph

node so if it is more than one

centimeter that indicates malignancy so

in the lymph nodes the size is more than

one centimeter and they appear irregular

it is usually a malignant lymph node

then you examine for the consistency of

the lymph nodes normally the lymph nodes

are rubbery and they are elastic in

nature if the lymph node is hard again

it indicates malignant condition or if

it is

fixed or and it is very firm usually in

tuberculosis you get a very firm lymph

node so you have to differentiate and

with practice it comes whether the lymph

nodes is hard or it is firm then you

look for the

mobility of the lymph nodes now it could

they could be mobile or they could be

fixed again in malignancy the lymph

nodes are fixed to the adjacent area

okay then you have to look for the

tenderness when we are examining the

lymph nodes if the patient complains of

pain that indicates there is some

inflammation around the area where the

lymph nodes have been drained and in

malignancy usually the lymph nodes are

non-tether so now what are the causes of

lymphedeopathy the causes of lymphede as

we have seen it could be neoplastic

acute or chronic leukemias carcinoma of

the breast carcinoma of the lungs or it

could be inflammatory causes like

tuberculosis syphilis those are the

causes where lymph nodes can be enlarged

certain drugs could also cause a

lymphadenous and severe infections can

also lead to lymphadenopathy and our

last point in the pickle is edema edema

is the swelling of the skin under

subcutaneous tissue which is caused

because of excess of fluid accumulation

in the interstitial spaces now edema can

be localized or generalized or it could

be a pitting or a non-fitting edema now

where do you look for edema now edema is

usually examined

on the dependent parts so above the

median malleables just apply pressure on

the skin for at least 20 seconds

and just look for any pit which will be

formed once you release the skin so

there is no edema here so edema

pitting type of edema there could be

four causes of pitting type of vedima

either it could be a cardiac cause a

congestive cardiac failure it could be a

renal cause nephrotic syndrome or acute

nephritis it could be a liver pathology

like in hepatitis or cirrhosis of liver

or it could be because of anemia so

these all uh in this all these

conditions you will get the pitting type

of edema a non-pitting edema is usually

seen in mixed edema or hypothyroidism

now what is the special features or how

you differentiate between these four

different types of pitting edema now in

cardiac if the cause is a cardiac edema

pitting type of edema usually along the

edema in the dependent past the patient

will also complain of dyspnea that is

the feature you should remember when you

when you want to differentiate between a

cardiac and other

other types of edema in renal area if

there is a cause is renal then there

will be along with the edema there will

be puffiness of the face which will be

seen especially around the orbital

region that could then that indicates

that the renal involvement is there if

the patient is anemic and the patient is

having anemia anemia along with edema

there will also be the edema is usually

generalized if liver is the cause or if

all hepatic involvement is there then

along with edema the patient will also

have ascitis so this is how we will

differentiate between adrenal cardiac

hepatic and anemic edema fitting type of

edema now what is the pathological basis

behind this edema now in congestive

cardiac failure where the cardiac output

is decreased the blood pressure is

decreased now because of decrease in the

cardiac output there is accumulation of

blood that right ventricular failure

occurs and there is

increase in the back pressure in the

venous circulation and that causes edema

accumulation of fluid in the

interstitial spaces we demo because of

decreased blood pressure activates the

renin system that any angiotensin in

turn increases the aldosterone secretion

the aldosterone in turn increases the

water and sodium reabsorption and that

causes edema then the renal causes of

edema while edema occurs in nephrotic

syndrome or in acute nephritis now here

the capillary permeability to the

proteins increases so there is a lot

amount of loss of protein in the urine

causing hyper proteinaemia now because

of hypoprotein amino there is decrease

in the colloidal osmotic pressure in the

capillaries and that causes fluid to

filter into the industrial spaces and

that leads to eating

similarly in anemia also there is

hypoproteinaemia is the major cause in

anemia which causes edema

lastly in liver disease or wherever

there is hepatitis or cirrhosis of liver

the liver cells are damaged leading to

decreasing the protein synthesis again

leading to hyperproteinaemia and hence

decrease in the colored osmotic pressure

and that leads to eating

so now we have finished the six

important uh parameters that is the

pickle palette

now we will go to the four vital signs

which should be examining all your

patients that is a tpr vp temperature

pulse respiration and blood pressure now

temperature has to be examined using a

thermometer usually the thermometer is

placed under the in the mouth or under

the axilla and taken for one minute

recording of the temperature gives you a

lot of information usually a temperature

chart is maintained in the water normal

temperature is around 98 to 99 degree

fahrenheit increasing temperature above

99 degree fahrenheit will be labeled as

fever now there are three different

types of fevers we can have intermittent

continuous or remittance fever

continuous fever which is present

throughout the day usually the cause of

continuous fever is urine track

infection

if the patient is having fear which is

high throughout the day and never

touches the baseline and is called as

limited fever remittance fever is

usually seen in infective endocarditis

then you have intermittent fever where

the fever remains high throughout the

day when you look for the pulse the

ladle artery is used to examine the

pulse normal pulse rate is around 70 to

80 beats per minute

along with the pulse you also look for

the respiration calculate the

respiratory rate which is around 12 to

16 per minute and examine the bp normal

blood pressure is 120 to 80 millimeters

of mercury now these three practicals

will be taken separately a link of which

will be provided to you

thank you