General Exam Flashcards
What are looked for in the hands and fingers
State five causes of weight loss
State two useful markers of malnutrition
Koilonychia: Koilonychia, also known as spoon nails, is a nail disease that can be a sign of hypochromic anemia, especially iron-deficiency anemia.
Water-drop test is a classically described clinical test to diagnose koilonychia. In this test, a few water drops are poured over the nail plate using a 1 ml syringe. In koilonychia, these droplets pool over the concave nail plates, unlike the normal convex nail plates.
Weight loss or malnutrition may be due to inadequate energy consumption or utilisation (such as malabsorption, anorexia, glycosuria) or to conditions in which nutritional demand is increased (such as fever, infection, thyrotoxicosis, malignancy, surgery). Psychiatric disease and alcohol or drug dependency may also result in weight loss. Useful markers of malnutrition include arm muscle circumference and grip strength.
With looking at a patient’s appearance what does gait indicate? State the seven types of gait ,explain them and what diseaseeach of them indicate?what can people w Parkinson’s ,people w hyperthyroidism,people w acromegaly,people w Paget’s disease,people w ophthalmic herpes zoster,scleroderma,ankylosing spondylitis ,nephritis,Downs syndrome present w concerning their appearance, how is weight loss assessed? State three causes of weight loss and how a patient’s demeanor can show the causes
The gait may indicate neurological or locomotor disturbance.
pathognomonic signs of neurological or musculoskeletal disease: for example, 1.the hemiplegic gait after stroke, 2.the ataxic gait of cerebellar disease or3. the marche à petits pas (‘walk of little steps’) gait or propulsive gait (steps are shorter and faster)in a patient with diffuse cerebrovascular disease or Parkinsonism
- Scissors gait. This type of gait gets its name because the knees and thighs hit or cross in a scissors-like pattern when walking . Occurs in patients w spastic cerebral palsy
- Spastic gait. Common to patients with cerebral palsy or multiple sclerosis, spastic gait is a way of walking in which one leg is stiff and drags in a semicircular motion on the side most affected by long-term muscle contraction. 6. Steppage gait. A “high stepping” type of gait in which the leg is lifted high, the foot drops (appearing floppy), and the toes points downward, scraping the ground, when walking. Peroneal muscle atrophy or peroneal nerve injury, as with a spinal problem (such as spinal stenosis or herniated disc), can cause this type of gait. 7.Waddling gait. Movement of the trunk is exaggerated to produce a waddling, duck-like walk. Progressive muscular dystrophy or hip dislocation present from birth can produce a waddling gait.
People with Parkinson’s have an immobile stare and a lack of facial movements associated with the shuffling gait
People w hyperthyroidism have a startled appearance and gross exophthalmus(bulging eyes )
the coarse features with large jaws and hands of acromegaly;
the big head of Paget’s disease,
the rash of ophthalmic herpes zoster; puckered mouth of scleroderma ,
stiff awkward movements of ankylosing spondylitis can all be diagnosed at a glance,
as can the pale puffy face of nephritis ,or the eyes of a patient with Down’s syndrome.
loss of weight can be assessed by:The wasted patient with gaping collar bone, baggy trousers ,tightened belt
The patients demeanor can give an idea of the cause of the weight loss
The inexorable life-sapping progress of the patient with extensive tuberculosis or disseminated cancer may be suspected at first sight. The perky, bird-like features of the school girl with anorexia nervosa may provide early clues as may the restlessness of the thyrotoxic
Face and appearance as a way of diagnosing
How is anaemia checked
State four things alcoholics can present with?
State two things a smoker can present with
What are some things that help to identify depression and hypomania in a patient
Anemia is checked by measuring hemoglobin level
Alcoholics present with plethoric (red faced due to excess body fluid particularly blood) and suffused conjunctiva (Conjunctival suffusion is characterized by redness of the conjunctiva that resembles conjunctivitis but that does not involve inflammatory exudates. ) associated with a pervading aroma of alcohol especially early in the morning and sweating palms and fine tremors.
The smoker smells of nicotine and a quick look at his nicotine-stained finger confirms this.
Also look for signs of self inflicted trauma in the young.
The patient’s face may betray psychiatric disease.
Depression is probably the earliest to identify. The withdrawn expressionless retarded patient with advanced disease is quickly identified but milder depression may be difficult to distinguish from simple unhappiness. At the other extreme the hypomanic patient may demonstrate few obvious facial stigmata but the constant flow of conversation and disarmingly frank comments may all alert the doctor.
