GENERAL EXAMINATION

This will help examination in acute and chronic cases.

Necessary step for acute and chronic case management.
The History and Physical in Perspective
70% of diagnoses can be made based on
history alone.
90% of diagnoses can be made based on
history and physical exam.
Expensive tests often confirm what is
found during the history and physical
examination.
PURPOSE OF GENERAL PHYSICAL
EXAMINATION

To confirm overall state of health.

To diagnose medical problem (clinical diagnosis).
To help focus on the types of investigations needed.
To formulate treatment plan/ drug therapy.
 Equipment for physical examination
Optional
Required
Thermometer,
Gloves,
Stethoscope,
Gauze pads and cotton,
Tongue blades/
Lubricant gel, depressor, Penlight,
Tape measure,
Nasal speculum,
Sphygmomanometer,
Tuning fork: 128 Hz,512Hz,
Reflex
Pockethammer,
visual acuity card,
Safety pins
Oto-ophthalmoscope.
 ROLE OF MEDICAL ASSISTANT
ADMINISTRATIVE DUTIES CLINICAL DUTIES
Using computer applications. Taking medical histories.
Greeting patients. Preparing patients for
Updating and filing patient examination.
medical records. Assisting the physician during
Scheduling appointments. examination.
Arranging for hospital Instructing patients about
admissions and laboratory medication and special diets
services. as advised by the physician.
Handling correspondence, Preparing and administering
billing, and bookkeeping. medications as directed by a
physician.
 Important aspects of physical
examination----physician
Elegant appearance
Decent manner
Kind attitude
Highly responsibility
Good medical morals
 Important aspects of physical
examination---physician
Wash your hands, preferably
while the patient is watching

Washing with soap and

water is an effective way to
reduce the transmission of
disease
 How to perform the physical examination?

Exposing only the area that

are being examined.
Offer a chaperone for both
sexes.
Explain what you're going to
do.
Sequentia (forming or
following in a logical order or
sequence).
Important aspects of physical examination
The examiner should continue
speaking to the patient

Showing care to his disease and

answer to patient’s questions

It can not only release patient’s

nervousness, but also help to
establish the good physician-
patient relationship
 Gloves should be worn when..
Examining any individual
with exudative lesions or
weeping dermatitis
When handling blood-soiled
or body fluid-soiled sheets or
clothing
 General principles of exam

Good light.
Relaxed patient.
Full exposure of area.
 General principles of exam
Have the patient empty their
bladder before examination
Have the patient lie in a
comfortable, flat, supine
position
Have them keep their arms at
their sides or folded on the
chest
 General principles of exam
Before the exam, ask the
patient to identify painful areas
so that you can examine those
areas last
During the exam pay attention
to their facial expression to
assess for sign of discomfort
 General principles of exam
Use warm hand, warm
stethoscope, and have short
finger nails.
Approach the patient slowly
and deliberately explaining
what you will be doing.
 General principles of exam

 Stand right side of the bed.

 Exam with right hand.
Head just a little elevated.
Ask the patient to keep the
mouth partially open and
breathe gently.
 General principles of exam

If muscles remain
tense, patient may
be asked to rest
feet on table with
hips and knees
flexed.
Other helpful points on examination

