OHCEPS - General Examination Flashcards
From the moment you set eyes on the patient, what questions should be asked?
- Is the patient comfortable or distressed?
- Is the patient well or ill?
- Is there a recognizable syndrome or facies?
- Is the patient well nourished and hydrated?
Mention some examples about bed-side clues regarding patient’s state.
- Oxygen tubing
- Inhalers
- GTN spray
- Insulin injections
- Glucose meter
- Cigarettes
What are the vital signs?
- Temperature
- BP
- Pulse
- Oxygen sat
- Respiratory rate
- Blood glucose
What must be done BEFORE the beginning of the physical exam?
- Ensure that the patient has adequate privacy to undress.
- Make sure that you will not be disturbed.
- Check that the examination couch or bed is draped/covered by a clean sheet or disposable towelling.
- If the patient is accompanied, ask them if they would like their companion to stay in the room.
- Check that any equipment you will require is available (torch, cotton wool, tendon hammer, stethoscope etc.)
- When ready, the patient should ideally be positioned supine with the head and shoulders raised to -45degrees.
What should we look regarding color?
- Pallor
- Central or peripheral cyanosis
- Jaundice
- Abnormal skin pigmentation
Of what is facial pallor often a sign?
SEVERE anemia –> Inspecting the palpebral conjunctiva - nail beds - and palmar skin creases.
Is pallor of the palpebral conjunctiva a reliable sign?
Not always - Not in:
- Shocked patients
- Those with vascular disease
- -> Peripheral vasoconstriction or poor blood flow causes skin and conjunctival pallor, even in the absence of blood loss.
What is the amount of deoxygenated Hb for cyanosis to occur?
At least 2.5g/dL.
Central cyanosis can occur with what conditions?
- Lung disease with V/Q mismatch –> COPD +/- cor pulmonale + massive pulmonary embolus.
- Polycythemia
- Hemoglobinopathies (methemoglobinemia, sulphemoglobinemia)
When is jaundiced best appreciated?
In fair-skinned individuals in natural sunlight.
With what should jaundice NOT be confused?
Carotenemia –> Yellow discoloration of the skin, but the sclera remain white.
Mention other distinctive color patterns.
- Classic slate-grey –> hemochromatosis.
- Silver-grey –> argyra (silver poisoning)
- Incr. skin-fold pigmentation –> Addison
- Non-pigmented patches –> Vitiligo
What is the diurnal variation of temperature?
Peak –> 6-10pm
Lowest –> 2-4am
Persistent pyrexia may be a sign of what?
- Malignant hyperthermia
- Drug fever (halothane, suxathonium)
- Typhus
- Typhoid fever
Intermittent pyrexia may be a sign of what?
- Lymphomas
2. Pyogenic infections such as milliary TB.
A relapsing high temperature or Pel-Ebstein fever is usually indicative of what?
Hodgkin disease –> 4-5days of persistent fever which then returns to baseline before rising again.
Fever with rigors (uncontrollable shaking) may accompany what?
- Biliary sepsis
2. Pyelonephritis
What is hypothermia?
Core (rectal) temperature of <35C.
Occurs usually from cold exposure (e.g. near drowning) or secondary to an impaired level of consciousness (e.g. following excess alcohol or drug OD), or in the elderly (myxedema).
What are the signs of patients with hypothermia?
- Pale
- Cold, waxy skin
- Stiff muscles
- Consciousness often reduced
At what temperature level do patients typically lose consciousness?
<27C.
Mention some conditions that may result in dehydration?
- Sepsis
- Bleeding
- Bowel obstruction
- Vomiting
Beginning the examination for dehydration, what should be inspected?
- Any obvious clues –> Fluid restriction signs, catheter bag, nutritional supplements.
- Sunken orbits (sign of moderate-severe dehydration).
What are the main sites that should be inspected during examination for hydration?
- Mucous membranes
- Skin turgor
- Capillary refill
- Pulse rate
- BP
- JVP
- Edema
Is skin turgor reliable in elderly patients?
NO - The skin may have lost its normal elasticity.
How is capillary refill tested?
Raise the patient’s thumb to the level of the heart, pressing hard on the pulp for 5 sec and then releasing.
Measure the time taken for the normal pink color to return.
Normal capillary refill time should be Prolongation is indicative of poor blood supply to the peripheries.
What is one of the most sensitive ways of judging intravascular volume?
Assessing the height of the JVP.
