Chapter 1 GENERAL EXAMINATION Flashcards
CHARACTERISTIC FACIES 1
- 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,
Characteristics of facies 2
- 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.
In general examination;
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.
Upon seeing the patient
The first question to ask yourself under physical examination
“Does this patient look ill?”
Scleroderma Features
- 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
Parkinson’s disease
- pill rolling tremor of Parkinsonism,
- poverty of expression or masklike facies
Tremors / Abnormal movements
- coarse pill rolling tremor of Parkinsonism,
- the flapping tremor of encephalopathy due to hepatic failure,- Uraemic twitching in renal failure
- the fine tremor thyrotoxicosis.
In general examination
After asking yourself
Does the patient look ill
- Characteristic faces
- Pigmentations
- Abnormal movement or tremors
- Abnormal sounds
- Abnormal odor
- Anthropometry
- Hydration
Abnormal sounds
- 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.
Abnormal odour
- 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.
Anthropometry
- 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,
In clubbing
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
Palmar erythema refers to redeeming of the thenar and hypotherna eminences
It is as a result of Nitric oxide
PP- CHORD Prempeh College
- liver cirrhosis due to hyperestrogenemia
- pregnancy due to hyperestrogenemia
- portal circulation
- hyperthyroidism
- polycysthemia
- rheumatoid arthritis
-chemotherapy induced - oral contraceptive usage
Drugs : 5- flouracil
Palmar pallor at the creases
- 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
Dupuytren’s contracture
10
Liver cirrhosis Epilepsy Trauma Aging Associated with: smoking, alcohol usage, diabetes mellitus, hiv, familial, phenytoin use
Onchomychosis
Fungal infection of the nail bed which leads to discoloration, thickening and separation of nail from nail bed
- fungal infection
Lindsay’s nail
Proximal part being white and distal part red
50/50
- chronic kidney disease
Terry nails
Proximal part is white and distal part red
70/30
- liver disease
- congestive heart failure
- diabetes
- kidney failure
- aging
Boutenniere deformity or swan neck deformity
Rheumatoid arthritis
Trauma
Tremors
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
At the foot of the bed
- 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
Onycholysis refers to separation of the nail from the nail bed
11
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
Pitting nails PALE where l is R
Psoriasis
- alopecia ateleca
- reactive arthritis
- eczema
Koilynychia spoon shaped nail
7
- chronic iron deficiency anemia
- fungal infection
- acromegaly
- hypothyroidism
- repeated exposure to detergents
- Raynaud syndrome
- congenital
Upper GI carcinoma
Systemic lupus erythematous
Trauma
Muehrcke’s lines
Decreased protein synthesis
Protein loss
Leukonychia
Protein losing enteropathy Nephrotic syndrome Trauma Infection Marasmus Kwashiorkor Liver cirrhosis Poisoning Chemotherapy Calcium deficiency
Xtics of sickle cell anemia patients
- obvious pain
- frontal, parietal and occipital bossing
- gnathopathy
- tachycardia pulse
- arachynodactyl in cvs
- medial malleolus ulcers or sores
Mental state of patient
- alert and conscious
- drowsy
- lethargic
- unconsciousness
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
Horner’s syndrome
- ptosis
- miosis
- hypohydrosis
- enophthalmus
Palmar pigmented creases
- Addison’s disease
- hemochromatosis
- Nelson syndrome
Anarsaca
- ascites
- periorbital swelling
- pedal swelling
- abdominal distension
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
-
One is at risk of congenital cyanosis
Genetic reasons
- Marfan syndrome
- Turner syndrome
- Down syndrome
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
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
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
