General examination

Dr.vishnav.c
PG scholar
Dept of RogaNidana
SDMCAH
 OBJECTIVES
 Obtain physical data about the client’s functional
abilities
 Evaluate the physiologic outcomes of health care
and thus the progress of a patient’s health problem
 To confirm an overall state of health

 To diagnose a medical problem

 Focuses on an organ system
 Based on patient’s chief complaint
 General physical
examination

General physical examination includes

examination of the patient from head to
the toes for the external markers of
disease
 REQUIREMENTS
 Wooden spatula
 Stethoscope
 Magnifying glass
 Pen-torch
 Disposable gloves,
 Measuring tape lubricant jelly and a
 Ophthalmoscope proctoscope may also be
required
 Sphygmomanometer  Facilities for obtaining
 Tendon hammer blood samples, urinalysis
and faecal occult blood
 Tuning fork testing
 Cotton wool  Accurate weighing scales
and a height-measuring
device
 General concepts
 Approach the client calmly and confidently.
 Provide privacy.
 Make sure that all needed instruments are available
before starting the physical assessment
 Several positions are frequently required during the
assessment. Consider the client’s ability to assume a
position.
 Be systematic and organized when assessing the client.
(Inspection, Palpation, Percussion, Auscultation
 If a client is seriously ill, assess the systems of the body
that are more at risk
 Perform painful procedures at the end of the
examination
 positions
 Sitting
 Supine (recumbent)
 Dorsal recumbent
 Lithotomy
 Trendelenburg’s
 Fowler’s
 Prone
 Supine/
Sitting recumbent

Dorsal
recumbent

Lithotomy
 Fowler’s
Sims

Prone
Trendelenbur
 CHECK LIST

 SKELETAL HEIGHT  LYMPHADENOPATHY

 NOURISHMENT  EDEMA
 VITAL SIGNS  HANDS & FEET
 PALLOR  GENETALIA
 ICTERUES  BREAST
 CYANOSIS  SKIN & HAIR
 CLUBBING
 POINTS BEFORE PHYSICAL
EXAMINATION

• Handshake .
• Facial expression
• Clothing
 Importance of Handshake

Cold, sweaty hands------------ Anxiety

Cold, dry hands ---------------- Raynaud's phenomenon
Hot, sweaty hands------------- Hyperthyroidism
Large, fleshy, sweaty hands--- Acromegaly
Dry, coarse skin---------------- Regular water exposure
Manual occupation
Hypothyroidism

Delayed relaxation of grip----- Myotonic dystrophy

Deformed hands/fingers------- Rheumatoid arthritis
 IMPORTANCE OF FACIAL
EXPRESSION
 Features Diagnosis
 Poverty of expression Parkinsonism
 Startled expression Hyperthyroidism
 Apathy, with poverty of expression and poor eye contact
Depression
 Apathy, with pale and puffy skin Hypothyroidism
 Lugubrious expression with
bilateral ptosis Myotonic dystrophy
 Agitated expression Anxiety
Hyperthyroidism
Hypomania
 IMPORTANCE OF CLOTHING

 Young people ---dirty cloth-------------drug addiction

 Elder people ---same with smell of faeces & urine--

unable to look themselves

 Anorectic people ------baggy pants --------obesity,fat

 inappropriate dress -------psychiatric illness

 SKELETAL HEIGHT

 Measured from vertex to sole of

foot
 Upper segment – top of head to
upper border of symphysis pubis .
 Lower segment – symphysis pubis
vertical to sole of foot
 arm spam - stretch limb
outwards – distance b/n tips of
middle fingers of 2 out-stretched
hands .
 ABNORMALITIES
Increased height (gigantism) -
marfans syndrome
homocystinuria
kleinfleter’s syndrome
Decreased height (dwarfism)-
hypopitutarism
primary hypothyroisdism
cushings syndrome
pseudohypoparathyroidism
 NUTRITIONAL STATUS

assessed by
 MUSCLE BULK
 SUBCUTANEOUS FAT
 DEFICIENCY SIGNS
measure the muscle bulk and subcutaneous fat while
assessing nutrition
Subcutaneous fat – measure the triceps skin fold thickness
of the left mid arm
Avg adult measure of triceps skin fold thickness:
 In male – 12.5mm
 In female – 16mm
 Muscle bulk – measure the left mid upper arm
circumference :
 In male – 25.5mm
 In female – 23mm

