Written by Dr.Md.Redwanul Huq (Masum)

Sunday, 23 December 2012 14:14

General Examination(Components):

General Examination includes the followings:

1. Appearance(A)- Well looking / Ill looking / Anxious looking / Depressed /Vacant look (Expressionless)
2. Body built(B)- Average / Tall / Short.
3. Co-operation(C)- Co-operative / Non co-operative.
4. Decubitus(D)- On choice / Tripod position / Mohammadian’s position.
5. Nutritional status(N)- Well nourished / Malnourished-Undernourished or Obese/Cachexic or Emaciated.
6. Anaemia- Absent / Present.
7. Jaundice- Absent / Present.
8. Cyanosis- Absent / Present.
9. Clubbing- Absent / Present.
10. Oedema- Absent / Present.
11. Dehydration- Absent / Present.
12. Koilonychia- Absent / Present.
13. Leuconychia- Absent / Present.
14. Lymph nodes- Normal / Enlarged.
15. Jugular vein(Neck vein)- Normal / Engorged.
16. Thyroid gland- Normal / Enlarged.
17. Pigmentation- Absent / Present.
18. Body hair distribution- Normal / Decreased.
19. Bony tenderness- Absent / Present.
20. Deformities- Absent / Present.
21. Gynaecomastia – Absent / Present.
22. Temperature(T)- Normal / Increased / Decreased.
23. Pulse(P)- Rate, Rhythm,Volume,Tension,Condition of the vessel wall.
24. Respiratory rate(R)- Normal / Increased / Decreased.
25. Blood Pressure(BP)- Normal / Increased / Decreased.
26. Heat coagulation test of urine – if the clinical findings from examination suggest renal problem(s).

General Examination(Practical):

For examination of the patient- it is better to maintain the following chronology –

•  Ensure that all the necessary equipments of examination are with you.
• Ensure personal hygiene and proper lighting (Daylight is preferable).
• Observe all the events & objects surrounding the patient.
• Introduce yourself to the patient and take permission of examination from him/her.
• Stand by the right side of the patient.
• Ensure proper positioning & exposure of the patient with privacy.
• Ask the patient about having tenderness in any part of the body, if present-examine that part at last with care, if not- then start as following-

1.Observe the whole body for body built, decubitus, nutritional status,skin complexion (Pallor/Jaundice), any pigmentation, change in hair distribution or any deformity.

2.Look at the face for appearance and any definite type of facies like- Cushingoid facies, Mongoloid facies, Haemolytic facies etc.

3.Look at the scalp and head and feel them by both hands for any disorder.

4.Feel the temperature by dorsum of your left hand on the forehead.

5.Look at the eyes to see wetness & any gross disorder of cornea or sclera.

6.Elevate both upper eye lids and ask the patient to look at his/her foot or below

and see the upper sclera for jaundice.

7.Pullboth lower eye lids and ask the patient to look above and see the lower palpebral

conjunctiva for anemia / pallor.

8.Look at the cheek, nose, lips & ears to see any disorder.

9.Look at the interior of the nostrils with a torch light.

10.Check both ears and their interiors with auroscope and torch light.

11.Ask the patient to open his/her mouth and look at the inside of the mouth cavity with a torch to detect any abnormality in teeth, gum, buccal mucosa, tongue, hard & soft palates, palatine tonsils, oropharynx.

12.Record the temperature(sub-lingual) by a thermometer.

13.Examine the sub-mental, sub-mandibular, pre-auricular and post-auricular lymph nodes, both parotid glands, cervical lymph nodes(anterior & posterior cervical chains) of both sides, bilateral supra-clavicular and scalene groups of lymph nodes,sub-occipital lymph nodes. Among these- posterior cervical lymph nodes of both sides and sub-occipital lymph nodes should be examined from front & the rest of the lymph nodes from back(better to examine in sitting position).

14.Palpate the thyroid gland and ask the patient to deglutate at that time (better to examine in sitting position).

15.Examine dehydration by pulling skin over the clavicle (in case of adult).

16.Test bony tenderness by pressing over the body of the sternum, but look at the face of the patient while pressing.

17.Palpate both breasts for gynaecomastia (in case of male).