Take a spare bed

sheet and drape it
over their lower body
such that it just
covers the upper
edge of their
underwear.
 General principles of exam
If the patient is ticklish or
frightened-
1. Initially use the patients
hand under yours as you
palpate.
2. When patient calms then
use your hands to palpate.
3. Watch the patient’s face for
discomfort.
 SAFETY PRECAUTIONS
HAND WASHING
Before and after contact with each patient.
Before and after each procedure.
WEAR GLOVES
When in contact with broken skin, blood and body fluids.
WEAR MASK
When in contact with infectious diseases.
ISOLATION PRECAUTIONS
Infective patients to be isolated
Personal protective equipment.
 SAFETY PRECAUTIONS
Discard all disposable equipment and supplies
appropriately.
Clean and disinfect examination room in cases of
communicable diseases.
Sanitize, disinfect and sterilize equipment appropriately.
 EXERCISE
8 years old Saba came along with her mother in your clinic.
They belong to a very low socio- economic status and
probably living conditions in the house are also not good.
She has eruptions all over her body with moderate grade
fever. She also has severe cough and at times blood in
sputum. What actions should you take before, during and
after examination?
 ANSWER
Saba seems to be suffering from some kind of
communicable disease. She should be examined first so
that she can go home fast and thus other patients in the
waiting area will not be affected. A separate room should be
used for examination and other patients will not be
examined in this room. Physician should wear gloves and
also mask so as to keep himself/ herself safe. All equipment
like tongue depressor, thermometer should be cleaned and
also room should be cleaned and sanitized following the
appointment.
 EXAMINATION POSITIONS
SITTING
STANDING
SUPINE OR PRONE
DORSAL RECUMBENT
LITHOTOMY
KNEE CHEST
SIM’S
PROCTOLOGIC
TRENDLENBURG’S POSITION
FOWLER’S
 EXAMINATION METHODS
INSPECTION
PALPATION
PERCUSSION
AUSCULTATION
MENSURATION
MANIPULATION
 INSPECTION

ONLY OBSERVING, NO TOUCHING

 INSPECTION
Overall appearance of health or illness
Signs of distress
Facial expression and mood
Body size
Grooming and personal hygiene
Assess size, shape, colour, position, symmetry
Presence of abnormalities
 PALPATION
Pre- requisites: Short fingernails, warm your hands prior
to placing them on the patient.
Encourage the patient to continue to breathe normally
throughout the palpation.
If pain is experienced during the palpation, discontinue
the palpation immediately.
Inform the patient where, when, and how the touch will
occur, especially when the patient cannot see what you
are doing.
Useful to feel texture, temperature, shape etc.
Helps identify presence of vibration or movements.
 PALPATION

LIGHT DEEP BIMANUAL

PERCUSSION
 MENSURATION

Means measurement of various parameters like-

 Height and weight.
Length or diameter of extremity.
Growth of uterus during pregnancy.
 MANIPULATION

Systemic moving of a patient’s body parts.

Example- Range of motion of joints.
Points to consider for general examination
Built
Body proportion, Height and weight.
Nutrition
Decubitus
Clubbing- bulbous enlargement of soft parts of the
terminal phalanges with both transverse and longitudinal
curving of nails.
Cyanosis- bluish discoloration of nails due to reduced
hemoglobin.
Jaundice
Pallor- paleness of skin and MM due to decreased blood
supply or circulating blood cells.
Lymphadenopathy
Edema
Skin and hair- texture and nourishment.
Vertebral column- Kyphosis (abnormal anteroposterior
curvature of the spine with forward concavity and dorsal
prominence), Scoliosis (abnormal lateral curvature),
Lordosis (abnormal anteroposterior curvature of the spine
with forward convexity)
Joints- examine for pain, swelling, range of movements.
Pulse, Temperature, BP, JVP
 BUILT
Skeletal structure in relation to age and sex of the
individual as compared to a normal person.
1. Tall stature- simple gigantism, hyperpituitarism,
Klinefelter’s syndrome, Marfan’s syndrome, Soto’s
syndrome, hypogonadism etc.
2. Short stature- Turner’s syndrome, Down’s syndrome,
Noona’s syndrome, Cushing’s syndrome,
Hypopituitarism, achondroplasia, adrenal hyperplasia,
cretinism etc.
EXERCISE
 EXAMPLES
KLINEFELTER’S SYNDROME-
Klinefelter syndrome is a genetic condition that results when a boy is born with an extra copy of
the X chromosome. Klinefelter syndrome is a common genetic condition affecting males.
Klinefelter syndrome adversely affects testicular growth, and this can result in smaller than
normal testicles. This can lead to lower production of the sex hormone testosterone. Klinefelter
syndrome may also cause reduced muscle mass, reduced body and facial hair, and enlarged
breast tissue. The effects of Klinefelter syndrome vary, and not everyone with it develops these
signs and symptoms. BABIES BOYS AND TEENAGERS MEN
•Weak muscles •Taller than average stature •Infertility
S/S •Slow motor •Longer legs, shorter torso and broader •Small testicles
development — taking hips compared with other boys and penis
longer than average to •After puberty, less muscular bodies and •Taller than
sit up, crawl and walk less facial and body hair compared with average stature
•Delay in speaking other teens •Weak bones
•Quiet, docile •Small, firm testicles •Decreased facial
personality •Small penis and body hair
•Problems at birth, •Enlarged breast tissue (gynecomastia) •Enlarged breast
such as testicles that •Weak bones tissue
haven't descended •Low energy levels •Decreased sex
into the scrotum drive
 SIMPLE GIGANTISM

