3-General Physical Examination Oct 2008

General Physical Examination:

General Physical Examination Dr Waseem Suleman Assistant Professor Dept of Family & Community Medicine Oct 2008

Objectives:

Objectives By the end of this session, students should be able to: Demonstrate a concise General Physical Examination (GPE) in an organized manner

Outline:

Outline Description of GPE Video: Vital Signs Practicing GPE in subgroups

Aims of GPE:

Aims of GPE Assess patient's general condition Detect manifestations of internal & systemic diseases Key component of diagnostic approach

Examining a Patient: Diagnostic clues :

Examining a Patient: Diagnostic clues Diagnostic process has 3 components: History taking – Clues are the symptoms Physical exam - Clues are the signs Investigations - Clues are test results

Instruments And Equipment :

Instruments And Equipment Stethoscope Sphygmomanometer Thermometer Torch Wooden tongue depressors Measuring tape

Examining a Patient: General Principles & Etiquettes:

Examining a Patient: General Principles & Etiquettes Meet, greet, introduce Sign Post Consent Explain to patient Be polite: say “please” & “thank you” Patient Comfort Thank the patient and cover at the end Most patients view physical exam with apprehension & anxiety - feeling vulnerable & exposed

Examining a Patient: Examination environment:

Examining a Patient: Examination environment Hand Washing Proper light Privacy & Confidentiality Use curtains & shades Presence of a chaperon when examining female patients Correct position of Doctor & Patient Ideally examiner should be on right side of patient Proper Exposure Ensure your hands are warm

Examining a Patient:

Examining a Patient Basic Steps : Inspection Palpation Percussion Auscultation

Components of GPE Systematic approach:

Components of GPE Systematic approach General Appearance Height & Weight Vital Signs Skin & Hair Head & Neck Lymph Nodes Hands Edema Feet Head to Toe ALWAYS Use a consistent technique!

General Appearance:

General Appearance OBSERVE your patient During the communication make judgment about the patient’s general appearance Well presented Well spoken Clean Intelligence and level of education First step: Eyes cannot see what mind does not know

General Appearance:

General Appearance Age & Physique Posture & Attitude Look of Patient: Healthy/ill Mental & Emotional State Odour

Height & Weight:

Height & Weight Nutrition status Child Growth Fluid Status Metabolic Status

Vital Signs: Pulse:

Vital Signs: Pulse Rate: beats/min Rhythm: Regular Irregular

Pulse: Technique:

Pulse: Technique Radial pulse commonly used to assess heart rate Palpate with index & middle fingers Rhythm regular & rate normal: count for 30 seconds & multiply by 2 Rate unusually fast or slow: count for 60 seconds Rhythm irregular: evaluate heart rate by cardiac auscultation

Vital Signs: Respiratory Rate:

Vital Signs: Respiratory Rate Count respirations with your hand on pulse Count for at least 30 sec: multiply by 2 Normal Adult R/R: 14-18

Vital Signs: Blood Pressure:

Vital Signs: Blood Pressure Patient seated in quiet, calm environment Bared arm supported: midpoint of upper arm heart level Proper cuff size: bladder inside the cuff should encircle 80% of arm Place midline of bladder over arterial pulsation Lower edge of cuff should be 2.5 cm above the antecubital fossa adapted from Perloff et al

Blood Pressure: Palpatory method:

Blood Pressure: Palpatory method Method Inflate cuff while palpating the radial pulse Note reading at which pulse disappears & then reappears during deflation This is Systolic Pressure To determine systolic blood pressure To avoid auscultatory gap

Slide 21:

Inflate bladder to pressure 20-30 mm above level determined by palpation Deflate bladder at 2 mm/sec: listen for appearance of Korotkoff sounds Note manometer readings at: Appearance of repetitive sounds (phase I): Systolic Disappearance of these sounds (phase V): Diastolic After last Korotkoff sound, deflate cuff slowly for another 10 mm, then rapidly & completely deflate Blood Pressure: Auscultatory method

Blood Pressure:

Blood Pressure Record systolic (phase I) & diastolic (phase V) pressure s, to the nearest 2 mm Hg Measure blood pressure in both arms at first visit Measure in different positions (lying, sitting, standing) if indicated

Vital Signs: Temperature:

Vital Signs: Temperature Wash the thermometer before use Shake mercury down Wash after use For oral: ask patient to breath through nose & keep lips firmly closed Keep thermometer for at least one minute

Vital Signs: Temperature:

Vital Signs: Temperature Conscious Adults: Oral / Axillary Young Children: Groin/ Rectal Tympanic Membrane Temperature Oral/ Rectal Temperature 0.5°C > Axillary/ Groin Normal: 36.6-37.2°C Febrile: >37.2°C

Pallor:

Pallor Conjunctiva Oral mucous membrane Nails Palms Normal Pale Conjunctivitis

Skin: Cyanosis:

Skin: Cyanosis Tongue Lips Ear lobes Fingers & toes Central Cyanosis: Generalize, Peripheries Warm Peripheral Cyanosis: Peripheral, Peripheries Cold

Skin: Jaundice:

Skin: Jaundice Sclera Skin & mucous membrane

Skin & Hair:

Skin & Hair Skin: Dehydration Pigmentation/ De-pigmentation Skin lesions Hair: Texture & grooming

Head:

Head General Appearance Eyes: Sclera: Jaundice Conjunctiva: Pallor Oral Cavity: Pallor Cyanosis Jaundice: undersurface of tongue Oral hygiene

Hands: Palms:

Hands: Palms Pallor Sweating / Temperature Muscle wasting Palmar Erythema Dupuyten's Contracture Osler’s Nodes

Hands: Dorsum:

Hands: Dorsum Muscle wasting Joints/ deformity Nails: Pallor Koilonychia Clubbing Cyanosis Leukonychia Splinter Hemorrhages Pitting Tremors Look from side Fluctuation at the base Schamroth Sign

Slide 32:

Normal First degree Second degree Third degree

Lymph Nodes:

Lymph Nodes Cervical Axillary Epitrochlear Groin Assess: Number Size Tenderness Consistency Matted or Discrete Mobile or Fixed

Edema:

Edema Pitting edema: Press firmly but gently for at least 5 sec Foot: Dorsum Behind Medial Malleolus Shin Sacral

Feet:

Feet Pitting edema Peripheral vessels Nail changes

Thank you:

Thank you

GPE: Check List:

GPE: Check List General Appearance: Age & Physique Posture & Attitude Look of Patient: Healthy/Ill Mental & Emotional State Height & Weight Vital Signs: Pulse BP Temperature Respiratory Rate Hands: Palmar Dorsum Head / Face: Eyes Oral Cavity Lymph Nodes: Cervical Axillary Groin Edema Feet

Assignment :

Assignment What is Continuous/ Remittent/ Intermittent Fever Difference between central and peripheral cyanosis: Clinical & Pathophysiological Grades of clubbing & causes of clubbing Name and drainage of lymph nodes in cervical, axillary and inguinal groups

Slide 40:

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Practice what you have learned, for theory without practice is like a spirit without a body. :

Practice what you have learned, for theory without practice is like a spirit without a body. -Al-Hujwiri, "The Kashf al-Mahjub"