BMI – measured by weight in kg divided by body height in

meters squared .
 Normal -18-25
 Overweight -25-30
 Obesity – 30 and above
 Extreme obesity – 40 and above
 Underweight – less than 18
 PALLOR
 Pallor suggests pale appearance of skin
 Depends upon skin pigmentation & skin
thickness
CAUSES
ANAEMIC DISORDER
HYPOPITUTARISM & HYPOGONADISM
LEFT HEART FAILURE
SHOCK ASS CONDITION
 SITES FOR PALLOR

 ORAL MUCOSA
 TONGUE
 CONJUCTIVA
 NAILBED
 PALMS
 SOLES
 ICTERUS
 DEFN – yellowish discoloration of skin , sclera and mucous
membranes due to excess circulating bilirubin .

CAUSES –
 unconjugated hyperbilirubinemia
 Conjugated bilirubinemia
a)Acute & chronic hepatitis
b)Cirrhosis
c)Malignancy of liver

 Obstruction to outflow of bile from liver to duodenum

 SITES FOR ICTERUS

 Sclera
 Sublingual mucosa
 Oral cavity
 Pals
 Soles
 Skin
 Jaundice is best appreciated in day light
 Jaundice becomes clinically detectable when bilirubin is
exceeds 3 mg/dl
 CYANOSIS
 DEFN –bluish discoloration of mucous membrane
and extremities due to decreased oxygenation of
blood

 Cyanosis occurs either due to increase in the

desaturated hemoglobin or due to abnormal
hemoglobins.

 Cyanosis appears when the level of desaturated

hemoglobin 5gm/dl
 TYPES
 Peripheral cyanosis
 Central cyanosis
Peripheral cyanosis – occurs due to the decreased
capillary blood flow allowing more time for the removal of
oxygen by the tissues
 Site – extremities – fingers & toes /tip of nose
Central cyanosis - excess of desaturated hemoglobin in
the blood leaving the aorta
Site– tip of tongue & oral mucosa
 CAUSES OF CYANOSIS

CARDIAC CAUSES
RESPIRATORY CAUSES
ABNORMAL HEMOGLOBINS

DIFFERENCE B/N CENTRAL & PERIPHERAL CYANOSIS

CENTRAL CYANOSIS PERIPHERAL CYANOSIS
EXTREMITIES WARM COLD
WARMING THE PART NO EFFECT CYANOSIS DECREASES
BREATHING OXYGEN ABOLISH CYANOSIS NO CHANGE
CLINICAL ASPECT OF CYANOSIS
 Left heart failure causes central and
peripheral cyanosis
 Peripheral cyanosis and acutely developed
central cyanosis are not ass with clubbing
 Central cyanosis may appear only on
excertion and peripheral cyanosis only on
exposure to cold
 Pt with central cyanosis will also have
peripheral cyanosis with warm
extremities ,except in pt with heart
failure .
 CLUBBING
 DEFN – bulbous enlargement of distal segments of
fingers and toes .