With pigmentation as a way of diagnosing a disease,what will cause increased skin pigmentation of chronic debilitating illness or something that affects someone’s strength or ability to carry out regular activities and neoplastic disease
State four debilitating diseases
In renal failure what happens to the skin or if someone has renal failure what will show in the skin
What is seen in the skin of someone w cirrhosis ,pregnancy,Addisons disease,Nelson’s disease,haemochromatosis,chronic administration of some drugs,vitiligo(what is vitiligo and state three diseases it’s linked with),what’s the commonest cause of patchy de pigmentation of skin,what else can cause patchy depigmentation ,what is seen in oculo-cutaneous albinism
It is poorly understood but it is mainly due to increased deposition of melanin
COPd,Alzheimer’s,Parkinson’s,MUltiple sclerosis,cystic fibrosis
deposition of pigments called urochromes in the skin occurs causing skin discoloration .Normally these are excreted by healthy kidneys. Patients with this condition tend to have a grayish, almost metallic color skin. Another discoloration is called uremic frost)
diffuse telangiectatic mat over the cheeks may be seen in patients with cirrhosis of the liver.
Some increased pigmentation of the cheeks and forehead (chloasma) occurs during and fades after pregnancy
. The most gross hypermelanotic pigmentation in disease is seen with Addison’s disease and with Nelson’s syndrome in association with extremely high levels of adrenocorticotrophic hormone.
The pigmentation of haemochromatosis is characteristically slaty grey.
The chronic administration of some drugs such as Busulphan may darken the skin.
Patchy loss of pigmentation of the face may be due to vitiligo, a curious disorder linked with other auto-immune disorders such as Addison’s disease, pernicious anaemia and thyrotoxicosis.
However, the commonest cause of patchy depigmentation of the skin is bleaching of the face for cosmetic reasons.
Inflammatory skin eruptions can also cause patchy depigmentation of the skin as seen in onchocerciasis infestation.
Complete depigmentation of skin hair and uveal tract is seen in oculo-cutaneous albinism.
With abnormal movements and sounds and odours used in diagnosing diseases,what abnormal movements are seen in Parkinson’s,hepatic failure,renal failure,thyrotoxicosis ,alcohol withdrawal,side effect of.m neuroleptic therapy ,Huntingtons disease
Hoarseness of voice indicates what two diseases? What sounds are present in people w myxoedema
What sounds are heard in people w respiratory illness
What will you smell in someone w liver failure,someone w diabetic ketoacidosis,what does mal Odour indicate,what does Halitosis indicate,what does foul smelling belching indicate,what does faecal smell indicate ,what does a fishy or ammoniacal smell on breath indicate
What is pulmonary suppuration?
Observe any abnormal movement such as the coarse pill rolling tremor of Parkinsonism, the flapping tremor of encephalopathy due to hepatic failure, uraemic twitching in renal failure and the fine tremor thyrotoxicosis. Notice any abnormal movements such as tremor (in alcohol withdrawal, for example), dystonia (perhaps as a side effect of neuroleptic therapy) or chorea (jerky, involuntary movements, characteristic of Huntington’s disease).
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.(Pulmonary suppuration is defined as necrosis of the pulmonary parenchyma caused by microbial infection.)
fetor hepaticus: the stale, ‘mousy’ smell of the volatile
amine dimethylsulphide in patients with liver failure
• uraemic fetor: a fishy or ammoniacal smell on the breath in
uraemia
• foul-smelling belching in patients with gastric outlet
obstruction
• a faecal smell in patients with gastrocolic fistula.
What are the 13 Things to look for when examining the hands and one thing to look for all over the body
Go to notes to see pics of it
What is another name for Dupuytren contracture and what is Dupuytren contracture . Which part of the hand does it most often affect? How do you check for this sign?
Clawing of fingers is seen in which
nerve lEsions in which two diseases?
What causes ulnar nerve palsy
What is the ulnar nerve
What is Heberden’s and Bouchard’s nodes
What is arachnodactylyl and state three syndromes it can be seen in
State and explain the stages of clubbing
What does koilonychia look like and when is it seen,what sign is used to check for it
What is Hypertrophic osteoarthropathy
What test is used to check finger clubbing?(there are two other ways check McLeod pictures on clubbing)
What is Pitting of the nail and name three things it can be a sign of
What are Splinter hemorrhages? They’re a sign of what? And how do they occur
What is myotonic dystony
- The palm is pale (pallor) in anaemia.
