Chapter 1 GENERAL EXAMINATION Flashcards
1
Q
CHARACTERISTIC FACIES 1
A
- The immobile stare and poverty of facial movements associated with the shuffling gait of Parkinsonism;
- the startled appearance and gross exophthalmus in hyperthyroidism in a young person;
- the coarse features with large jaws and hands of acromegaly;
- the big head of Paget’s disease,
2
Q
Characteristics of facies 2
A
- the rash of ophthalmic herpes zoster;
- puckered mouth of scleroderma and stiff awkward movements of ankylosing spondylitis can all be diagnosed at a glance
- can the pale puffy face of nephritis
- the eyes of a patient with Down’s syndrome.
3
Q
In general examination;
A
The greeting, handshake or dressing of the patient will give one early impression of the patient’s condition. The gait may indicate neurological or locomotor disturbance. The posture of the patient can be informative.
4
Q
Upon seeing the patient
The first question to ask yourself under physical examination
A
“Does this patient look ill?”
5
Q
Scleroderma Features
A
- Puckered mouth==tightening of the mouth area. This is due to the skin in the face contracting, making the mouth smaller.
- stiff awkward movements of ankylosing spondylitis can all be diagnosed at a glance
- tact with stretched facies
- Raynaud’s disease
6
Q
Parkinson’s disease
A
- pill rolling tremor of Parkinsonism,
- poverty of expression or masklike facies
7
Q
Tremors / Abnormal movements
A
- coarse pill rolling tremor of Parkinsonism,
- the flapping tremor of encephalopathy due to hepatic failure,- Uraemic twitching in renal failure
- the fine tremor thyrotoxicosis.
8
Q
In general examination
After asking yourself
Does the patient look ill
A
- Characteristic faces
- Pigmentations
- Abnormal movement or tremors
- Abnormal sounds
- Abnormal odor
- Anthropometry
- Hydration
9
Q
Abnormal sounds
A
- Pay attention to the patient’s voice and speech.
- Note the hoarseness of voice in laryngitis and a lesion of recurrent laryngeal nerve.
- Note the presence of dysarthria and the pitched slow deliberate ‘thick’ speech in myxoedema.
- Note the presence of wheezing, rattling or stridor in respiratory illness.
10
Q
Abnormal odour
A
- Note the smell of foetor hepaticus in liver failure, the sweet smell of acetone in the breath of the patient with diabetic ketoacidosis.
- Mal-odour from dirty clothes and general soiling occur in the elderly infirm patients who are unable to look after themselves as in mentally defective patients.
- Halitosis may be due to poor oral hygiene or pulmonary suppuration.
11
Q
Anthropometry
A
- Note obesity or thinness in the patient.
- Increase in height may indicate gigantism or Marfan’s syndrome, Soto’s syndrome, familial/ constitutional tall stature, Klinefelter syndrome, Ehler’s Danlos
- Note dwarfism or the presence of achondroplasia, familial short stature, idiopathic short stature, Turner syndrome, Down syndrome,
12
Q
In clubbing
A
Clawing of the fingers seen in ulnar nerve lesions.