CAUSES
 Cardiovascular
 respiratory
 gastrointestinal
 hepatic
 congenital
 idiopathic clubbing
 DIFFERENTIAL DIAGNOSIS

Hyperparathyroidism
Psoriatic arthritis
Vinyl chloride exposure
pachydermoperiostosis
 LYMPHADENOPATHY

Lymphatic system includes

 LYMPH NODES
 LYMPH VESSELS
 LYMPHATIC TISSUES
 KEY POINTS

 Soft ,flat lymph nodes more than 1

cm size are usually benign and
requires follow up.
 Inguinal lymph nodes of less than 2
cm size are not abnormal
 Lymph nodes greater than 2 cm are
significant and to be avaluated.
EXAMINATION OF LYMPH NODES

 Number  Mobile/fixed
 Size  Tenderness
 Site  Fluctuations
 Consistency  Surrounding skin
 Discrete/matted  Draining area
CHARACTERISTICS OF DIFF
TYPES OF LYMPADENOPATHY
 TUBERCULAR NODE
soft ,tender , matted nodes ,discharge
 TENDER NODE
Inflammatory or infective pathology with acute
stretching of the capsule
 LYMPHANGITIS
superficial lymphatic vessels appears red streaks
running between the nodes and sites of original
infections.
 GENERALISED LYMPHADENOPATHY
 LOCALISED LYMPHADENOPATHY

GENERALISED LYMPHADENOPATHY
 3 or more areas of non contiguous areas of lymph nodes.
Causes
 INFECTION
 IMMUNOLOGIC
 MALIGNANCIES
 ENDOCRINE DISORDERS
 DRUG INDUCED
 LOCALISED LYMPHADENOPATHY

 DEFN- enlargement of lymph nodes in a single

anatomical area.
 Cervical lymphadenopathy
 Axillary lymphadenopathy
 Epitrochlear lymphadenopathy
 Inguinal lymphadenopathy
 Popliteal lymphadenopathy
 Intra thoracic lymphadenopathy
 CERVICAL LYMPHADENOPATHY

CAUSES
Viral illness
Oral or dental leisons
primary head,neck,breast,lung & thyroid
malignancies
Lymphoma & leukaemias
all causes of generalised lymphadenopathy
 EXAMINATION

 From behind, examine the submental, submandibular,

preauricular, tonsillar,supraclavicular and deep cervical glands
in the anterior triangle of the neck
 Palpate deeply for the scalene nodes
 From the front of the patient, examine the posterior triangles, up
the back of the neck and the posterior auricular and occipital
nodes
 1. Preauricular—in front of the ear
 2. Posterior auricular—superficial to the mastoid process
 3. Occipital—at the base of the skull posteriorly
 4. Tonsillar—at the angle of the mandible
 5. Submandibular—midway between the angle and the tip of the
mandible.
 6. Submental—in the midline a few centimeters behind the tip of the
Mandible
 7. Superficial cervical—superficial to the sternomastoid
 8. Posterior cervical—along the anterior edge of the trapezius
 9. Deep cervical chain—deep to the sternomastoid
 10. Supraclavicular—deep in the angle formed by the clavicle and the
sternum
 AXILLARY LYMPHADENOPATHY

CAUSES

 Infection or injury to lateral upper limb

 Breast and chest wall diseases
 Lymphoma
 Part of generalised lymphadenopathy
 EXAMINATION
 Examiner sitting in front of the patient supporting patient’s
upper limb with his own.
 Finger tips are inserted into the axillary
vault ,anterior,posterior,medial walls are palpated.
 Make sure your nails are short to avoid causing your patient
discomfort.
 EPITROCHLEAR LYMPHADENOPATHY

 Infection and inflammation of ipsilateral hand

 Secoandary syphilis
 Non-hodgkins lymphoma

EXAMINATION
Support the patient's right wrist with your left hand, grasp
the patient's partially flexed elbow with your right hand and
use your thumb to feel for the epitrochlear gland. Examine
the left epitrochlear gland with your left thumb
 INGUINAL LYMPHADENOPATHY

CAUSES

 Infection/ trauma to lower extremeties

 Std
 Lymphomas
 Metastatic cancer in the rectum,genetalia and
lower extremities
 POPLITEAL LYMPHADENOPATHY

CAUSE
 Knee joint disease
 Infection and trauma to the lower limb
 All causes of generalised lymphadenopathy

EXAMINATION
 Palpate deeply into the popliteal fossa with both hands with
knee partially flexed.
 INTRA ABDOMINAL
LYMPHADENOPATHY
CAUSES
Tuberculosis
Lymphomas
Intra abdominal malignant disorders
Germ cell tumors
EXAMINATION
Palpate deeply in umblical region along aortic pulsations.
Felt as round , firm masses
Felt only when enlargement is there.
 INTRA THORACIC
LYMPHADENOPATHY

 CAUSES
Bronchogenic carcinoma
Lymphomas
Tuberculosis
Sacroidosis
histoplasmosis
 EDEMA

DEFN-edema is due to excess collection of fluid in the

intestinal tissues causing swelling of the tissues.