- Palmar erythema-reddening on the thenar and hypothenar areas(The word “thenar” means fleshy mounds. … The thenar eminence is the fleshy mound at the base of the thumb. The hypothenar eminence is the mound located at the base of the fifth digit (little finger) )is seen in liver diseases.
3.Observe for Dupuytren’s contracture (palmar fibromatosis)– thickening and contraction of the tendons in the middle of the hand .
The condition most often affects the 4th (ring) and 5th (little) fingers. seen in patients with chronic liver disease. You can check for it by the being able to lay your hand flat on a table, palm down (called the tabletop test)
- Observe any wasting of the intrinsic muscles of the hand in nerve or muscle lesions.
- Observe any deformity of the hand. 6.Clawing of the fingers seen in ulnar nerve lesions(ulnar neuropathy or ulnar nerve palsy (When the nerve compressed in the elbow, a problem called cubital tunnel syndrome may result)
The ulnar nerve is the terminal branch of the medial cord of the brachial plexus and contains fibers from the C8 and T1 spinal nerve roots; i
7.Look for the presence of Heberden’s nodes – bony swelling of the distal inter-phalangeal joint (. the joint closest to the tip of your finger. )seen in osteoarthrosis and Bouchard’s node – fusiform swelling or proximal inter-phalangeal joint – seen in rheumatoid arthritis
Bony bumps on the finger joint closest to the fingernail are called Heberden’s nodes. Bony bumps on the middle joint of the finger are known as Bouchard’s nodes
- 8.Look for arachnodactyly – long spidery fingers seen in Marfan’s syndrome, Achard syndrome, the
MASS syndrome and kindred hereditary disorders of connective tissue - clubbing stages as already seen in the pic above
* No visible clubbing - Fluctuation (increased ballotability) and softening of the nail bed only. No visible changes of nails. Or increased sponginess of the nail bed or nail fold
* Mild clubbing - Loss of the normal <165° angle (Lovibond angle) between the nailbed and the fold (cuticula). Schamroth’s window (see below) is obliterated. Clubbing is not obvious at a glance. Or obliteration of the Lovibond angle
* Moderate clubbing - Increased convexity of the nail fold. Clubbing is apparent at a glance.
* Gross clubbing - Thickening of the whole distal (end part of the) finger (resembling a drumstick) or bulbous swelling of the distal ends of the finger
* Hypertrophic osteoarthropathy - Shiny aspect and striation of the nail and skin
*
* Hypertrophic osteoarthropathy (HOA) is a syndrome characterized by clubbing of the digits, periostitis of the long (tubular) bones(It is caused by inflammation of the periosteum, a layer of connective tissue that surrounds bone)., and arthritis
Schamroth’s sign or Schamroth’s window test
10.Note koilonychia (concavity of the nail) in iron deficiency anaemia (Spoon nails (koilonychia) are soft nails that look scooped out. The depression usually is large enough to hold a drop of liquid. Often, spoon nails are a sign of iron deficiency anemia or a liver condition known as hemochromatosis, in which your body absorbs too much iron from the food you eat. )
- pitting of the nail in psoriasis (Nail pitting is when you have tiny dents in your fingernails or toenails. It can be a sign of psoriasis, eczema, or joint inflammation. You might also get them if they run in your family )
- splinter haemorrhages in infective endocarditis .Splinter hemorrhages are tiny blood spots that appear underneath the nail. They look like splinters and occur when tiny blood vessels (capillaries) along the nail bed are damaged and burst. Could also be due to trauma
- 13.whitening of the nail (leuconychia) in hypoalbuminaemia. Leukonychia is a condition where white lines or dots appear on your finger or toenails
myotonic dystrophy (which is over-represented in candidate assessments) causes a patient to fail to release the handgrip (due to delayed muscle relaxation
Localized edema is another thing to look for all over the body
What 19 things are you looking for With regards to the mouth, what is seen in riboflavine deficiency
What is seen in angular stomatitis
What two things are needed for examination of the mouth
What are you supposed to inspect the teeth for?
Peridontitis can cause what ?
What is gum disease?
What is the characteristic of teeth in fluorosis and juvenile hypoparathyroidism
What happens to the gums in epileptics on phenytoin ?