What happened?
• Also known as “gigantism”.
• The person is a lot taller than other people same age with him or her.

• Why?
• Excessive growth hormone during childhood leads to abnormally robust
growth of bones, muscles, and many internal organs.

Sign and symptoms

• Very tall height.
• Puberty may be delayed, and the genitals may not develop fully.
• Thick facial bones and skin
• Weakness
 HYPOPITUITARISM
Hypopituitarism is a rare disorder in which your pituitary gland either fails to produce one
or more of its hormones or doesn't produce enough of them. In hypopituitarism, you have
a short supply of one or more of these pituitary hormones. This deficiency can affect any
number of your body's routine functions, such as growth, blood pressure and reproduction.

s/s
• Fatigue
• Weight loss
• Decreased sex drive
• Sensitivity to cold or difficulty staying warm
• Decreased appetite
• Facial puffiness
• Anemia
• Infertility
• Hot flashes, irregular or no periods, loss of pubic hair, and inability to produce milk
for breast-feeding in women
• Decreased facial or body hair in men
• Short stature in children
Women Man Children & adult
FSH&LH FSH&LH GH (children)
• Stopped menstruation • Loss of body and facial • Short height
• Infertility hair • Fat around waist and
Prolactin • Lack of interest in face
• Lack of milk production sexual activity • Poor growth
• Fatigue • Erectile dysfunction GH(adult)
• Loss of underarm and • infertility • Low energy
pubic hair • Low strength
• Weight gain
• Low muscle mass
• Anxiety

ACTH Nausea, depression, fatigue, low BP, weight loss, weakness

ADH Increased thirst, and urination, constipation, weight gain, low energy, muscle
weakness
 BODY PROPORTION
NORMAL ADULTS- upper segment (from vertex to pubic
symphysis) is equal to lower segment (from pubic
symphysis to heels)
INFANTS- upper segment greater than lower segment.
 NUTRITION AND DECUBITUS
NUTRITION- a normal person is well nourished as
regards proteins, fats, carbohydrates, vitamins and
minerals. It can be assessed by measuring arm
circumference which is reduced in cases of
malnourishment.
DECUBITUS- it is a posture patient adopts when lying in
bed. Ex. Renal colic- patient is restless and moving about,
Pneumonia- patient is most comfortable lying on the
affected side because the movement on the affected side
is restricted.
 CLUBBING
It is bulbous enlargement of soft parts of the terminal
phalanges with both transverse and longitudinal curving
of nails.
Causes:
PULMONARY CARDIAC ALIMENTARY ENDOCRINE MISCELLANEOUS

Lung Carcinoma Infective Ulcerative colitis Myxoedema Heriditary

endocarditis
Bronchiectasis Cyanotic CHD Crohn’s disease Grave’s disease Idiopathic

Tuberculosis Cirrhosis Acromegaly

GRADES OF CLUBBING
1. Softening of nail bed.
2. Obliteration of angle of
nail bed.
3. Parrot beak.
4. Swelling of the fingers in
all direction with pain-
drumstick appearance
SIGN TO ASSESS CLUBBING

SCHAMROTH’S SIGN- Normally when two fingers are held

together with nails facing each other, a space is seen at the level of
proximal nail fold. This space/ window is lost in case of clubbing
 CYANOSIS
It is bluish discolouration of the nails due to increased
amount of reduced hemoglobin (more than 5mg%) in
capillary blood.