Look for the presence of Heberden’s nodes – bony swelling of the distal inter-phalangeal joint – seen in osteoarthrosis
Bouchard’s node – fusiform swelling or proximal inter-phalangeal joint – seen in rheumatoid arthritis
13
Q
Palmar erythema refers to redeeming of the thenar and hypotherna eminences
It is as a result of Nitric oxide
PP- CHORD Prempeh College
A
- liver cirrhosis due to hyperestrogenemia
- pregnancy due to hyperestrogenemia
- portal circulation
- hyperthyroidism
- polycysthemia
- rheumatoid arthritis
-chemotherapy induced - oral contraceptive usage
Drugs : 5- flouracil
14
Q
Palmar pallor at the creases
A
- low perfusion levels due to shock
- anemia low red blood cells due to git bleeding
- very coarse dry skin for a hypothyroidism patient or a manual worker
- hypo pigmentation: hypopituitarism, vitiligo, albino
- peripheral shutdown due to increased sympathetic activity
15
Q
Dupuytren’s contracture
10
A
Liver cirrhosis Epilepsy Trauma Aging Associated with: smoking, alcohol usage, diabetes mellitus, hiv, familial, phenytoin use
16
Q
Onchomychosis
Fungal infection of the nail bed which leads to discoloration, thickening and separation of nail from nail bed
A
- fungal infection
17
Q
Lindsay’s nail
Proximal part being white and distal part red
50/50
A
- chronic kidney disease
18
Q
Terry nails
Proximal part is white and distal part red
70/30
A
- liver disease
- congestive heart failure
- diabetes
- kidney failure
- aging
19
Q
Boutenniere deformity or swan neck deformity
A
Rheumatoid arthritis
Trauma
20
Q
Tremors
A
Fine tremor: thyrotoxicosis, recent usage of beta adrenergic therapy (salbutamol)
Flapping tremors: uremic due to chronic kidney disease when kidney is unable to remove toxins from the body
Hepatic encephalopathy refers to when the liver is unable to metabolize ammonia into urea
Increased CO2 retention
Severe congestive heart disease
Electrolyte disturbance
Drug intoxication
Pin rolling: Parkinson’s disease
21
Q
At the foot of the bed
A
- position of the patient and bed
- is the patient healthy or ill
- is the patient in distress or cachetic
- is the patient alert/ conscious, drowsy, unconscious, lethargic
- is the patient tall, short, (slightly) obese, thin
- is the patient dehydrated, jaundiced, cyanotic
- facies
- pedal oedema
22
Q
Onycholysis refers to separation of the nail from the nail bed
11
A
Exogenous: - psoriasis - allergic or irritant chemicals - yeast candida infections - bacteria pseudomonas Virus herpes simplex onfection Endogenous; -sarcoidosis - anemia - diabetes mellitus - hyperthyroidism - hypothyroidism - leprosy - syphyllis - trauma
23
Q
Pitting nails PALE where l is R
A
Psoriasis
- alopecia ateleca
- reactive arthritis
- eczema
24
Q
Koilynychia spoon shaped nail
7
A
- chronic iron deficiency anemia
- fungal infection
- acromegaly
- hypothyroidism
- repeated exposure to detergents
- Raynaud syndrome
- congenital
Upper GI carcinoma
Systemic lupus erythematous
Trauma
25
Muehrcke’s lines
Decreased protein synthesis
| Protein loss
26
Leukonychia
```
Protein losing enteropathy
Nephrotic syndrome
Trauma
Infection
Marasmus
Kwashiorkor
Liver cirrhosis
Poisoning
Chemotherapy
Calcium deficiency
```
27
Xtics of sickle cell anemia patients
- obvious pain
- frontal, parietal and occipital bossing
- gnathopathy
- tachycardia pulse
- arachynodactyl in cvs
- medial malleolus ulcers or sores
28
Mental state of patient
- alert and conscious
- drowsy
- lethargic
- unconsciousness
29
Exopthalmus
Also known as proposed of the eye
6
Graves’ disease
- hyperthyroidism
- eyelid retraction
- shallow orbit
- exopthalmus of the other eye
- tumors of the orbit
30
Horner’s syndrome
- ptosis
- miosis
- hypohydrosis
- enophthalmus
31
Palmar pigmented creases
- Addison’s disease
- hemochromatosis
- Nelson syndrome
32
Anarsaca
- ascites
- periorbital swelling
- pedal swelling
- abdominal distension
33
Cyanosis
Occurs more readily in polycysthemia than anemia
PALMS
Polycysthemia
Altitude
Lung cancer
- asthma
- copd
- pulmonary embolism
- pulmonary oedema
-pneumonia
Methaemoglobimia congenital or acquires red cell disorder
Shunts
- tetralogy of fallot: ventricular septal defect, overriding of the aorta, pulmonary stenosis, right ventricular hypertrophy