When you see gingivitis In the mouth what two things can be causing it
What is cancrum oris
Which people are more susceptible to trench mouth
What is seen in scurvy,acute leukemia,chronic lead poisoning
When you see the fasciculations of the tongue what does it indicate
What is a lower motor neuron lesion
Name one major characteristic used to identify lower motor neuron lesion and upper motor neuron lesion
What is progressive bulbar palsy
When you see tongue wasting what does it indicate
When you see an enlarged tongue what does it indicate
State three inherited or congenital disorders associated w macroglossia and four acquired causes
What is geographical tongue?
What does it indicate
What does a smooth tongue Indicate
- Red denuded epithelium in the line of closure of the lips, known as cheilosis occurs in riboflavine deficiency.
- Angular stomatitis, consisting of painful inflamed cracks at the corners of the mouth is due to deficiency of iron or riboflavin deficiency,dry mouth. A torch and a tongue depressor are needed for examination of the mouth.
The Teeth
Inspect the teeth for 3. discolouration, 4.caries and missing teeth,5.(Periodontitis (per-e-o-don-TIE-tis), also called gum disease, is a serious gum infection that damages the soft tissue and, without treatment, can destroy the bone that supports your teeth. Periodontitis can cause teeth to loosen or lead to tooth loss. ).
6.The teeth may be pitted , mottled and yellow in colour in fluorosis and
7.poorly developed (hypoplastic) in juvenile hypoparathyroidism.
8.Gingivitis is common and may bleed. Hypertrophy of the gums occurs in epileptics who are on Phenytoin. Gingivitis occurs as a side effect of calcium channel blockers.
Painful ulcero-membranous gingivitis may be due to Vincent’s infection which is due to a combination of a spirochaete and a fusiform bacillus. This leads to cancrum oris.(Noma, or cancrum oris, is a fast-acting gangrene infection that destroys the mucus membranes of the oral and facial tissues. This causes trench mouth or acute necrotizing ulcerative gingivitis)
Smokers and immunocompromised people (they get foul breath)
9.Note the soft spongy haemorrhagic gums of scurvy,10.
the hypertrophied bleeding gums of acute leukaemia and 11.
the blue line(Burton’s line) in chronic lead poisoning.
12. The Tongue
1.Fasciculation of the tongue is seen in lower motor neurone disease (lower motor neuron lesion is a lesion which affects nerve fibers traveling from the lower motor neuron(s) in the anterior horn/anterior grey column of the spinal cord, or in the motor nuclei of the cranial nerves, to the relevant muscle(s)
One major characteristic used to identify a lower motor neuron lesion is flaccid paralysis – paralysis accompanied by loss of muscle tone. This is in contrast to an upper motor neuron lesion, which often presents with spastic paralysis – paralysis accompanied by severe hypertonia. )such as progressive bulbar palsy(Progressive bulbar palsy is a motor neuron disorder that involves the lower motor neurons. These neurons conduct messages from the brain stem and spinal cord to the brain. Initially, patients with progressive bulbar palsy only have muscle weakness that affects speech and swallowing. ),poliomyelitis,bell palsy,spinal muscular atrophy
13.Wasting of the tongue occurs with lesions of the hypoglossal (XII cranial nerve) and when the tongue is protruded forwards it deviates towards the affected side .
14.The tongue is enlarged in some cases of primary amyloidosis, in acromegaly and myxoedema, The tongue may protrude from the mouth. Inherited or congenital disorders associated with macroglossia include Down syndrome, Beckwith-Wiedemann syndrome, primary amyloidosis, and congenital hypothyroidism. Acquired causes may include trauma, cancer , endocrine disorders , and inflammatory or infectious diseases
15.surface of the Tongue
Variation in colour may be due to foods, particularly coloured sweets or they may be due to changes in the haemoglobin.
Central cyanosis is best assessed by inspecting the under surface of the tongue.
Fungiform papillae are small red flat elevations seen on the surface of the tongue especially at the tip and edges. Filiform papillae are situated in parallel rows across the tongue and they give rise to the fur. 16.Transient denuded islands give rise to the term ‘geographical tongue’. (Benign migratory glossitis)
17.Leukoplakia
18.Oral candidiasis
19.smooth tongue indicating iron or hemoglobin deficit
What is leukoplakia
What is the difference between leukoplakia and oral candidiasis
Continuation of things to look for in the mouth: name eight other things to look for apart from the 19 already mentioned
What comprises the posterior one third of the palate ?
What does an immobile soft palate indicate when the normal size moves up moving the uvula towards the normal side when the patient is asked to say ah
Tumours of the tonsils may occur either in isolation or as part of lymphatic leukaemia or lymphoma true or false
What is seen in the mouth w measles?
