GENERAL PHYSICAL EXAMINATION

GENERAL PHYSICAL EXAMINATION
INTRODUCTION
The general examination should follow the same three principles as any
other element of the diagnostic process:
(what are the aims of performing general physical exam?)
1.to establish or refute diagnostic hypotheses generated by the history
2 .to screen for important abnormalities
3. to satisfy patient requests for reassurance
When undertaking a physical examination the following rules should be considered:
1-keep the patient comfortable and relaxed.
2-explain what you are going to do.
3-warm environment is essential.
4-consider privacy of the patient.
5-optimal (preferably natural) lighting.
6-examine exposed parts of the body or undress the patient down to
underclothes and cover him with a sheet or blanket.
7-expose both sides when examining paired structures in order to compare the
diseased with normal.
8-the examiner stands on the right side of the patient.
9-examination time should be short especially in ill patients and in emergencies.
10-interpret findings as you go along.
PROCEDURE:
- Introduce yourself and explain the procedure. Ensure the patient is
comfortable and maintain the patient’s dignity.
-Look at the patient from the end of the bed:
Does the patient prefer a fixed position(eg: knees up, bending forward etc) ?
-Introduce these as localising signs and concept of pain being enhanced by
tissue tension
-Patient lying rigid or restless?
Classical position adopted to
ease pancreatic pain
(patient with chronic
pancreatitis)
The general examination should contain the following elements:
1-General impression:
-age
-sex
-built: signs of weight loss
-looks: well, ill, in pain or depressed…
-hydration
-state of hygiene
2-Mental status:
-consciousness and orientation (to time, place and persons)
Glasgow Coma Scale (GCS)
-restlessness, anxiety ,sweating ,apathy ,depression ,rapid breathing ,
speech
3-Abnormal facies and body configuration : Down’s,Turner’s and
Marfan’s syndromes,acromegaly,Cushing’s syndrome,Hippocratic facies
,myxoedema and thyrotoxicosis, parkinsonism and renal failure.
Face:pallor,anaemia,cyanosis.oedema,jaundice,polycythaemia.
Cushing’s syndrome (moon face )
hypothyriodism
Acromegaly
Down's syndrome
Marfans Syndrome
4-Eyes :
pupils , exophthalmos , ptosis , squint , eye movements ,
conjunctiva (anaemia),
sclera (jaundice)
Exophthalmos
One of the eye signs of thyrotoxicosis
5-Hands : sweating , temperature , size , deformity , pallor , cyanosis ,
erythema , nicotine stains, tremor.
Nicotine- stained fingers of a chain smoker
Paronychia
Vitiligo
It is often autoimmune in origin
Dupuytren´s contracture
The acromegalic hand
is large with wide
long fingers
Leprosy
The muscle wasting is due to
peripheral nerve damage
Palmar erythema of a patient with chronic liver failure
Rheumatoid
Thrombophlebitis
arthritis deformity
6-Nails: brittled , clubbing , pallor of anaemia and hypoalbuminaemia ,
splinter haemorrhages , spoon shaped , paronychia , Beau’s lines, Mei’s lines.
Koilonychia it indicates iron deficiency
Beau's
lines
Onychomycosis
Fungal infection of the
nails
7-Skin: skin of the palm of the hand (erythema) , colour of skin creases ,
spider naevi, laxity of the skin , bruising , skin nodules and moles , ulcers ,
Osler’s nodes , Dupuytren’s contracture
8-Hair
9-Mouth: -halitosis (foetor oris) ,special mouth odores (diabetic keto
acidosis, renal and hepatic failure ,alcohol smell. oral candidiasis , angular
stomatitis, tongue : hydration, congenital abnormalities , tumours , anaemia ,
central cyanosis , jaundice , vitamine deficiency , hydration , tongue
atrophy,smooth tongue , ulceration (aphthous ulcers) , inflammation (glossitis) ,
coating , size of the tongue , tongue movement.
Aphthous
ulcer
.
Carcinoma of the tongue
Macroglossia of
acromegaly
Leukoplakia
10-Lymphadenopathy
11-Leg oedema.
Pallor
The pallor of anaemia is noticeable in the following areas:
1- mucous membranes.
2- The inner surface of the lower lid .
3- Palm and palmar creases.
Jaundice:
Is a yellowish discoloration of the skin and mucous membranes due to
excess circulating bile pigments .
Mild degrees of jaundice are easily picked up by staining of the sclera
As jaundice becomes more pronounced there is yellow discoloration of the
skin and this may progress to yellow/orange or even dark brown with high levels
of plasma pigment.
Cyanosis:
Is blue discoloration given to the skin by deoxygenated blood.
However,a minimum of 5g/dl is required to produce visible cyanosis;it is thus
not detectable in severe anaemia.
Cyanosis is difficult to elicit in dark-skinned
people with anaemia.
A-Peripheral cyanosis: bluish discoloration of the skin of fingernails and
ear lobes in the presence of normal oxygen saturation ,it occurs due
vasoconstriction caused by cold.
B-Central cyanosis: bluish discoloration of the lips and tongue due to
excess of deoxygenated blood . It occurs in the following conditions:
1-Respiratory abnormalities: chronic obstructive airways disease.
2-Mismatched arterial ventilation and perfusion : pulmonary
embolism;pulmonary shunts; AV fistula.
3-Hypoventilation: head injuries; drug overdosage.
4-Cardiac conditions: congenital abnomalies with
right-to-left shunt.
5-High altitude.
Pitting oedema
Unilateral leg oedema
Facial
oedema
Raccoon eyes a sign for basal skull fracture
The Hippocratic facies in diffuse terminal peritonitis
Port Wine Stain
Laxity
With aging skin
becomes thinner and
loses its elasticity
Angular stomatitis
with cracking and fissuring of
the lips:
A feature of vitamin deficiency
Acanthosis nigricans
Cutaneous pigmentation &
thickening associated with an
underlying malignancy.
Vitiligo
An autoimmune destruction
of melanocytes