TYPES CAUSES
CENTRAL Congenital Heart disease (CHD), Congestive heart
failure (CCF), COPD, Collapse lung, fibrosis lung, high
altitude.
PERIPHERAL Cold (vasoconstriction), Shock
MIXED Acute Left Ventricular failure (LVF), Mitral stenosis
DUE TO Methemoglobinemia, Sulphemoglobin
ABNORMAL
PIGMENTS
 CENTRAL CYANOSIS PERIPHERAL CANOSIS

MECHANISM Diminished arterial oxygen Diminished flow of blood to local part

saturation

SITES On skin and mucous membranes On skin only

e.g. Tongue, lips, cheeks etc.

TEMPERATURE OF THE Warm Cold

AFFECTED PART

CLUBBING Usually associated Not associated

LOCAL HEAT EFFECT Cyanosis remains Cyanosis abolished

BREATHING PURE Cyanosis decreases Cyanosis persists

OXYGEN
CENTRAL CYANOSIS PERIPHERAL CYANOSIS
 JAUNDICE
Jaundice is a symptom complex which is characterized by yellow colouration of
tissues and body fluids due to an increase in bile pigments.
Normal values:
1. Serum bilirubin- Total: 1mg%, Direct: 0.25mg%.
2. Urine urobilinogen- 100- 200 mg/day.
3. Fecal urobilinogen- 300mg/day.
It may arise due to:
1. Increased bile pigment load to the liver.
2. Affection of bilirubin diffusion into the liver cells.
3. Defective conjugation.
4. Defective excretion
Distribution:
1. Nervous tissue- esp. basal ganglia.
2. Elastic tssue- skin, sclera, blood vessels.
 PALLOR
PALENESS of skin and mucous membranes either as result of diminished
circulating red blood cells or diminished blood supply.
SITES where anemia can be detected-
1. Lower palpebral conjunctiva.
2. Tongue.
3. Soft palate.
4. Palm and nails.
5. Other mucosal areas.
CAUSES
ANEMIA VASOCONSTRICTION CUTANEOUS
Hemorrhagic Shock, fright, syncope Thick skin and nails
Hemolytic Cold exposure Edema
Dyshemopoietic Arterial occlusion Myxedema
 EDEMA
Edema is collection of fluid in the interstitial spaces or
serous cavities. It becomes evident only when 5-6 liters of
fluid has accumulated in the water depots. Pitting on
pressure occurs when the circumference of the limb is
increased by 10%

CHECK AT: 2 inches above medial malleolus

on shin of tibia
 EDEMA CAUSES AND GRADES
BILATERAL UNILATERAL
Cardiac- CCF, LVF, Pericarditis Lymphatic- Filariasis, Metastasis
Renal- Acute Nephritis, Nephrotic Syndrome Traumatic- Bruises, Sprains, Fractures
Hepatic- Cirrhosis, Portal hypertension Infections- Cellulitis, bois, carbuncles
Venous- IVC obstruction Metabolic- Gout
Endocrine- Myxoedema Venous- Varicose veins
Allergic- Angioneurotic edema
Nutritional- Anemia, Beri beri

GRADES OF PITTING EDEMA:

 Grade 0 : (none)
 Grade +1 :( trace , 2 mm)- Disappear rapidly.
 Grade +2 ( moderate , 4 mm)- Remains for 10-15 sec.
 Grade +3 (deep, 6 mm)- Remains for ≥ 1min.
 Grade +4 (very deep, 8 mm)- Remains for 2-5min
 TEMPERATURE
The body temperature refers to the temperature of viscera
and tissues of the body.
It is kept within normal levels by maintaining balance
between heat gain and heat loss, which is regulated by
hypothalamus.
The body temperature is best recorded with mercury
thermometer, which should be kept in position for about a
minute.
Temperature can be recorded in axilla or orally or rectally
especially in neonates and in cases of cholera where skin
is cold but actual temperature is high.
 Temperature in 0C Temperature in 0F