Pathological pigmentation of the mouth Indicates what four diseases?
What is Peutz-Jeghens syndrome ?
What does a persistent indolent ulcer in the mouth indicate?
What’s causes thrush
Thrush occurs in which two groups of people
Leukoplakia is characterized by grey opaque areas interspersed with few red inflamed patches. This lesion is precancerous.
Leuko:flat white lesions that cannot be brushed from the oral mucosa. Is potentially malignant and warrants biopsy
Oral:white plaque that easily brushes off w underlying erythema
Treated w anti fungals
The soft palate with the uvula comprise the posterior one third of the palate. 20.In lesion of the vagus (X cranial nerve) the soft palate on that side remains immobile while the normal size moves up, moving the uvula towards the normal side when the patient is asked to say ‘ah’.
21.Note any deformity such as cleft palate.
22.Look for enlarged and inflamed tonsils. The tonsils, in common with lymphoid tissue elsewhere enlarge to reach a maximum size between the ages 8-12 years after which it involutes.
23.
Inspect the buccal mucosa for Koplik’s spots – whitish areas like sprinkled salt on a reddish background, seen in measles ,Koplik spots are seen with measles. They are small, white spots (often on a reddened background) that occur on the inside of the cheeks early in the course of measles.
24.Pathological pigmentation of the mouth is seen in Addison’s disease. Other conditions giving pigmentation of the buccal mucosa are chronic cachexia, malabsorption syndrome, haemochromatosis or the rare Peutz-Jeghen’s syndrome of polyposis of the small intestine with pigmentation in and around the mouth and particularly on the lips and fingers.
25.Any indolent ulcer in the mouth for which an adequate explanation is not forthcoming and which persists should be suspicious of carcinoma.
26.
Thrush is seen as white deposits on the mucous membrane of part of the mouth. It is caused by the fungus – candida albicans. Thrush occurs in the elderly in association with febrile or debilitating diseases. Thrush is also common in patients being treated with antibiotics, prednisolone or immuno- suppressive drugs.
27. Hydration
Looking at the skin to make diagnosis,
What caused dark or pigmented or thick velvety patches in body folds and creases and what three things do these signs indicate
What is pyodenrma gangrenosum?
What are the signs of this condition ?
How’s it treated?
Temperature of a patients hand is a good guide to what
In which disease will hands be cyanosed and warm and why
In which disease will the hands be cyanosed and cold ? Why?
What does it mean if though usually cold it’s warm
1.pigmentation or darkening and thickening of the skin in the axilla (armpit,groin,) and flexures of the limbs a rare condition termed acanthosis nigricans (skin condition characterised by dark, velvety patches in body folds and creases.
Acanthosis nigricans typically occurs in people who are obese or have diabetes. More rarely, it can be a warning sign of a cancerous tumour in an internal organ, such as the stomach or liver. ) may be a marker of internal malignancy especially carcinoma of the stomach.
2. pallor,
3.yellowness,
4..cyanosis and
5. cutaneous eruptions.
6. Another example is pyodenrma gangrenosum. (So this lesion on the leg is associated w ulcerative colitis) This rare skin lesion is a classic example of a skin condition associated with internal disease.
The necrotic ulcers, most often on the legs are usually associated with ulcerative colitis. Pyoderma gangrenosum (pie-o-DUR-muh gang-ruh-NO-sum) is a rare condition that causes large, painful sores (ulcers) to develop on your skin, most often on your legs. The exact causes of pyoderma gangrenosum are unknown, but it appears to be a disorder of the immune system .Total proctocolectomy (proctocolectomy is the surgical removal of the colon and rectum. A colectomy is the surgical removal of the colon. ) almost always results in rapid healing.
temperature of the patient’s hand is a good guide to peripheral perfusion. In chronic obstructive pulmonary disease the hands may be cyanosed due to reduced arterial oxygen saturation but warm due to vasodilatation from elevated arterial carbon dioxide levels. In heart failure the hands are often cold and cyanosed because of vasoconstriction in response to a low cardiac output. If they are warm, heart failure may be due to a high-output state, such as hyperthyroidism.
