General Examination

General Examination of Nutritional State

Nutritional state of the patient must be assessed. Certain signs help us to determine deficiency states.

• Hypoproteinemia causes edema, dry also rough skin, weight loss, brittle hair, etc. should be measured during general examination.
• Moreover; Fat deficiency leads to weight loss, dry skin, loss of shape of hips, etc.
• During general examination signs of vitamin deficiency states should be studied thoroughly by all students.
• Deficiency of iron (in other words; koilonychia) and calcium (in other words; tetany) can be diagnosed clinically.

General Examination of Decubitus Patient

Note the posture patient adopts in bed. For example, in renal, biliary or intestinal colic, the patient is restless and turns and tosses about. In acute inflammatory abdominal disease, patient lies quietly with legs drawn up. In tetanus, opisthotonos may be noted. Furthermore, Meningitis is characterized by a stiff neck. All in all, In cardio-respiratory embarrassment, patient is more comfortable in sitting-up position.

General Examination of Clubbing:

It is bulbous enlargement of soft parts of terminal phalanges with transvers and longitudinal curving of nails.

Grades:

Some of the common causes of clubbing are Bronchogenic CA, Lung abscess, Tuberculosis with secondary infection, Infective carditis, Inflammatory bowel disease, etc.

Method of examination of Clubbing

Normally, when two fingers are held together with nails facing each other, there should be a space between the nail folds. This space is lost in clubbing. This is Schamroth’s sign.

General Examination of Cyanosis

More than 5 mg% of reduced hemoglobin in capillary blood gives rise to bluish discoloration of tissues (especially seen in nails, palate, tongue, lips, etc.). This is known as cyanosis.
It can be central, peripheral, mixed or due to abnormal pigments.

Common causes of central cyanosis are congestive cardiac failure, congenital cyanotic heart disease, chronic obstructive lung disease and either fibrosis or collapse of lung. Common causes of peripheral cyanosis are vasoconstriction due to cold, shock due to any cause and increased viscosity of blood. Both can occur in acute left ventricular failure and mitral stenosis.

General Examination of Jaundice

Yellow coloration of tissues (e.g. skin, mucous membranes and sclera) and body fluids due to increase in bile pigments is jaundice.
Basically, total serum bilirubin is 1 mg% also direct serum bilirubin is 0.25 mg%. It appears in urine if direct serum bilirubin is more than 0.4 mg%.
In haemolytic jaundice, a pale lemon-yellow tint may be present. Orange or dark yellow colouration is characteristic of obstructive jaundice. Additionally, in obstructive jaundice, there may be scratch marks from itching evoked by bile salts. Occasionally, yellowness may appear due to carotenaemia.

The etiology may be:

Congenital i.e.-

Gilbert’s syndrome, Crigler Najjar syndrome, Dublin Johnson syndrome, Rotor’s syndrome

Hemolytic i.e.-

thalassemias, sickle cell disease, infections, drugs, etc.

Hepatocellular i.e.-

Viral, drugs and chemicals – e.g. chloroform, rifampicin, DDT, arsenic, etc., cirrhosis

Obstructive i.e.-

cholecystitis, cholelithiasis, CA head of pancreas, biliary atresia, etc.

General Examination of Pallor

Paleness of the skin and mucous membranes may arise due to diminished circulating RBCs or diminished blood supply. It also depends on the thickness and quality of the skin. Pallor occurs in persons with thick or opaque skins, in hypopituitarism, in shock, syncope or left heart failure. If locally, blood supply obstruct, pallor may occur in that part (i.e. Raynaud’s disease). Generalized pallor occurs in anemia due to any cause.
Lower palpebral conjunctiva, tongue, soft palate, palms and nails the sites usually check for detecting pallor.

General Examination of Lymphadenopathy

Enlargement of the lymph nodes should check for. The cause may either inflammatory or non-inflammatory.

Neck Glands:

In general, examine submental, submandibular, tonsillar, cervical, posterior auricular and occipital groups. Furthermore, they may enlarge in TB, tonsillitis, dental infections, etc. The neck should slightly flex also examiner should stand behind the patient.

Axillary Glands:

It should checked with patient’s arm slightly abducted and inserting the finger in the axilla. Additionally, the apical, anterior, posterior, medial and lateral groups should be examined.

They may enlarge in mastitis, breast abscess also upper limb infections.

Inguinal Nodes:

It must examine in supine position with the thigh extended. Medial also lateral groups must examined. Infections of the lower limbs, leg ulcers, genital infections, etc. enlarge them.

Other important groups:

It include para-aortic, femoral and popliteal.

Basically, the lymph nodes are non-tender, firm and smooth. The surface matted in TB also irregular in malignancy. The consistency is rubbery in Hodgkin’s disease, firm also shotty in syphilis and hard in malignancy.

