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Clinical Skills: General Examination - Coggle Diagram
Clinical Skills: General Examination
List the aims of the General Examination
The General Examination aims to:
Asses the patients general condition
Detect manifestations of internal and systemic diseases
It consists of 3 components:
History taking - Clues are symptoms
Physical Exam - Clues are signs
Investigations - Clues are test results
What are the General Principles ?
Introduce yourself to the Patient
Obtain consent
Explain procedure to patient
Ensure privacy
Ensure patient comfort
ALWAYS start with a general examination
Directed by the history from the patient
Throughout you examination you must constantly ask yourself:
What am I looking for ?
What does the sign mean ?
What other evidence to corroborate this particular finding should I look for ?
Then move on to System Based Examination.
List the Prerequisites of an Examination
Prerequisites of an examination:
W - Wash your Hands
I - Introduce yourself to the patient
P - Permission: Explain and Obtain Consent. Asses for pain
E - Expose ONLY the necessary parts
R - Reposition patient so comfortable
ALWAYS ENSURE:
A safe and conducive examination environment for yourself and patient
Proper light
Privacy and confidentiality
Presence of chaperone when examining female patients
Correct Position of Doctor and Patient: Ideally the examiner should be on the right side of the patient
That your hands are warm to make examinations as comfortable for the patient
General Examination
What is the Purpose of a General Examination ?
To confirm an overall state of health: Gathering clinic data which are baseline values for vital signs
To diagnose medical problem
It usually focuses on an organ system based on the patient's chief complaint
To confirm an overall state of health of a patient
Clinical Diagnosis
Based on signs and symptoms of a disease
Looking for symptoms: This is is subjective information from the patient
Looking for signs: This is subjective information that can be detected
To perform diagnostic tests to be analyzed in a laboratory
To confirm clinical diagnosis
It also supports to form differential diagnosis and developing a prognosis
To assist the clinician in formulating a treatment plan and/or drug therapy.
Starting the General Examination
How do we start a general examination ?
Environmental Inspection: The Bedside
We ALWAYS start our general examination by looking at the patient's surrounding.
This may provide useful information even before you use your stethoscope.
Outline the cues we look for that may provide essential information regarding a patient's surrounding
Is the patient using Oxygen ?
If yes: How much ?
By what Method: Nasal Cannula, Oxygen Mask, CPAP (Continuous Positive Airway Pressure), Intubated & Ventilated
Does the patient require specific continuous vital signs monitoring ?
Is the patient receiving any Intravenous (IV) fluid ? Blood transfusion/ medications/ other transfusion
Does the patient have a Nasogastric Tube in Situ ?
This may indicate difficulty in feeding, an obstruction in the Mouth, Oesophagus or a Neurological or GIT condition
Are there any visible:
Urinary Aids: Catheter, Bed Pan, Urine Bottle
Medication: Inhalers, Nebulizer
Sputum Pot: To inspect Sputum
Mobility Aids: Wheelchair, Tripods, Crutches
What is the position of the Bed ?
This may provide indicators on breathing difficulties.
Any clue on about the patient's lifestyle and support systems
Eg; Cigarettes at bedside, flowers, book, Religion
End of the Bed
What First Impressions and General Appearances do we inspect ?
Vital Signs
Inspect Temperature, Pulse Rate and Respiratory Rate ( any change since day of admission)
Severity of illness, Distress, Dehydration
Recognise the type of distress: Pain, Coughing or Dyspnea
Mental State
Is the patient orientated, lethargic, drowsy, comatose, anxious, irritable, depressed
Natural State/Physique
Is the patient Thin/Obese, Muscular, Fit/Unfit
What is the Weight, Height, Proportion, or any obvious deformities ?
Evidence of weight loss, Cachexia ?
Note the Height, Weight, Proportions or any Obvious deformities
Face
Does the patient appear to be Flushed, Pallor, Puffy or Hirsute ?
General colour of the Skin and Mucosae
Do you recognise any Pallor, Pigmentation or Jaundice
Cyanosis
What is the colour of the Lips, Nails and Mucosae
Skin
Any Sweating, Rashes, Loss of Elasticity or Subcutaneous Fat, Nodules, Spider Naevi, Purpura
Oedema
Do you notice any Dependent Oedema: Legs, Lumbosacral, Periorbital, Abdominal and Ascites
Do you notice any Generalised (Anasacra) Oedema
Cyanosis
What is Cyanosis ?
