3. general principles of physical examination Flashcards
principles of starting physical examination WIPER
Wash hands before and after - wear gloves where appropriate
Introduce yourself to the patient and seek his/her consent
Position the patient correctly
Expose the patient as needed (e.g please take off your shirt for me now, if that’s alright
Right side of the bed
vital signs
related to cardiac and respiratory functions and comprise of:
- pulse
- BP
- Respiratory rate
- temperature
must be assessed at once if a paitent appears unwell
facies and what type of diagnosis can clue you in on
- acromegalic
- amiodarone - deep blue discolouration arount the malar area and nose
- agitated faces - seen w/ anxiety, mania or hyperthyroidism
- cushing syndrome
- cyanosis
- depression - flat expression and apathy if severe ( also in hypothy)
- downs syndrome
- hippocratic ( advanced peritonitis) eyes are sunken, temples collapsed, nose is pinched w/ crusts on the lips and the forehead is clammy
- lipodystrophic atrophy of fat (antiretroviral tx)
- marfans
- mitra facies
- myopathis
- myotonic
- myxoedematous
- pagets
- parkinsons disease
- rickets
- risus sardonicus
- SLE facies
- thyrotoxicosis
- Turner’s syndrome
- Virile facies
jaundice
- increase in serum bilirubin twice the upper limit of normal -> deposition in the tissues of the body causing yellow discoloration and in sclera (vascular conjunctiva)
- caotenaemia ( excess consumption of carrots or mangoes)
- acriflavine
- fluorescein
- picric acid ingestion
- jaundice can be from excessive destruction of RBCs (haemolytic anaemia) -> pale lemon - yellow scleral discoloration or
- bile flow obx -> dark yellow/ orange tint, can be with pruritis
- gilberts -> mild elevation of unconjugated bilirubin (inherited EZ def)
cyanosis
> 50g/L deoxygenated haemoglobin in present in the capillary blood
** does not occur when in anaemic hypoxia because the total haemoglobin content is low
central cyanosis
abnormal amount of deoxygenated Hgb in the arteries and that a blue discoloration is present in parts of the body with a good circulation, such as the tongue
central cyanosis should lead to a careful examination of the cardiovascular and respiratory systems
peripheral cyanosis
blood supply to a certain part of the body is reduced and the tissues extract more oxygen than normal from the circulating blood
e.g lips are often cold in cold weather, but the tongue is spared
causes of central and peripheral cyanosis
Central cyanosis 1. Decreased arterial oxygen saturation ○ Decreased concentration of inspired oxygen: high altitude ○ Hypoventilation: coma, airway obstruction ○ Lung disease: chronic obstructive pulmonary disease (COPD) with cor pulmonale, massive pulmonary embolism ○ Right-to-left cardiac shunt (cyanotic congenital heart disease) 2. Polycythaemia 3. Haemoglobin abnormalities (rare) ○ Methaemoglobinaemia (ferrous [Fe2+] ions of haem are oxidised to the ferric [Fe3+] state, usually owing to drugs such as dapsone or topical anaesthetics in adults, which can be fatal if not immediately recognised and treated)*
Peripheral cyanosis
1. All causes of central cyanosis cause peripheral
cyanosis
2. Exposure to cold
3. Reduced cardiac output: left ventricular failure
or shock
4. Arterial or venous obstruction
Pallor
- def in hgb (anemia) -> produce pallor of skin and should be noticeable especially in the mucous membranes of the sclerae if the anaemia is severe <70g/L
- pull the lower eyelid down and compare the colour of the anterior part of the palpebral conjunctiva with the posterior part where it reflects off the sclera.
- facial pallor may also be found in shock, which is usually defined as a reduction of cardiac output along with clammy cold and significant hypotension
causes of shock
1. Hypovolaemia ○ External fluid loss (e.g. blood, vomitus, diarrhoea, urine, burns, excess sweating) ○ Sequestration of body fluids in the abdomen (e.g. ascites), chest (e.g. haemothorax) or limbs (e.g. fracture) 2. Cardiac ○ Pump failure (e.g. myocardial infarction, acute mitral regurgitation) ○ Cardiac tamponade ○ Dissecting aortic aneurysm ○ Arrhythmia 3. Massive pulmonary embolus 4. Sepsis (e.g. Gram-negative bacteria [endotoxin]) 5. Anaphylaxis 6. Endocrine failure (e.g. adrenal failure) 7. Neuropathic—from drugs (e.g. antihypertensives, anaesthesia), spinal cord injury of autonomic neuropathy
weight, body, habitus and posture
- obesity apple or pear distribution
- BMI
<25, >30 obesity, >40 morbid obesity - WHR was to hip ratio circumference measurement of the waist ( mid point b/w the coastal margin and the iliac crest) divided by the hips (at the widest part around the buttocks)
increased risk when this exceed 1.0 for men and 0.85 for women - waist circumference of more than 80 for females and 94 for males indicates increased risk and more than 88 and 102 cm indicated greatly increased risk
- signs of vitamin deficiencies e.g VIT C - scurvy small bleeds around the hair follicles as well as bruising
Medical conditions associated with obesity BMI >30
-Endocrine Type 2 diabetes Amenorrhoea Dyslipidaemia Infertility Polycystic ovary syndrome Hypogonadism
-Respiratory
Sleep apnoea
Dyspnoea
-Cardiovascular Hypertension Cardiac failure Ischaemic heart disease Cor pulmonale (right heart failure secondary to lung disease) Pulmonary embolism
-Musculoskeletal
Arthritis
Immobility
-Skin
Skin abscesses; cellulitis; fungal infections
Venous stasis
-Gut
Gastro-oesophageal reflux disease
Non-alcoholic steatohepatitis
Hernias
hydration
-all drs must be able to assess approximate state of hydration of a patient e.g severely dehydrated patients is at risk of death from developing acute renal failure, whereas an overhydrated pt may develop fluid overload and pulmonary edema.
rehydration w/ water during sports event - > reduced blood sodium levels and cause confusion and even LOC
assessment of dehydration
- inspect for sunken orbits, dry mucous membranes and moribund appearance of severe dehydration
- reduced skin turgor
- dry axilla
- dry tongue
- a fall in blood pressure when the pt sits or stands up after lying down (postural hypotension)
- an increase in the pulse rate of 30 beats per minute or more is also a sign of hypovolemia
- assessment of patients jugular venous pressure is one of the most sensitive ways of judging intravascular volume overload or over hydration
classical physical signs of dehydration
Mild (<5%): = 2.5 L deficit
Mild thirst
Dry mucous membranes
Concentrated urine
Moderate (5%–8%): = 4 L deficit As above Moderate thirst Reduced skin turgor (elasticity), especially arms, forehead, chest, abdomen Tachycardia
Severe (9%–12%): = 6 L deficit As above Great thirst Reduced skin turgor and decreased eyeball pressure Collapsed veins, sunken eyes, ‘gaunt’ face Postural hypotension Oliguria (<400 mL urine / 24 hours)
Very severe (>12%): >6 L deficit As above Comatose Moribund Signs of shock