General Examination of Edema

Collection of excess fluid in interstitial spaces or serous cavities is edema. It may become evident when 5-6 liters of fluid has accumulated in water depots.
It may be caused due to:

1. Increased capillary permeability (acute inflammations)
2. Increased capillary pressure (cardiac failure)
3. Decreased serum osmotic pressure (hypoproteinemia)
4. Impaired lymphatic drainage (e.g. filariasis, obstruction)

– In congestive cardiac failure also hypoproteinemia, the edema is typically dependent. It first appears at the ankles and over the dorsum of the foot, and gradually involves the legs, thighs and trunk. In bed ridden, it first appears over the sacrum.
– The skin over the edematous part is pale and glossy and has a doughy feel. Generally, it pits on finger pressure. It is important to press firmly and for a sustained period, and the ‘pit’ can be seen on removing the finger. Besides this, The edema of lymphatic obstruction also myxedema do not pit on pressure.

General Examination of Skin, Hair and Nails

These tell us a lot about the internal processes going on in the body. A magnifying glass should be kept handy while examining these.

Color:

Colour of the skin should be noted. It may be pale, cyanosed, yellow, red, etc. Besides this, Depending on this, underlying cause should be identified.

Pigmentation:

 Pigmentation is whether hyper ( Addison’s also Cushing’s disease, hemochromatosis, kwashiorkor, lichen planus, malignancy, etc.) or hypo (leprosy, leucoderma, albinism, fungal infections, etc.) should be carefully noted.

Types:

Various types of eruptions should be identified.

– Hemorrhages under skin should identify, e.g.: Petechiae are less than 1 cm in diameter, purpura is 2-5 mm in diameter. These may seen in scurvy, thrombocytopenia, HIV, leukemia, etc.
– Type of skin also tells us a lot about many conditions. For e.g.: dry skin may seen in myxedema, dehydration. Moist skin may occur in shock due to myocardial infarction, thyrotoxicosis. Thick skin suggests myxedema, acromegaly, scleroderma.

HAIR changes:

• Falling of hair – after typhoid, protein deficiency, etc. Additionally, Patchy hair loss seen in alopecia areata, syphilis, etc.
• Absence of axillary, pubic also facial hair seen in hypopituitarism, hypogonadism. Excessive facial hair may seen in Cushing’s and adrenocortical syndromes.

NAILS changes:

• Pallor, cyanosis, clubbing
• Moreover, Spoon shaped deformity of the nails may seen in iron deficiency anemia.
• Onychia is deformity of the nails following fungal or tuberculous infection.
• Splinter hemorrhages may seen under the nail beds in SBE also bleeding disorders.

General Examination Of Vertebral Column:

Normally, the vertebral column has two antero-posterior curves – one in upper dorsal region(concave forwards) and other in dorsolumbar column (convex forwards).
It should be palpated for abnormality, angular deformity, swelling or tenderness. After that, the mobility should be tested. Normally, it is mobile antero-posteriorly as well as laterally.

• Lordosis – abnormal antero-posterior with forward convexity (for example pregnancy, muscular dystrophy, large abdominal tumors, etc.)
• Kyphosis – abnormal antero-posterior curvature with forward concavity and dorsal prominence) wedge shaped vertebrae, prolonged carrying of heavy weights, Pott’s spine, RA, OA, etc.)
• Scoliosis – abnormal lateral curvature of the spine (congenital, prolonged carrying heavy weights in one arm, poliomyelitis, to reduce length of or pain in one of the limbs, etc.)

General Examination:

Nerves may enlarge in leprosy, neurofibromatosis, diabetes, amyloidosis, sarcoidosis also few other rare syndromes. Moreover; Each nerve is a cordlike structure and can feel like an electric cable.
Most commonly affected nerves are ulnar also lateral popliteal.

Ulnar nerve:
In general, The forearm of the patient is bent at 90°-110° over the arm. The examiner uses his left hand to palpate the right ulnar nerve and his left hand to palpate the right ulnar nerve. additionally, the nerve can palpate first at the elbow in the olecranon groove, between the olecranon and the medial epicondyle of the humerus. Lastly, Then it can feel and evaluated immediately above the groove.

Lateral popliteal nerve (Common peroneal nerve):
The lateral popliteal nerve can palpate, with the knee joint semi-flexed, in the popliteal fossa, just medial to the biceps femoris tendon also as it passes round the neck of the fibula.
Other nerves which should palpate are– Supraorbital, Great auricular, Radial, Median, Superficial peroneal, Posterior tibial also Sural.