Hypothermia 35 95

Subnormal 35.0-36.7 95-97

Normal 36.7- 37.2 98-99
Mild fever 37.2- 37.8 99-100
Moderate fever 37.8- 39.4 100-103

High fever 39.4- 40.5 103-105

Hyperpyrexia > 40.5 > 105

Diurnal variations: normal variation of 1 0C, the lowest

between 2-4 am and highest in the afternoon.
Fever or pyrexia is an increase of more than1 0C or any rise
above maximal normal temperature.
METHODS OF ELICITING TEMPERATURE
 PULSE
Pulse is the rate at which your heart beats. Pulse is
usually called your heart rate, which is the number of
times your heart beats each minute (bpm). But the rhythm
and strength of the heartbeat can also be noted, as well
as whether the blood vessel feels hard or soft. (So rate,
rhythm and volume of pulse can be established)
Changes in your heart rate or rhythm, a weak pulse, or a
hard blood vessel may be caused by heart disease or
another problem.
 JUGULAR VENOUS PRESSURE (JVP)
The jugular venous pressure A man with congestive heart
(JVP, sometimes referred to failure and marked jugular
as jugular venous pulse) is the venous distention.
indirectly observed pressure
over the venous system via
visualization of the internal
jugular vein.

It can be useful in the

differentiation of different
forms of heart and lung
diseases.
PROCEDURE: Patient is given back rest to keep him at 45
degrees. Once the vein is visualized, a ruler is kept at the upper
level of the vein parallel to the ground. Another ruler is kept at
angle of louis perpendicular to the first ruler. The distance from
angle of louis to the first ruler gives JVP. Normal pressure is 3-
4 cm.

SIGNIFICANCE: The jugular veins are in direct continuity with

the superior vena cava and the right atrium. Hence, it reflects
pressure changes in the right atrium.

JVP is increased in: RVF, TS, SVC obstruction, Asthma,

Emphysema etc.
 BLOOD PRESSURE
Blood pressure (BP) is the pressure exerted by circulating
blood upon the walls of blood vessels. When used without
further specification, "blood pressure" usually refers to the
arterial pressure in the systemic circulation. It is usually
measured at a person's upper arm.
Blood pressure is usually expressed in terms of the systolic
(maximum) pressure over diastolic (minimum) pressure and is
measured in millimeters of mercury (mm Hg). It is one of the
vital signs along with respiratory rate, heart rate, oxygen
saturation, and body temperature. Normal resting blood
pressure in an adult is approximately 120/80 mm Hg.
 NORMAL RANGE OF BP
Category Systolic, mm Hg Diastolic, mm Hg
Hypotension < 90 < 60
Desired 90–119 60–79
Prehypertension 120–139 80–89
Stage 1 hypertension 140–159 90–99
Stage 2 hypertension 160–179 100–109
Hypertensive emergency ≥ 180 ≥ 110
Isolated systolic hypertension ≥ 140 < 90
 HEAD TO TOE EXAMINATION
Hair- colour, thickness, nourishment, brittle hair, alopecia, hirsutism etc.
Scalp- lesions, lumps, lice, dandruff, wig etc.
Eyes and eyelids- vision, discharge, reflexes, shape and symmetry.
Ears- structure, symmetry, discharges, hearing etc.
Nose- shape, nostrils- symmetry, discharges.
Sinuses- frontal and maxillary.
Lips, mouth, teeth, gums, tongue for colour and health.
Nails- symmetry, brittleness, colour etc.
Neck- glands
Breast- lumps
Genitals- for abnormalities and discharges.