What are you to do before you start a physical exam
Be sure to look for any venepuncture marks of intravenous drug use or linear (usually transverse) scars from recent or previous deliberate self-harm
True or false
Always introduce yourself to the patient, shake hands (which may provide diagnostic clues; Box 3.1 and see later) and seek permission to conduct the consultation. Make sure you have the relevant equipment available (Box 3.2) and that you have observed local hand hygiene policies (Fig. 3.1). As discussed on page 4, privacy is essential when assessing a patient. At the very least, ensure screens or curtains are fully closed around a ward bed; where possible, use a separate private room to avoid being overheard. Seek permission from the patient to proceed to examination, and offer a chaperone where appropriate to prevent misunderstandings and to provide support and encouragement for the patient. Regardless of whether the patient is the same
gender as the doctor or not, chaperones are always appropriate for intimate (breast, genital or rectal) examination. Chaperones are also advised if the patient is especially anxious or vulnerable, if there have been misunderstandings in the past, or if religious or cultural factors require a different approach to physical examination. Record the chaperone’s name and presence. If patients decline the offer, respect their wishes and record this in the notes. Tactfully invite relatives to leave the room before physical examination unless the patient is very apprehensive and requests that they stay. A parent or guardian should always be present when you examine children (p. 307).
The room should be warm and well lit; subtle abnormalities of complexion, such as mild jaundice, are easier to detect in natural light. The height of the examination couch or bed should be adjustable, with a step to enable patients to get up easily. An adjustable backrest is essential, particularly for breathless patients who cannot lie flat. It is usual practice to examine a recumbent patient from the right-hand side of the bed. Ensure the patient is comfortably positioned before commencing the physical examination.
Seek permission and sensitively, but adequately, expose the areas to be examined; cover the rest of the patient with a blanket or sheet to ensure that they do not become cold. Avoid unnecessary exposure and embarrassment; a patient may appreciate the opportunity to replace their top after examination of the chest before exposing the abdomen. Remain gentle towards the patient at all times, and be vigilant for aspects of the examination that may cause distress or discomfort. Acknowledge any anxiety or concerns raised by the patient during the consultation.
What are the two
Main causes of clubbing
Under acquired causes of clubbing,state four thoracic causes of clubbing,state three cardiovascular causes of clubbing and three GIt causes
Causes of clubbing
Congenital or familial (5–10%)
Acquired:
Thoracic (~70%) :
• Lung cancer
• Chronic suppurative conditions: pulmonary tuberculosis,
bronchiectasis, lung abscess, empyema, cystic fibrosis
• Mesothelioma
• Fibroma
• Pulmonary fibrosis
- Cardiovascular:
- Cyanotic congenital heart disease
- Infective endocarditis
- Arteriovenous shunts and aneurysms
- Gastrointestinal:
- Cirrhosis
- Inflammatory bowel disease
- Coeliac disease •
Others:
• Thyrotoxicosis (thyroid acropachy)
• Primary hypertrophic osteoarthropathy
State three ways pallor is assessed and what other ways apart from using the three ways can show iron deficiency anaemia and can be used to assess pallor
What causes peripheral and central cyanosis
llor
Pallor can result from anaemia, in which there is a reduction in circulating oxyhaemoglobin in the dermal and subconjunctival capillaries, or from vasoconstriction due to cold exposure or sympathetic activation. The best sites to assess for the pallor of anaemia are the conjunctiva (specifically the anterior rim; Fig. 3.15), the palmar skin creases and the face in general, although absence of pallor does not exclude anaemia. Nail-bed pallor lacks diagnostic value for predicting anaemia but is still often assessed by clinicians. In significant iron deficiency anaemia there may be additional findings of angular stomatitis, glossitis (Fig. 3.16), koilonychia (spoon-shaped nails) and blue sclerae.
Central cyanosis
Central cyanosis can be seen in the lips, tongue and buccal or sublingual mucosa (Fig. 3.18; see Fig. 5.12), and can accompany any disease (usually cardiac or respiratory) that results in hypoxia
sufficient to raise the capillary deoxyhaemoglobin concentration above 50 g/L (5 g/dL). Since the detection of cyanosis relies on the presence of an absolute concentration of deoxyhaemoglobin, it may be absent in anaemic or hypovolaemic patients despite the presence of hypoxia. Conversely, cyanosis may manifest at relatively mild levels of hypoxia in polycythaemic patients.
Peripheral cyanosis
Peripheral cyanosis is seen in the distal extremities and may simply be a result of cold exposure, when prolonged peripheral capillary flow allows greater oxygen extraction and hence increased levels of deoxyhaemoglobin. As the patient is warmed and the circulation improves, so does the cyanosis. Pathological causes of peripheral cyanosis include low cardiac output states, arterial disease and venous stasis or obstruction.