 Generalized edema may be due to a disorder of the

heart, kidneys, liver or may be nutritional in origin.
 Localized edema may arise from venous or lymphatic
obstruction, allergy or inflammation.
 Postural edema is relatively common in the lower limbs
of inactive patients.
 SITES
 Legs,thigh,back and limbs
 Sacral edema is common in bedridden patients
 Abdominal wall edema can occur in pt with
anasarca.
 TYPES & CAUSES
CONJUNCTIVAL EDEMA ( chemosis )
Graves disease
Superior venacaval obstruction
Hypoalbuminemia

LOCALISED EDEMA
Lymphatic and venous obstruction
Allergic disorders
Inflammatory disorders
GENERALISED EDEMA

All causes of hypoalbuminemia

Cirrhosis of liver
Nephrotic disorder
Nutritional

ALLERGIC EDEMA
Angioneurotic edema – involves face and lips ,sometimes affects glottis
and larnyx
UNILATERAL EDEMA
Cellulitis
Lymphatic obstruction
Deep vein thrombosis

LYMPHATIC EDEMA
Normally lymphatics absorb small quantity of albumin filtered from
the capillaries
 VITAL SIGNS

 PULSE
 RESPIRATORY RATE
 BLOOD PRESUURE
 TEMPERATURE
 PULSE

RATE
 No absolute normal.
 Varies in diff individual
 Male 60—80/ min
 Female 70-90/min
 Slower during sleeeping
Bradycardia –pulse less than 60
Tachycardia–pulse more than 100
 RHYTHM
normally regular in rhythm

 IRREGULAR RHYTH
REGULAR RHYTHM
Sinus arrhythmia
Sinus bradycardia
Partial heart block
Complete heart block
Atrial fibrillation
Sinus tachycardia
Atrial flutter with varying
Atria flutter
block
 VOLUME OR FORCE

 Corresponds to systolic blood pressure

 Press radial artery against underlying bone with 2
palpating fingers till the pulse wave felt on distal finger .

 TYPES OF PULSE
 Small weak pulse
 Large bounding pulse
 Twice beating pulse
 Jerky pulse
 BLOOD PRESSURE

 Blood pressure measured by using sphygmomanometer.

 Cuff size -40 % arm size.
 Mercury or aneroid
 MEASURES BEFORE BP TAKING
 ask the patient to avoid smoking or drinking caffeinated beverages
for 30 minutes before the blood pressure is taken and to rest for at
least 5 minutes.
 Check to make sure the examining room is quiet and comfortably
warm.
 Make sure the arm selected is free of clothing.
 Palpate the brachial artery to confirm that it has a viable pulse.
 Position the arm so that the brachial artery, at the antecubital
crease, is at heart level—roughly level with the 4th interspace at its
junction with the sternum.
 If the patient is seated, rest the arm on a table a little above the
patient’s waist; if standing, try to support the patient’s arm at the
midchest level.
 Auscultation on brachial artery produces korotkoff sound
 5 phase of sound.
 Phase 1 – first appearance of systolic sound
 Phase 2 &3 – increasingly loud sound
 Phase 4 – abrupt muffling of sound
 Phase 5 – disappearance of sound.
 Blood pressure should be taken in both arms at least
once. Normally, there may be a difference in pressure of
5- 10 mm Hg.
 RESPIRATORY RATE