General Examination of Joints

Proper history in joint diseases is of utmost importance. It should cover onset, details of pain, stiffness and swelling, medical history and family history.
Pain and stiffness, leading to loss of function, is a classic feature of joint disease.
Examination of should i.e.:

• • Inspection – joints affected (whether symmetrical or asymmetrical, large/small, etc.), swelling, redness, muscular wasting, etc.
  • Palpation – Local temperature, tenderness, whether swelling is fluctuant or non-fluctuant, etc.
  • Range of motion – check the range in passive and active motion at the joint, pain on movement, compensatory muscular spasms, etc.
  • Measurements – length of the limb, circumference of the limb, relation of various bony points to the joint, etc.

Also conduct a general and systemic examination for clues in relation to the joint disease (for example; tuberculosis, syphilis, scurvy, other infections, etc.).

General Examination of Temperature:

The body and visceral temperature maintain by hypothalamus. Ideally, a clean, aseptic mercury thermometer is kept in axilla for a minute. If there is lot of perspiration, it should kept in mouth, under the tongue. In collapsed, comatose also elderly patients, rectal temperature may be recorded.
In children, the thermometer can place in the fold of the groin with the thigh flexed on the abdomen. The temperature of the mouth and rectum is usually at least half a degree higher than that of the either axilla or groin.
Normal body temperature varies from 36oC to 37.5oC. Moreover, Hypothermia may cause in hypopituitarism, hypoglycemia, alcoholic intoxication, ketoacidocis, shock, etc. Fever or pyrexia may occur due to infections, neoplasm, immunological diseases, endocrine or metabolic disorders, mechanical or physical causes, etc.

 Pulse Examination:

Palpate and count the peripheral pulsations for a minute when the patient is at rest and composed. The normal pulse has:

• Anacrotic wave (a) which is not felt
• Tidal or percussion wave (t) which is felt
• Dicrotic notch (n) also Dicrotic wave (d), both of which are not felt.

Variations in these waves suggest some abnormalities. For e.g., in aortic stenosis, we feel an anacrotic pulse, which beats twice and is slowly rising. Additionally, A dicrotic pulse is when first percussion wave is felt during systole and second dicrotic wave is felt in diastole. This is seen when peripheral resistance and diastolic pressures are low.

COMMON SITES TO BE PALPATED FOR PULSES:

UPPER LIMB
Front of right upper extremity

• Axillary pulse: specifically, located inferiorly of the lateral wall of the axilla.
• Brachial pulse: anterior aspect of the elbow, additionally medial to the tendon of the biceps.
• Radial pulse: palpable in the anatomical snuff box also on the anterior aspect of the arm over the carpal bones.
• Ulnar pulse: especially located on the medial of the wrist.

LOWER LIMB

• Femoral pulse: located in the inner thigh, at the mid-inguinal point, halfway between the pubic symphysis also anterior superior iliac spine.
• Popliteal pulse: Above the knee in the popliteal fossa, found by holding the bent knee. In detail, The patient bends the knee at approximately 125°, and the physician holds it in both hands to find the popliteal artery in the pit behind the knee.
• Dorsalis pedis pulse: located on top of the foot, additionally immediately lateral to the extensor of hallucis longus.
• Tibialis posterior pulse: located on the medial side of the ankle, 2 cm inferior also 2 cm posterior to the medial malleolus.

HEAD AND NECK

• Carotid pulse: located in the neck between the larynx also the anterior border of the sternocleidomastoid muscle at the level of the cricoid cartilage. The carotid artery should be palpated gently as stimulating its baroreceptors with low palpitation can provoke severe bradycardia or even stop the heart in some sensitive persons. Also, a person’s two carotid arteries should not be palpated at the same time. Doing so may limit the flow of blood to the head, possibly leading to fainting or brain ischemia.
• Facial pulse: located on the mandible (lower jawbone) on a line with the corners of the mouth (facial artery).
• Temporal pulse: located on the temple directly in front of the ear (superficial temporal artery).

Jugular Venous Pulse:

The jugular venous pulse has a flickering character caused by ‘a’ and ‘v’ waves separated by ‘x’ and ‘y’ descents. The ‘a’ wave produced by atrial systole precedes tricuspid valve closure. The ‘c’ wave cause by closure of the tricuspid valve. It follow by the ‘x’ descent (marking descent of the tricuspid valve ring). Atrial pressure then rises again, producing the ‘v’ wave as the atrium fills passively during ventricular systole. The ‘y’ descent produce because of decline in atrial pressure as the tricuspid valve opens to allow ventricular filling.
Variations in these waves may study in detail and they suggest corresponding abnormalities.

Jugular Venous Pressure:

During general examination patient is laid at 45° angle using a backrest. Normally, the jugular vein seen just above the clavicles. A ruler place horizontally at the upper level. Another ruler kept perpendicular to the first up to the angle of Louis (anterior angle formed by the junction of the manubrium and the body of the sternum). The distance from angle of Louis to the first ruler gives jugular pressure. Normally, it should 3-4 cms. The jugular vein is in direct continuity with the SVC and right atrium. Therefore, it varies in right ventricular failure, cardiac temponade, tricuspid stenosis, SVC obstruction, long standing asthma, etc.