Cyanosis occurs due to an increase in reduced Haemoglobin.
This may be masked in Severe Anaemia
List the 2 types of Cyanosis
Central Cyanosis
Peripheral Cyanosis
Outline Central Cyanosis
Evidence by a decreased SaO2 (Arterial Oxygen Saturation)
It is mostly seen in patients with Cardiac and Respiratory Pathology
List the Specific Areas to Assess for Central Cyanosis Sign
Specific Areas to assess for this sign by examining:
Tongue
Inner aspect of the Lips
Gums
Soft Palate
Buccal Mucosa
Peripheral Cyanosis: What are the causes of Peripheral Cyanosis ?
Peripheral Cyanosis may be due to:
Exposure to cold
Poor Cardiac Output
Arterial Obstruction
Venous Obstruction
List the Specific Areas to Assess for Peripheral Cyanosis Sign
Specific Areas to assess for this sign by examining:
Nose Tip
Ear Lobes
Nail Bed
Extremities (Black Finger Tips)
Breathing
What do we asses for in Breathing ?
We asses for:
Cyanosis
Respiratory Rate: 1 Inspiration and 1 Expiration
The use of Accessory Muscles: Neck, Shoulder Muscles used to assist breathing, Tripod Stance (hands on Knees)
Pursed Lip Breathing (COPD)
Respiratory Disease: Chronic Obstructive Airways Disease (COPD), Severe Asthma, TB, Pneumonia
Hands
Shakes hands if it is culturally appropriate or take hand to inspect and assess pulse
When Inspecting the Hand, What do we Asses for ?
Temperature
Cold or Clammy Skin may be a sign of:
Low Cardiac Output
Peripheral Vascular Disease
Peripheral Vasoconstriction
Hot or Sweaty Skin may be due to:
Thyrotoxicosis/ Nervousness
Skin Condition
Eczema, Psoriasis, Dermatitis
Colour
Cyanosis may be a sign of Respiratory and Cardiac Pathology
Reynard's Disease
Palmar Erythema may be a sign of Liver disease or seen in Pregnancy
Palmar Pallor may be a sign of Anaemia
Nicotine Staining: Commonly seen in smokers
What do we pay close attention to when Assessing the Hands ?
Pay close attention when Assessing the hands for the following:
Posture, Muscle Wasting and Shape
This may be affected in patients who may have had a Stroke, Nerve Injury, or with an Endocrine Disorder
Size of Hands
Size of Hands may be affected by:
Endocrine Disorders (Acromegaly)
Occupation (Hypertrophy)
Joint Deformity
Joint Deformity may lead to or be due to Arthritis
Lumps, Lesions or Rashes
May be due to Psoriasis or Tendon Xanthoma
Clubbing
What do we pay close attention to when Assessing the Nails ?
Pay close attention when assessing the Nails for the following:
Clubbing of the nails due to:
Familial
Cardiac Pathology: Bacterial Endocarditis, Congenital Cyanotic Heart Disease
Respiratory Pathology: TB and Bronchiectasis
Gastrointestinal (GIT) Pathology: Irritable Bowel Diseases(IBD), Liver Cirrhosis
Colour
White: Leukonychia (Hypalbuminemia)
Nicotine Staining
Splinter Haemorrhages due to Bacterial Endocarditis
Shape
Koilonychias: Spoon shaped due to Iron Deficiency
Onycholysis due to trauma, fungal infection, psoriasis, hyperthyroidism
Beau's Lines: arrested nail growth due to severe illness.
What do we pay close attention to when Assessing the Skin ?
Pay close Attention when Assessing the Skin for the Following:
Colour:
Jaundice/ Carotenaemia
Peripheral Cyanosis
Pallor
Erythema/Plethora
Hyperpigmentation
Texture: Course, Thin or Dry
Temperature: Cool, Warm, Clammy
Bruising: may be an indication of Clotting Disorder, Liver Failure, Sepsis or Anticoagulants
Discolouration or Rashes
Scratch Marks (due to Pruritus) may indicate Renal Failure, Cholestatic Jaundice, Iron Deficiency
Tracking: Indicates IV Drug Use
What do we pay close attention to when Assessing the Hair ?