 Normal 14-16 breath / min

 Tachypnoea is increased respiratory rate noticed by
doctor
 Dyspnoea is increased repiratory rate felt by pt
 Cheyne stokes breathing – deeply and quickening of
breathing followed by diminished respiratory rate and
rhythm
 Common in cardiac failure , narcotic drug
poisoning ,neurologic disorder
 CHEST EXPANSION & SYMMETRY

 Explored by palpation
 Face the patient
 Place finger tip of both hand on lower ribcage
 Deep breath causes the expansion of thumb
 Indicates the degree of expansion
 TEMPERATURE
 Use thermometer

KEY POINTS
 Thermometer should be accurate
 Keep for at least half a minute for temperature raise to
occur
 While taking oral temperature ,pt should breath through
nose with lips tightly closed.
 Wash thermometer with cold water and then with
antiseptic after usage
 Shake thermometer to bring the mercury column below
normal before recording the temperature
 ADULTS –oral or axillary temperature
 CHILDREN – rectal temperature or axilla
 COLLAPSED/UNCONSIOUS – rectal temperature

 NORMAL TEMPERATURE -36.6 37.2 degree Celsius or 98-

99 degree F
 FEVER

 Increase in the body temperature with rise

in hypothalamic set point .
 Morning temp – more than 98.9°F or
 evening temperature -more than 99.9°F

 Menstruating women - 1°F greater in the

morning time and stay still till the starting
of next period.
 HYPOTHERMIA

 Increasing in body temp but no change in

hypothalamic set point
 Temperature felt when body dispose the
body heat
 Heat stroke
 Neuroleptic malignant syndrome
HYPERPYREXIA & HYPOTHERMIA

 Temperature greater
 Temperature less than
than 107°F
95°F
 CAUSES
 CAUSES
 Malaria
 Head injury
 Neuroleptic malignant
 Near drowning
syndrome
 Alcohol intoxication
 Heat stroke
 Severe hypothyroidism
 FACE
DIFF TYPES OF FACIAL APPEARANCE
ENDOCRINE DISORDERS
Hypothyroidism – dull appearance ,facial puffiness
thyrotoxicosis - prominent eyes
Cushings syndrome – moon face
NEUROMUSCULAR DISORDER
Facial palsy- deviation of angle of mouth to one side
3rd nerve palsy – ptosis of affected side
Parkinsonism – expressionless , mask like face
Myotonic dystrophy – frontal baldness , ptosis ,wrinkling of
fore head , narrowing of lower half of face
 EYES

 Check for
Ptosis
Squint
Pupillary irregularity

EXOPHTHALMUS - prominent eyeball with prominent

protrusion
ENOPHTHALMUS - inward movement of eyeball
HYPERTELORISM – increased distance b/n 2 eyeball.
 DIFF PART OF EYE RELATION TO
DISEASES
 CONJUNCTIVA
Suffused ,pallor ------anemic disorder
Dry ------vit A disorder
Hemorrhage ---------leptospirosis , bleeding disorder
 SCLERA
Jaundice -------------- hepatobiliary disorder ,hemolytic anemia
Blue sclera ------------connective tissue disorder
 CORNEA
Opacity ---------------keratitis
 IRIS
Iritis --------------wilsons’s disease ,rheumatoid arthritis
 LENS
cataract -------albinism ,diabetic mellitus ,hypocalcaemia
 ABNORMALITIES OF LIP

 CLEFT LIP --------congenital

 ANGULAR STOMATITIS ----inflamed and painful

cracking of the corners of mouth

 COLD SORES --------------vesicles over lips

 THICK LIPS ---------------- acromegaly , myxedema

 ABNORMALITIES OF CHEEKS

 PUFFINESS ------- edema states

 BUTTERFLY RASH --- sle

 MITRAL FACIES ----- mitral stenosis

 HEAD & NECK

 HYDROCEPHALUS –  Thyroid enlargement

increased size of head  Lymphadenopathy

compared to body size  Neck veins
Protrusion of fore head  Arterial pulsation
Downward deviated eyes  Trachea
 Scar mark
 EXAMINATION OF NOSE
 Enlargement ------ -----------------acromegaly
 Reddening -------------------------sle ,alchoholics
 Saddle ------------------------------congenital syphilis
 Destruction of nasal structure ----tuberculosis