- transposition of the great blood arteries
- right to left shunt ( ventricular septal defect with Eisenmenger’s syndrome I.e a hole in the Heart esp at the VSD)
- tricuspid atresia
-
34
One is at risk of congenital cyanosis
| Genetic reasons
- Marfan syndrome
- Turner syndrome
- Down syndrome
35
Differential diagnosis of pallor
It can be assessed from the buccal mucosa, conjunctiva and palmar creases
If one digit is pale may be due to embolism
FA2S2TH2 where T is silent
- familial
- anemia
-albinism
- shock
- stokes-Adams attack
- hypothyroidism
- hypopitutarism
-
36
Skin pigmentation 9
- Addison disease
- Nelson syndrome abnormal hormone secretion from pituitary gland
- ectopic ACTH in bronchial carcinoma
- chronic kidney disease due to increased urea
- malabsorption
- Melasma seen in pregnancy or oral contraceptive pills
- biliary cirrhosis
- haemochromatosis
- Carotenemia
37
Obesity 9
- hypothyroidism : coarse dry hands
- Cushing syndrome
- Prader- Willi syndrome
- Lawrence- Moon syndrome
- trauma or tumor damage to the hypothalamus therefore leading to early satiety levels
- sedentary life
- oral contraceptive drugs
- hypogonadism
- glucocorticoids
38
Generalized Lymaphadenopathy 15
```
Infective:
Bacterial: TB, syphyllis , brucellosis
Virus: infectious hepatitis , HIV, EBV
Others: trypanosomiasis, toxoplasmosis
Non infective: sarcoidosis, amyloidosis, SLE, eczema, psoriasis
Lymphoma
Leukemia
```
39
Pitting oedema
- fluid squeezed out of vein: deep vein thrombosis, right heart failure
- reduced oncotic pressure: cirrhosis, protein losing enteropathy, kwashiokor, marasmus, nephrotic syndrome
40
Non pitting oedema
- lymphoedema due to poor lymphatic drainage
- radiotherapy
- malignant infiltration
- infection
- filariasis
41
Periorbital oedema
| GA2S3 On Ec
- contact dermatitis ( from eye make up, stings)
- angioedema
- orbital cellulitis
- Epstein Barr virus
- sinusitis
- Graves’ disease
- SLE
- sarcoidosis
- amyloidosis
42
Cachexia
| 11
- famine
- decreased eating: stroke, dementia, anorexia nervosa
- malabsorption: AIDS, Cryptosporidium, Whipples disease,
- increased catabolism; neoplasm, TB, chronic kidney disease, increased leptin
Thyrotoxicosis
43
Goitre
```
Diffuse:- Graves’ disease
- Hashmoto’s thyroiditis
- Subacute thyroiditis
- Physiological
Nodular: - Multinodular goitre
- Adenoma
- Carcinoma
```
44
Dehydration
- delayed recovery of skin after being pinched
- enopthalmus
- delayed capillary refill
- dry cracked lips and skin
- dry tongue
45
Decreased pigmentation
- Albinism
- Vitiligo
- hypopituatarism
- bleaching
46
Mouth Odour 4
- Note the smell of foetor hepaticus in liver failure,
- the sweet smell of acetone in the breath of the patient with diabetic ketoacidosis.
- Halitosis may be due to poor oral hygiene or pulmonary suppuration (necrosis of pulmonary parenchyma by microbes)
- alcoholic smell
47
Beau’s lines
Severe infection: - malaria
- typhus
- rheumatic fever
- Kawasaki disease
- myocardial infarction
- chemotherapy
- trauma
- high altitude climbing
- deep sea diving
48
Mee’s lines
- arsenic poisoning
- carbon monoxide poisoning
- chronic kidney disease
49
Muehrcke’s disease
```
- chronic hypoalbunemia
‘ kwashiokor, marasmus, whipples disease, celiac sprue, tropical sprue, Crohn’s disease, ulcerative colitis, protein losing enteropathy, nephrotic syndrome
- Hodgkin’s disease
- pellagra
- chronic kidney disease
```
50
Terry nails ( 70%proximal nail is white or pink and 30% distal nail red or brown)
- congestive heart failure
- chronic kidney disease
- liver cirrhosis
51
Wasting of thenar and hypotherna eminences
- carpal tunnel syndrome: median nerve constriction
| - generalized wasting
52
Splinter haemorrhages
- infective endocarditis
- vasculitis
- micro emboli
- systemic lupus erythematous
- rheumatoid arthritis
- psoaritic nails
- trauma
53
Herbeden’s nodes
| bony swelling of the distal inter-phalangeal joint
Osteoarthritis
54
Bouchard nodes
| fusiform swelling or proximal inter-phalangeal joint
Rheumatoid arthritis
55
Hand abnormalities
Clawed fingers: ulnar nerve lesions
Ulnar deviation of the hand- long standing rheumatoid arthritis
Wrist drop-radial nerve damage
Flexed hand and arm of hemiplegia
56
Nail fold infarcts
