General physical examination

Question 1

Introductions

Answer 1

Wash hands.
Introduce yourself: name and role.
Patient details: check name and DOB.
Explain the examination and get consent.
Exposure: state the ideal and ask if the patient needs help undressing.
Reposition: for most examinations this is 45 degrees; for abdo, patient should be lying flat.
Chaperone: the examiner will be acting as your chaperone for the purposes of this examination.
Pain: is the patient in any pain?
Stop: we can stop the examination at any point you feel uncomfortable.

Question 2

The examination framework

Answer 2

Inspection
Palpation
Percussion
Auscultation

Question 3

Inspection from the end of the bed

Answer 3

Is the patient comfortable or distressed?
Is the patient well or ill?
Is there a recognisable syndrome or facies?
Is the patient well nourished and hydrated?
Bedside clues: oxygen tubing, inhalers, GTN spray, insulin injections, glucose meter, cigarettes.
Vital signs: temperature, BP, pulse, oxygen sats, respiratory rate, blood glucose.
Conscious level: AVPU or GCS.

Question 4

Inspection: colour

Answer 4

Pallor: facial pallor suggests severe anaemia, e.g. conjunctival pallor, nail beds and palmar skin creases.
Cyanosis: central (tongue - in lung disease with V/Q mismatch, e.g. COPD ± cor pulmonate and massive pulmonary embolus; R-L cardiac shunts; polycythaemia and haemoglobinopathies) or peripheral (decreased blood supply or slowing of peripheral circulation; exposure to cold, reduced cardiac output, or peripheral vascular disease).
Jaundice: due to raised plasma bilirubin.

Question 5

Inspection: local causes of leg swelling

Answer 5

Cellulitis (usually unilateral).
Ruptured Baker’s cyst (usually unilateral).
Occlusion of a large vein (i.e. thrombophlebitis, DVT, extrinsic venous compression).
Chronic venous insufficiency (pigmentation induration, inflammation, lipodermatosclerosis).
Lipomatosis.
Gastrocnemius rupture (swelling and bruising around the ankle joint and foot).

Question 6

Inspection: systemic causes of leg swelling

Answer 6

Congestive cardiac failure.
Hypoproteinaemia (nephrotic syndrome, liver cirrhosis, protein-losing enteropathy, kwashiorkor).
Hypothyroidism.
Hyperthyroidism.
Drugs (e.g. corticosteroids, NSAIDs, vasodilators).

Question 7

Inspection: lymphoedema as a cause of leg swelling

Answer 7

Non-pitting oedema associated with thickened and indurated skin.
Idiopathic or secondary to proximal lymphatic obstruction, e.g. post-surgery, metastatic cancer, or chronic infection.

Question 8

Inspection: causes of generalised lymphadenopathy.

Answer 8

Haematological malignancies (e.g. lymphoma, acute and chronic lymphatic leukaemia).
Viral infections (e.g. HIV, infectious mononucleosis, CMV).
Bacterial infections (e.g. TB, syphilis, brucellosis).
Infiltrative diseases (e.g. sarcoidosis, amyloidosis).
Autoimmune disease (e.g. SLE, rheumatoid arthritis).
Drugs (e.g. phenytoin causes a 'pseudolymphoma'.