Low –> Dehydration
High –> Fluid overload (pulmonary edema)
How do we examine for edema?
Palpate the distal shaft of the tibia for edema by gently compressing the area for up to 10 sec with the thumb.
–> If edema is present, note its upper level. Edema may also involve the anterior abdominal wall and external genitalia.
When lying down, what happens to edema?
Fluid moves to the new dependent area causing a sacral pad.
–> This can be checked for by asking the patient to sit forwards, exposing the lower back and sacral region, and again applying gentle pressure with your finger-tips.
Mention some local causes of leg swelling.
- Cellulitis (usually unilateral)
- Ruptured baker’s cyst (usually unilateral)
- Occlusion of a large vein –> DVT, thrombophlebitis, extrinsic venous compression.
- Chronic venous insufficiency - pigmentation induration, inflammation, lipodermatosclerosis.
- Lipomatosis
- Gastrocnemius rupture - swelling and bruising around the ankle joint and foot.
Mention some systemic causes of leg swelling.
- CHF
- Hypoproteinemia (nephrotic syndrome, liver cirrhosis, protein-losing enteropathy, kwashiorkor).
- Hypothyroidism
- Hyperthyroidism
- Drugs (corticosteroids, NSAIDs, vasodilators)
Mention some conditions associated with malnutrition.
- Any very ill patient
- Malignancy
- Metabolic disease (renal failure)
- GI disease (especially small bowel)
- Sepsis
- Trauma
- Post-surgery
- Psychosocial problems (depression, anorexia nervosa, social isolation)
- Dementia
Mention some conditions associated with obesity.
- Simple obesity (psychosocial)
- Genetic - Prader-Willi, Lawrence-Moon-Biedl syndrome.
- Endocrine - Cushing, hypothyroidism.
- Drug-induced –> Corticosteroids.
- Hypothalamic damage due to tumor or trauma.
What must be done during palpation of the head-neck lymph nodes?
Nodes should be examined with the patient in an upright position and the examiner standing behind - similar to the examination of the thyroid gland.
What must done for the examination of the nodes in axillae?
RIGHT axilla examination:
- Patient should be sitting comfortably and you should stand at the right-hand side.
- Support their right arm abducted to 90degrees with your right hand.
- Examine the axilla with your LEFT hand.
How do we examine the inguinal nodes?
- Patient supine –> Palpate their inguinal region along the inguinal ligament –> Same position as for hernia or femoral pulse.
- There are 2 chains of superficial inguinal nodes –> Horizontal + Vertical.
How do we examine the epitrochlear nodes?
Place the palm of the right hand under the patient’s slightly flexed right elbow and feel with your fingers in the groove above and posterior to the medial epicondyle of the humerus.
How do we examine the popliteal nodes?
Best examined by passively flexing the knee and exploring the fossa with the fingers of both hands - much like feeling for the popliteal pulse.
During palpations of lymph nodes, what features should be assessed?
- Site
- Number
- Size
- Consistency
- Tenderness
- Fixation
- Overlying skin
Mention some causes of generalized lymphadenopathy.
- Hematological malignancies (lymphoma, acute/chronic lymphatic leukemias)
- Infections –> Viral (HIV, IM, CMV)
- Bacterial (TB, syphilis, brucellosis)
- Infiltrative diseases (sarcoidosis, amyloidosis)
- Autoimmune diseases (SLE, RA)
- Drugs (phenytoin causes a “pseudolymphoma”)
Mention the groups of cervical and supraclavicular lymph nodes?
- Supraclavicular
- Posterior triangle
- Jugular chain
- Preauricular
- Postauricular
- Submandibular
- Submental
- Occipital
Mention the group of the axillary lymph nodes.
- Lateral
- Pectoral
- Central
- Subscapular
- Infraclavicular
Examination of the dorsum and palm of the hand may give what diagnoses?
- RA
- Systemic sclerosis
- Psoriasis
- Ulnar nerve palsy
What should be kept in mind regarding skin color of the hand?
- Palmar erythema
- Vasculitis
- Digital ischemia
- Purpura
- Consistency of the skin
- -> Note that pathological palmar erythema can also be found on the thenar and hypothenar eminences and also continues along the digits.
What are the main sites that should be inspected during examination of the hand?
- Dorsum/Palm
- Skin color
- Discrete lesions
- Muscles –> Wasting or fasciculation.
- Joints –> DIP, PIP, MCP, wrist.
- Bony deformities
- Nails