Pay Close attention when Assessing the Hair for the following:
Distribution
Asses for Baldness/ Patchy Loss of Hair which may indicate Hypothyroidism, Malnutrition or an Autoimmune Disease
Female Facial Hair
This sign may be assessed in Females with Polycystic Ovarian Syndrome (PCOS)
Condition of the Hair
Is the Hair Sparse ? (normally seen in patients with Thyroid Pathology)
Colour
The colour of the hair may change due to a nutritional deficiency.
Lesions
Lesions may be due to Infection, Seborrheic Dermatitis, Psoriasis (Scalp)
What do we pay close attention to when Assessing the Face ?
Pay Close Attention when Assessing the Face to the Following:
Recognizable Syndromes
Trisomy 21 (Down's Syndrome)
Foetal Alcohol Syndrome (FAS)
Rashes
Systemic Lupus Erythematous(SLE)/ Mitral Stenosis - Malar Rash
Eczema
Infections
Facial Swelling
Protein Deficiency
Allergy
Nephrotic Syndrome (Preorbital Oedema)
What do we pay close attention to when Assessing the Eyes ?
Pay close attention when Assessing the Eyes for the Following:
Ptosis (Droopy Eyelids)
Corneal Arcus (Hyperlipidaemia)
Xanthelasma (Hyperlipidaemia)
Jaundice (Liver Disease, Haemolysis)
Haemorrhages (Hypertension and Infection)
Conjunctival Pallor (Anaemia)
Exophthalmos or Lid Lag (Hyperthyroid)
What do we pay close attention to when Assessing the Mouth ?
Pay close Attention when Assessing the Mouth to the following:
Appearance
Drooping/ Weakness due to Bell's Palsy, Stroke
Central Cyanosis: Lips/ Tongue Hypoxia, Palate, Frenulum
Pallor of Gums due to Anaemia
Infection
Herpes Simplex / Candidiasis
Angular Stomatitis (On mouth corners)
Caused by B12, Folate, Iron Deficiency or Candida Infection
Glossitis due to Vitamin B12, B3, B2, B6 Deficiency and Iron Deficiency
Dental Caries
Predisposes Bacterial Endocarditis
Lesions
Kaposi's Sarcoma
Oral Hairy Leukoplakia due to Immunocompromised - White Tongue
Oral Cavity
How do we examine the Oral cavity ?
You will need a penlight torch for this examination.
You will inspect the following structures:
Palate for Jaundice, Central Cyanosis and Lesions
Buccal Mucosae for Ulcer, Infections and Leukoplakia
Inspect the teeth for Dental Caries
Inspect the gums for Colour (Paleness/Pallor) or Hypertrophy
Inspect for Jaundice, Cyanosis and the presence of Lesions on the floor of the mouth
Ask the patient to stick their tongue out to inspect for tongue Lesions and Neurological function
Ask the patient to say "AH" to examine the Soft Palate and Tonsils
What do we pay close attention to when Assessing the Neck ?
Pay close attention when Assessing the Neck for the following:
Lymph Nodes found in the Head, Neck, Supraclavicular (Virchow)
Localised Lymph Nodes due to Infection in the Head and Neck
Systemic Lymph Nodes due to HIV, TB, Lymphoma
Thyroid Gland
Thyrotoxicosis due to Hyperthyroidism
Myxedema due to Hypothyroidism
What do we pay close attention to when Assessing the Feet ?
Pay close attention when Assessing the Feet for the following:
Colour, Temperature and Skin Changes
Cyanosis/ Ulceration (Peripheral Vascular Disease, Diabetes)
Varicose Eczema
Eczema, behind the Popliteal Fossa
Psoriasis of the Knee
Xanthomata due to Hyperlipidaemia
Erythema Nodosum due to Irritable Bowel Disease (IBD) or TB
Oedema
Unilateral or Bilateral
Pitting or Non-Pitting
Joints
Arthritis or Gout
Clubbing