 EPISTAXIS (bleeding from nose)

Local diseases of eye

Systemic bleeding & clotting disorders
Occ in hypertensives
 EXAMINATION OF EAR

 Ear discharge -----------------ear infection

 Vesicles over ear -------------herpes zoster
 Prominent crease seen over
the ear lobe ------------------coronary artery disease
 Bluish color -------------------peripheral cyanosis
 EXAMINATION OF BREAST

 CHECK
Symmetry of 2 breast
Ulcer
Swellings

 CHECK SKIN
Ulceration
Reddening
Dimpling
 EXAMINATION OF BREAST

 Use flat of hand in 4 quadrants

 Hand under her head
 Mass lesions- size ,shape ,surface & fixity
 Axillary tail , axilla, local lymph for any abnormalities
 Nipple for discharge
 Male breast for gynecomastia
 ABNORMALITIES OF BREAST
 SKIN CHANGES -----dimpling of skin , peau d ;orange
appearance , malignant infiltration of skin
 LESIONS OF NIPPLE – nipple inversion –symmetrical slit
like appearance ,distorted asymmetrical inversion
 DISCHARGE FROM NIPPLE –minimal clear fluid
( massage ) , blood stained ( carcinoma,papilloma) ,
milky discharge (hyperprolactinemia)
 FIBROCYSTIC DISEASES – common before menstruation
, irregular nodules
 CARCINOMA OF BREAST – firm & hard mass, fixed &
irregular
EXAMINATION OF HANDS & FEET

 COLOR –
Nicotine staining fingers - chronic smokers
Severe pallor -------------anemic disorders
Palmar erythema ---------liver disorders
Bluish discoloration ------peripheral cyanosis
TEMPERATURE –
Cold hand ----------------peripheral vasoconstriction
Warm hand---------------hyperthyroidism
DIFF SHAPE & ABNORMALITY
 Trauma
 Rheumatoid arthritis
 Marfans syndrome
 Carpal spasm –tetany
DIFF POSTURE OF UPPER LIMB
 Wrist drop – radial nerve palsy
 Ulnar deviation –rheumatoid arthritis
 Claw hand – ulnar and medial nerve palsy
 EXAMINATION OF FEET

 Edema of feet - renal,cardiac ,hepatic disorder

 Chronic venous stasis – pigmentation of lower part of
legs and feet
 Arterial ischemia – pallor
 Neuropathic ulcer – painless ulcers develop over
pressure points
 EXAMINATION OF NAIL

 Platynychia –iron deficiency anemia

 Koilonychia –iron deficiency anemia
 Leuconychia –hypoalbuminemia
 Nailbed infarct – vasculitis syndrome
 Onchylolysis- idiopathic
 Missing nail – patella syndrome
 Nail pitting –psoriasis
 Paronychia – trauma,diabetic mellitus
 Discoloration of nails –anti malarials ,phenothiazines
 EXAMINATION OF HAIR

 Scalp hair loss

 Nits , lice & dandruff
 Loss of body hair
 Flag sign
 Loss of sexual hair
 Excessive hair growth
 EXAMINATION OF SKIN
 Examine the patient in good lighting
 Inspect skin for the following:
 Color
 Texture
 Moisture
 Pigmentation
 Lesions
 Hair distribution
 Warmth: use back of hand
DIFF TERMINOLOGIES
 Asymmetry
Unequal or asymmetric moles are suspicious.
 Border
If the border is irregular or indistinct, it is more
likely to be cancerous
 Color
Variation of color (e.g., more than one color or
shade) within a mole is a suspicious finding
 Diameter
Any mole that has a diameter larger than a pencil's eraser in size
(> 6 mm) should be considered suspicious.