- vasculitis
57
tar/ nicotine stains
- for people who smoke
- occupation such as mechanics
58
Wasting of dorsal interrossei
- Rheumatoid arthritis
| - Generalized wasting
59
Unilateral pedal edema
- DVT
- cellulitis
- venous insufficiency
- lymphoedema
- abdominal malignancy
- gravity
- NSAIDS
- birth control
- steroids
60
Bilateral pedal oedema
- DVT
- birth control
- steroids
- NSAIDS
- gravity
- venous insufficiency
- lymphoedema
- cellulitis
- filariasis
- chronic kidney disease
- pregnancy
- congestive heart failure
- hypoalbunemia
61
Intravenous drug usage
- hepatitis
62
DDx of unconsciousness 9
- meningitis
- encephalitis
- stroke
- head trauma
- cerebral malaria
- hypoglycemia
- hypotension
- drug poisoning
- alcohol intoxication
-
63
Younger than stated age 5
- juvenile diabetes
- sickle cell disease
- hypopituarism
- cystic fibrosis
- endomyocardial fibrosis
64
Older than stated age
| 1
- pituitary tumor
65
Age
- infant below one year old
- toddler 1-3 years
School age child 4-12
Teenager 13-19
Young adult 20-39
Middle age 40-64
Old age 65 and above
66
Agitated expression
- hypomania
- anxious
- hyperthyroidism
67
Acromegaly
- large jaw
- large hand and sweaty and fleshy
- Macroglossia
68
Hands
- cold and sweaty : anxiety
- cold and dry: Raynaud syndrome and congestive heart failure
- dry and sweaty: hyperthyroidism
- dry and coarse: hypothyroidism and manual workers and palmar pallor
- large, fleshy and sweaty hands: acromegaly
- difficulty in releasing grip: myotonic dystrophy
- deformity of the hand: Dupuytren’s contracture and rheumatoid arthritis
69
Under production of melanin
- albinism
- vitiligo
- hypopituiriarism
70
Overproduction of melanin
- Addison disease
- Nelson disease
- haemochromatosis
- pregnancy
- Cushing syndrome
- oral contraceptive
71
Yellowing of the skin
- carotene
| - jaundice (bilirubin)
72
Blue nails
- hematoma
- Wilson’s disease
- hiv
- peripheral cyanosis
73
Places to check for wasting
- temporalis muscle
- zygomatic bone
- supraclavicular fossa
- rib cage
- biceps
- triceps
- thenar and hypotherna wasting
- wasting of the dorsal interrossei
- bony landmarks of the pelvis
74
Bossing of the head
- sickle cell disease
- acromegaly
- excess growth hormones
- paget’s disease
75
Obesity Ddx 6th
Endocrine disorders: hypothyroidism, Cushing’s syndrome, Polycystic ovarian syndrome
Genetic: Prader-Willi syndrome
Malignancy: Insulinoma
Medications: corticosteroids, antidepressants
76
Weight loss Ddx 6th
Endocrine: diabetes, hyperthyroidism, adrenal insufficiency
GI disorders: Inflammatory bowel diseases (Crohn’s disease, ulcerative colitis), Peptic ulcer disease, malabsorption syndrome
Malignancy: lung cancer, pancreatic cancer, stomach cancer
Infectious disease: TB, HIV/AIDS, endocarditis
Neurological disorders: disorders leading to dysphagia such as taking a corrosive drink
Psychiatry: anorexia nervosa, bulimia, anxiety
Rheumatologic: rheumatoid arthritis, lupus
Cardiovascular disease: Severe heart failure can cause cardiac cachexia
Chronic Kidney disease when advanced due to decreased appetite and weight loss
77
Talk for Age Ddx 6th
- Familial tall stature
- Marfan syndrome
- Kinelfelter syndrome affects males
- homocystinuria
- Pituitary gigantism
For children
- Soto’s syndrome
- Beckwith Weismann syndrome
- Precocious pubertal : growing tall but later in age they stop growing talk so their peers can be taller than them
78
Cyanosis Ddx 6th
Two types
1) Central cyanosis
- Congenital heart disease: tetralogy of fallot,
- lung disease: COPD, pulmonary edema
- pulmonary embolism
- methaemoglobinemia: a form of haemoglobin that is unable to carry oxygen properly
2) Peripheral cyanosis
- cold exposure or hypothermia
- Raynaud’s disease: finger’s and toes feel numb in response to stress or cold temperature
3) peripheral vascular disease
4) venous insufficiency: due to problem sending blood back from the legs to the heart
5) deep vein thrombosis
79
Anarsaca (swelling of the whole body) Ddx
- heart failure
- kidney disease: nephrotic syndrome, chronic kidney disease
- liver disease: cirrhosis of the liver
- venous insufficiency: occurs when your leg veins don't allow blood to flow back up to your heart, leading to swelling in the legs.
