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General Examination - Coggle Diagram
General Examination
First Impression
Diagnosis at first sight:
- Able to walk self?
- Appear distressed/ill?
- Recognizable Syndrome/Facies?
- Well nourished & Hydrated?
TTV: BP, HR, RR, Temp, O2, Pain level
Consciousness check using
Examination Preparation:
- Salam
- Penjelasan tindakan
- Verbal informed consent
- Privacy & Ask if need companion
- Bed covered by clean sheet
- Check complete equipment
- Patient Position
Color
Pallor --> Anemia, Shock, Vascular Disease Inspect:
- Palpebra conjunctiva
- Nail bed
- Palmar skin creases
- Central Cyanosis: COPD, Pulmo embolus, Cardiac shunts, Polycythemia, Hemoglobinopathies Pasti Central ada Peripheral juga)
- Peripheral Cyanosis: Only in extremities due to Cold / Reduced CO / Peripheral vascular dx
Jaundice (Plasma bilirubin >35umol/L)
- Differentiate from Carotenemia (Sclera remain white)
Other Abn. Coloration:
- Argyria = Silver-gray due to Silver poisoning
- Hyperpigmented skin fold in Addison's dx
- Vitiligo
Temperature
High temp: --> Persistent? Intermittent? Relapsing? with Rigors?
- Malignent hyperthermia
- Drug fever (Halothane Anesthesis gas, succinylcholine)
- Pyogenic Infection such as TB miliary
- Typhoid fever
- Hodgkin's dx
- Biliary sepsis
- Pyelonephritis
Hypothermia:
- Cold (Near-drowning)
- Secondary to impaired consciousness due to alcohol / drug overdose
- Elderly due to Myxedema
Hydration
Examine:
- Sign of sepsis / bleeding / vomiting?
- Sunken orbits
- Dry tongue
- Forearm skin turgor (Except elderly)
- CRT, HR, BP & JVP
- Ankle & Sakral Edema --> Fluid overload due to HF, Hypoalbuminemia, Nephrotic synd)
- Urinary catheter bag
Leg swelling
Local causes:
- Cellulitis (Unilat)
- Ruptured baker's cyst (Unilat)
- DVT / Thrombophlebitis
Systemic causes:
- CHF
- Hypoproteinemia (Nefrotic synd, Liver cirrhosis, Kwashiorkor)
- Hypo-/Hyper-thyroidism
- Drugs (CS, NSAID, Vasodilator)
Lymphedema = Non-pitting edema with thickened indurated skin due to lymphatic obstruction post surgery, metastatic cancer or chronic inf
Nutritional status
Malnutrition causes:
- Malignancy
- Metabolic disease (Rennal failure(
- GI disease
- Sepsis & Trauma
- Psychosocial problems & Dementia
Obesity causes:
- Simple obesity (Biopsychosocial)
- Genetic
- Endocrine (Cushing & Hypothyroid)
- Drug induced (CS)
- Hypothalamic damagte
Lymph node
Generalized lymphadenopathy are often accompanied with Liver and Spleen enlargement
- Head & Neck
- Axilla
- Inguinal
- Epitrochlear nodes
- Popliteal
Make diagram consist of:
- Site
- Number
- Size
- Consistency - Firm / hard and irregular r usu malignant but if rubbery r usu infection
- Tenderness - Painful nodes r usu inf
- Fixation - Fixed nodes r usu malignant
- Overlying skin - Red or Swelling skin r usu inflamationbut if edema and texture change usu malignant
Causes of generalized lymphadenopathy
- Hematological malignancies (Lymphoma, Leukemia)
- Infection (HIV, CMV, TB, Syphilis, Brucellosis)
- Infiltrative dx (Sarcoidosis, Amyloidosis)
- AI (SLE, RA)
- Drugs (Phenytoin)
Hands
Inspect:
- Skin color: Palmar erythema, vasculitis,digital ischemia, purpura)
- Discrete lesions
- Muscle wasting or fasciculation
- Joints and bony deformities in DIP, PIP and MCP
- Nails
Palpate tenderness at Snuff box --> +ve = scaphoid damage
Finger joint deformities:
- Swan neck
- Boutounniere
- z-shaped thumb
- Ulnar deviation
- Wrist subluxation
- Heberden's nodes
(due to osteophytes)
- Bouchard's nodes
(due to osteophytes)
- Dupuytren's contracture
Important nail / fingertip signs:
- Leukonychia (White spots due to Hypoalbuminemia of chronic liver dx)
- Koilonychia (Spoon nail due to ADB)
- Muehrcke's lines (White horizontal lines due to Hypoalbuminemia)
- Blue lanulae (Wilson's dx / Hematom / Argyria)
- Xanthomata (Firm waxy papules / bumps due to excess lipid)
- Osler's nodes VS Janeway lesions
- Splinter hemorrhages (Due to Endocarditis)
- Nail Pitting (Due to Psoriasis)
- Onycholysis (Kuku copot krn trauma)
- Beau's lines (Horizontal grooves due to injury / infeksi / DM)
- Paronychia (Cantengan / Inflamasi kuku akibat trauma/inf)
- Onichomycosis (Inf. jamur)
- Clubbing = Schamroth's sign due to chronic interstitial lung disease or inf, cystic fibrosis, congenital cyanotic heart disease, infective endocarditis, liver cirrhosis, IBD
Movement:
- Open and close hand quickly --> Myotonic dystrophy
- Wrist extension & Flexion using Prayer and Reverse prayer sign
- Finger Flexion and Extension by making fist and open
- Dorsal interossei / Fingers abduction
- Palmar interossei / OK sign each finger
- Abductor pollicis brevis / Thumb facing upward resist backforce
- Opponen pollicis / Thumb and Little finger making O
- Sensation: Light touch, pin prick, vibration and joint position sense
- Pulses: Radial & Ulnar pulses
- Elbows: Rheumatoid nodules? Psoriatic plaques? Xanthomata?
- Function: Writing, pour glass of water, buka tutup kancing, picking up coin
- Allan's test to examine hand perfusion
Other hand signs:
- Tinel's sign = Tingling sensation in the distribution of percussed nerve and indicate Carpal tunnel synd
- Froment's sign = Grasp a paper using thumb
- Finkelstein's test = De quervain's tenosynovitis
Recognizable syndromes:
- Down synd (Trisomy 21)
- Turner synd (45 X0)
- Marfan synd
- Tuberous sclerosis
- Neurofibromatosis type 1
- Peutz-jegher synd
- Oculocutaneous albinism
- Myotonic dystrophy
- Parkinson's disease
- Osler-weber-rendu synd
- Systemic sclerosis / CREST synd