What is the BMI value for underweight,normal,overweight,obese,morbidly obese for non Asians and Asians
How is BMI calculated
State five diseases that obesity is associated w an increased risk
What are you to note w regards to obesity?
What is the waist circumference and how does it correlate w increased risk of what diseases
What is the waist to hip ratio for a pear shape or an apple shape and which has a better prognosis
Underweight : Non Asian < 18.5 Asian < 18.5 Normal:non Asian -18.5–24.9 Asian -18.5–22.9 Overweight 25–29.9 ,23–24.9 Obese 30–39.9 ,25–29.9 Morbidly obese ≥40 ,≥30
The body mass index (BMI; calculated from the formula weight(kg)/height(m)2) is more useful than weight alone, as it allows for differing height.
increased risk of malignancy, particularly oesophageal and renal cancer in both sexes, thyroid and colon cancer in men, and endometrial and gallbladder cancer in women, as well as hypertension, hyperlipidaemia, type 2 diabetes mellitus, gastro-oesophageal reflux, gallbladder disease, osteoarthritis and sleep apnoea.
Note the distribution of fat, since central obesity (as judged by the waist circumference: the maximum abdominal girth at the midpoint between the lower costal margin and the iliac crest) correlates with increased visceral adiposity and has worse health outcomes due to its association with hypertension, insulin resistance, type 2 diabetes mellitus and coronary artery disease.
Waist-to-hip ratio can also be a useful assessment of adipose distribution: gluteal–femoral obesity or the ‘pear shape’ (waist:hip ratio of ≤ 0.8 in females or < 0.9 in males) has a better prognosis, whereas ‘apple-shaped’ patients with a greater waist:hip ratio have an increased risk of coronary artery disease and the ‘metabolic syndrome’.
State two pathological causes of gigantism and three symptoms of Marfans syndrome
State three causes of localized edema and explain how they cause localized edema
include Marfan’s syndrome, prepubertal hypogonadism and gigantism. In Marfan’s syndrome the limbs are long in relation to the length of the trunk, and the arm span exceeds height (Fig. 3.21A). Additional features include long, slender fingers (arachnodactyly; Fig. 3.21B), narrow feet, a high-arched palate (Fig. 3.21C), upward dislocation of the lenses of the eyes (Fig. 3.21D), cardiovascular abnormalities such as mitral valve prolapse, and dilatation of the aortic root with aortic regurgitation.
Or Tall stature, with the torso shorter than the legs (note surgery for aortic dissection). B Long fingers. C High-arched palate. D Dislocation of the lens in the eye.
Localised oedema (an excess of interstitial fluid) is most commonly caused by venous disease but may also develop in lymphatic, inflammatory or allergic disorders .
Venous causes
Increased venous pressure raises hydrostatic pressure within capillaries, producing oedema in the area drained by that vein. Venous causes include deep vein thrombosis, external pressure from a tumour or pregnancy, or venous valvular incompetence from previous thrombosis or surgery (Fig. 3.22). Conditions that impair the normal muscle pumping action, such as hemiparesis and forced immobility, increase venous pressure by impairing venous return. As a result, oedema may occur in immobile, bed-ridden patients, in a paralysed limb, or in a healthy person sitting for long periods such as during travel
Lymphatic causes
Normally, interstitial fluid returns to the central circulation via the lymphatic system. Any obstruction to lymphatic flow may produce localised oedema (lymphoedema; Fig. 3.23). If the condition persists, fibrous tissue proliferates in the interstitial space and the affected area becomes hard and no longer pits on pressure. In the UK the most common cause of chronic leg lymphoedema is congenital hypoplasia of leg lymphatics (Milroy’s disease); in the arm, lymphoedema usually follows radical mastectomy and/ or irradiation for breast cancer. Lymphoedema is common in some tropical countries because of lymphatic obstruction by filarial worms (elephantiasis).
Inflammatory causes
Any cause of tissue inflammation, including infection or injury, liberates mediators such as histamine, bradykinin and cytokines, which cause vasodilatation and increase capillary permeability. Inflammatory oedema is accompanied by the other features of inflammation (redness, tenderness and warmth) and is therefore painful.
Allergic causes
Increased capillary permeability occurs in acute allergic conditions: for example, an insect bite in an allergic individual. The affected area is usually red and pruritic (itchy) because of local release of histamine and other inflammatory mediators but, in contrast to inflammation, is not painful.
Angio-oedema is a severe form of allergic oedema affecting the face, lips and mouth, most commonly caused by insect bites, food allergy or drug reactions (Fig. 3.24). Swelling may develop rapidly and become life-threatening if the upper airway is involved.