- lymphedema- block in the lymphatic system
- deep vein thrombosis
- pregnancy
- arthritis: rheumatoid arthritis, gout
80
Signs of dehydration
- sunken eyes
- reduced skin turgor
- decreased urine output
- confusion
- capillary refill time greater than 2 seconds
81
Signs of respiratory distress
- flaring of the ala nasi
- presence of supplementary oxygen
- use of accessory muscles such as the sternocleidomastoid muscle, scalene muscle
- retraction of intercostal spaces or subcostal muscle
- increased respiratory rate
- pursed lips
82
Stigmata of infective endocarditis
- Osler’s node (tender and found at the pulp of the fingers)- They are thought to be caused by immune complex deposition and subsequent inflammation.
- Janeway lesions (non tender and found at the palmar surface)- They are caused by septic emboli (clusters of bacteria and clotted blood) that have traveled through the bloodstream.
- Roth’s spot: These are retinal hemorrhages with clear centers, found in the eye. They are thought to be caused by immune complex-mediated vasculitis or septic emboli.
- splinter haemorrhage: They are caused by small clots that damage the small capillaries under the nails.
- Petechiae:
- Clubbing
The diagnosis is usually confirmed by echocardiography ( vegetations seen on the heart valves) and positive blood cultures.
83
Moist or sweaty hands Ddx 6th
Palmar hyperhidrosis
- primary hyperhidrosis (genetic)
-thyrotoxicosis,
- anxiety or stress,
- exercise
- hypoglycemia
- menopause
- Parkinson’s disease
84
Dupuytren’s contracture Ddx 6th
condition characterized by the progressive thickening and tightening of the fascia (fibrous tissue) in the palm of the hand, leading to a bent position of the fingers, most often the ring and small fingers.
- alcholics
- carpal tunnel syndrome
- arthritis
- flexor tendon injury or inflammation
- aging
- epilepsy
- chronic liver disease-: cirrhosis, hepatocellular carcinoma, fatty
- trauma
85
Palmar erythema 6th
- liver cirrhosis
- -polycythemia
- pregnancy
- thyrotoxicosis
- rheumatoid arthritis
- systemic lupus erythematous
- medications like amiodarone
- idiopathic palmar erythema
86
Pigmentation of palmar crease
- Addison’s disease
- cushing’s disease
87
Pallor of palmar crease
- Anaemia
- Shock
- hypovolemia
- hypoglycemia
- chronic diseases such as chronic kidney disease
- Medications: chemotherapy
- certain cancers like leukemia,
88
Communication during medical consultation
- facilitating
- rephrasing
- clarification and elaboration
- further questioning
- summarizing periodically
89
Communication in history taking
- facilitating
- summarizing
- clarifying and elaborating
- rephrasing
- further questioning
90
Smoking pack years
Smoking must be quantified in pack-years: number of pack-years of cigarette use= packs smoked per day multiplied by number of years of smoking
91
Alcohol use
People are advised not to drink more than 14 units/week on a regular basis and to spread it over 3 or more days
1 unit =10 ml (8gm) of pure alcohol
Units in any drink is =Total volume of the drink (in ml) X Alcohol by volume (ABV) in % dividing the results by 1000
92
CAGE (alcohol)
Have you thought about Cutting down?”
• “Have you ever gotten Annoyed when people talk to you about your drinking?”
• “Have you ever felt Guilty about your drinking?”
• “Do you ever have a drink first thing in the morning (Eye opener)?”
An affirmative answer to 2 or more CAGE questions has a sensitivity and specificity of > 90% for alcohol dependence
93
Occupation
- what work do you do?
- how May years have you been doing this?
- do you get exposed to fumes, dust, radiation, loud noise?
- do you think your work is affecting your symptoms?
- do symptoms improve when you leave work?