Kussmaul’s sign: In general examination during inspiration, the pressure within the chest falls and there is a fall in the jugular venous pressure. In constrictive pericarditis, and cardiac tamponade, inspiration produces a paradoxical rise in the jugular venous pressure (JVP). This because the increase venous return cannot accommodated in the right heart.

Examination of Blood Pressure

It the lateral pressure exert by column of blood on the vessel wall. It denotes pressure in systemic arteries.
Explaining the procedure of measuring BP is important to the patient who is checking it for the first time. Exertion, meals, smoking, stimulants, etc. avoid for about 30 minutes before BP check. After 5 minutes of rest, check the BP in supine, sitting and standing position. The arm must kept at the level of heart in all positions.

APPARATUS

• Mercury sphygmomanometer most widely use and is more accurate.
• Aneroid meter reflects changes in pressure through a needle connected to a spring.
• An electronic BP meter may also employ.
• A stethoscope require in auscultatory method.

TECHNIQUE

– Palpatory method: Feel the radial pulse at wrist and raise the pressure in cuff until the pulse is no more felt. Reduce the pressure in the cuff now, and note the pressure when the radial pulse is again felt. This is the systolic pressure.
– Auscultatory method: Raise the pressure in cuff 40 mm above the level obtained in palpatory method. Additionally, Place the diaphragm (preferably bell) of the stethoscope over the brachial artery. No sound is heard. Now, reduce the pressure gradually. Note the pressure at which the first tapping sound heard (systolic pressure). The sound now diminishes in quality on reducing the pressure, and finally disappears (diastolic pressure). These are ‘Korotkoff sounds’. There are 5 phases in the sounds heard i.e.:

• Phase 1: First appearance of faint clear tapping sounds (thuds) which gradually increase in intensity.
• Phase 2: Softening of the sounds which may become swishing or blowing.
• Phase 3: Return of sharper softer sounds, which become crisper, but never fully regain the intensity of Phase 1 sounds.
• Phase 4: Distinct abrupt muffling of sounds, which become soft also blowing.
• Phase 5: Point at which all sounds disappear.

CLASSIFICATION OF BP

Respiratory Rate Examination:

In general examination of respiratory rate count the patient’s respirations for a minute, by diverting their attention elsewhere. This criterion is especially important because abnormalities in it suggest many pulmonary and cardiac diseases.
The normal respiratory rate is 16-20/min in adults and may be about 40/min in children. The pulse-respiration ratio should be about 1:4.

• Tachypnea refers to increased respiratory rate. It may occur after exertion or excitement, in fevers, anemia, acidocis, pain while breathing, etc.
• Bradypnea refers to decreased respiratory rate. It occurs during sleep, in narcotic poisoning e.g. opium, barbiturates, brain tumors, etc.

DYSPNOEA
Breathlessness inappropriate to the level of physical exertion, or even occurring at rest, is called dyspnoea.

Severity of dyspnoea:

RHYTHM
Along with rate of respiration, also watch for the rhythm. Normally, the rhythm is regular with inspiration longer than expiration.
Chyne-Stokes respiration characterize by rhythmical alteration of apnea and hyperapnea due to anoxemia. Seen in – Left ventricular failure, increased intracranial pressure, narcotic poisoning, uraemia, deep sleep, etc.
Kussmaul’s respiration deep and rapid (air hunger) usually seen in diabetic ketoacidosis, alcoholic or starvation ketoacidocis and uraemia.

TYPE
Generally, in males abdominal movements are more prominent while breathing (abdominothoracic). In females, thoracic movements are more prominent while breathing (thoracoabdominal).
Abdominal breathing seen in pleurisy, pain in chest, collapse of the lung, etc.
All in all, Thoracic breathing may seen in paralysis of diaphragm, peritonitis and gross ascites.

Frequently Asked Questions

What is General Examination?

The physical examination starts moment the patient enters the clinic. His orientation, gait, nutritional status, etc. can be observed. A thorough physical examination best done with a cooperative patient, in a well-lit, quiet and warm room.

What is considered in General Examination?

• Build and Body Proportion
• Nutritional State
• Decubitus Patient
• Clubbing
• Cyanosis
• Jaundice
• Pallor

What is the meaning of Clubbing?

It is bulbous enlargement of soft parts of terminal phalanges with transvers and longitudinal curving of nails.

What is Cyanosis?

More than 5 mg% of reduced hemoglobin in capillary blood gives rise to bluish discoloration of tissues (especially seen in nails, palate, tongue, lips, etc.). This is known as cyanosis.