About lymph nodes in general exam
What is lymphadenopathy
What diseases can lymphadenopathy herald
What 16 things do you ask about when you notice a lump
How do you measure the size of a lump
Position
The source of some lumps may be obvious from position, such as in the breast, thyroid or parotid gland; in other sites, such as the abdomen, this is less clear. Multiple lumps may occur in neurofibromatosis (see Fig. 3.20), skin metastases, lipomatosis and lymphomas. True or false
What will cause a lump to feel fixed immobile
What can lymphatic obstruction cause?
This obstruction is common in which disease
Consistency of a lump can range from what to what?
Very hard swellings indicate what ?
Fluctuation indicates what?
What can the edges of the LuMp look like ?
The margins of which organs are defined more clearly that which organs or masses
Indefinite margin suggests what? Clearly defined edge suggests what?
Surface of a lump
May be what or what?
Surface of the liver is what in acute hepatitis and what in metastatic disease
What kind of swellings are pulsatile and expand in time w the arterial pulse
When will other swellings transmit pulsations? When will a systolic murmur be auscultâted ?
What will make a thrill palpable
When are bruits heard over arterial aneurysms and arteriovenous malformation?
Explain the inflammation part of examining a lump
How is a lump checked for trans illumination
What swelling will light up and why ?
Patients often present with a lump or enlarged lymph nodes (lymphadenopathy), which, while usually benign, can herald a serious underlying infective or malignant process. Alternatively, when examining a patient you may find a lump of which they were unaware.
Lumps Ask about the rapidity of onset of the lump and the presence of any associated pain, tenderness or colour change. Document the following features ; Features to note in any lump or swelling (SPACESPIT) • Size;Callipers • Position • Attachments • Consistency • Edge • Surface and shape • Pulsation, thrills and bruits • Inflammation: Redness Tenderness Warmth • Transillumination
Attachment
Malignant masses commonly infiltrate adjacent tissues, causing them to feel fixed and immobile.
Lymphatic obstruction may cause skin swelling with fine dimpling where the skin is tethered by hair follicles, giving it an ‘orange peel’ appearance (peau d’orange; see Fig. 11.5). This is common in malignant disease when attachment to deeper structures, such as underlying muscle, may also occur.
Consistency
The consistency of a lump can vary from soft to ‘stony’ hard. Very hard swellings are usually malignant, calcified or dense fibrous tissue. Fluctuation indicates the presence of fluid, as in an abscess, cyst or blister (Fig. 3.25), or in soft, encapsulated tumours, such as lipoma.
Edge
The margin may be well delineated or ill defined, regular or irregular, and sharp or rounded. The margins of enlarged organs, such as the thyroid gland, liver, spleen or kidney, can usually be defined more clearly than those of inflammatory or malignant masses. An indefinite margin suggests infiltrating malignancy, in contrast to the clearly defined edge of a benign tumour.
Surface and shape
The surface and shape of a swelling can be characteristic. In the abdomen, examples include an enlarged spleen or liver, a distended bladder or the uterine fundus in pregnancy. The surface may be smooth or irregular: for example, the surface of the liver is smooth in acute hepatitis but is often nodular in metastatic disease.
Pulsations, thrills and bruits Arterial swellings (aneurysms) and highly vascular tumours are pulsatile, expanding in time with the arterial pulse. Other swellings may transmit pulsation if they lie over a major blood vessel. If the blood flow through a lump is increased, a systolic murmur (bruit) may be auscultated; occasionally, with sufficient flow, a thrill may be palpable. Bruits are also heard over arterial aneurysms and arteriovenous malformations due to turbulent flow.
Inflammation
Redness, tenderness and warmth suggest inflammation:
• Redness (erythema): the skin over acute inflammatory
lesions is usually red due to vasodilatation. In haematomas the pigment from extravasated blood may produce the range of colours in a bruise (ecchymosis).
• Tenderness: inflammatory lumps such as boils or abscesses are usually tender or painful, while non-inflamed swellings such as lipomas, skin metastases and neurofibromas are characteristically painless.
• Warmth: inflammatory lumps and some tumours, especially if rapidly growing, may feel warm due to increased blood flow.
Transillumination
In a darkened room, press the lighted end of a pen torch on to one side of the swelling. A cystic swelling, such as a testicular hydrocoele, will light up if the fluid is translucent, providing the covering tissues are not too thick .