18. Examine dehydration by pulling skin over the abdomen (in case of children).

19.Examine both hands of the patient as follows-

a) Shake your right hand with the same of the patient and feel the surface & temperature of the palm and strength of grip.

b) Keep both hands of the patient over your palm of left hand and

i)examine the nail beds for anemia, jaundice, cyanosis,nail bed infarcts,splinter hemorrhages etc.

ii)examine the nail plates for koilonychia, leuconychia, tobacco staining,half and half nail etc.

iii) examine the nail base for clubbing.

iv) examine the finger joints for findings of osteoarthritis, rheumatoid arthritis etc.

v)examine the palm for anaemia, jaundice(specially in palmar creases),palmar erythema etc.

vi)look for any abnormal movement or posture of hands.

c) Examine the pulse (rate, rhythm,volume,tension,condition of the vessel wall) for one minute over right radial artery.

d) Palpate the epi-trochlear lymph nodes of both hands.

20.Examine the axial group of lymph nodes(better to examine in sitting position)- medial, central, apical & lateral group of lymph nodes from front and posterior group of lymph nodes from back.

21.Count the respiratory rate for one minute.

22. Examine the inguinal group of lymph nodes of both sides.

23. Examine the popliteal lymph nodes of both sides after flexing both knees.

24.Look for edema on the medial surface of both tibia-2 cm above the medial malleolus.

25.Examine both feet for anemia, jaundice, cyanosis, koilonychia, leuconychia etc.

26.Ask the patient to lie on his/her left side & look for edema over both sacral dimples.

27.Examine the Jugular vein(Neck vein) while the patient reclines at 45 degrees.

28. Ask the patient to sit on the bed and examine the sub-mental, sub-mandibular, pre-auricular and post-auricular lymph nodes, both parotid glands,cervical lymph nodes(anterior & posterior cervical chains) of both sides,bilateral supra-clavicular and scalene groups of lymph nodes, sub-occipital lymph nodes of both sides (as described above)- if not done before.

29. Examine the axial group of lymph nodes (described above) in sitting position-  if not done before.

30.Examine the thyroid gland from back in sitting position of the patient -if not done before.

31.At last measure the Blood Pressure in lying, sitting and standing position.

32.If the clinical findings from examination suggest renal problem(s), do the heat  coagulation test of urine as a part of general physical examination.

Verbal description of normal findings of General examination:

Patient is good/ill looking with average body built, well co-operative, decubitus on choice, well nourished, non-anemic, non- ecteric, non cyanosed, non edematous, non dehydrated, there is no koilonychia, leukonychia or bony tenderness, JVP is not raised, lymph nodes are not palpable, thyroid gland is normal, there is no stigmata of CLD, Pulse is 78beats/min, BP is 120/80 mm of Hg, temp is 98 ºF & respiratory rate is 18 breaths/min.

Examination of edema:

Method:

Examination of edema is done by giving pressure for 30 seconds on the following sites by the thumb:

Just above the medial malleolus

Sacrum

Dorsum of the foot (specially in children)

Also over the bony prominences (e.g. wrist).

Examination of Lymph nodes:

Lymph nodes which should be examined are:

a) In neck: Lymph nodes in neck are-Sub mental, sub mandibular, pre- auricular, anterior cervical, supra clavicular, scalene group, posterior cervical, post-auricular & sub-occipital lymph nodes.

b) In axilla:- Central, apical, medial, anterior, lateral & posterior axillary lymph nodes.

c) In arm: Epitrochlear lymph node.

d) In abdomen: Para-aortic lymph nodes.

e) In Inguinal region: Superficial (Horizontal & vertical groups) and deep inguinal lymph nodes.

f) In popliteal fossa: Popliteal lymph nodes.

Clinical signs to be seen during examination of lymph nodes:

1. Sites-

Described above.

2. Size & number-

Usually 1 cm- it is pathological & if 2 x 2 cm² – possibility of neoplasia

3.Consistency-

i) Rubbery –  Lymphoma

ii) Firm- TB, lymphocytic leukaemia

iii) Hard- Malignancy, advanced stage of TB or lymphoma

iv) Soft- Pyogenic infection.

4. Tenderness:

Positive in phylogenic infections, e.g. tonsillitis, mastoiditis etc

5. Discrete or matted-

Matted : TB

Discrete: Lymphoma, leukemia

6. Fixation:

Fixed with overlying skin &/or underlying structure in case of malignancy.

7. Local temperature:

Increased in –  pyogenic infection

8. Discharging sinus-

Present in Lymph node TB

9. Margins-

irregular in case of malignancy.

Verbal description of findings of palpable lymph nodes:

Cervical/axillary/inguinal/popliteal lymph nodes are palpable, single/multiple in number, discrete/matted, variable in size ranging from 0.5 cm – 1/2/3 cm, the largest one is 1/2/3 cm, consistency is soft/firm/hard/rubbery with regular/irregular surface & regular/irregular margin, tender/non tender, local temperature is raised or not, adherent/not adherent with underlying structure &/or overlying skin, discharging sinus is present or absent.