CASE TAKING

General Physical Examination

Made by :
Ishant Arora-19
Kushagr Duggal-26
Shresta Sandhu-69

ACKNOWLEDGEMENT
We would like to thank Dr. Rekha
Thomas and Dr. Parul for giving us an
opportunity to present our views on
the most important topic of medical
diagnosis GENERAL PHYSICAL
EXAMINATION.

List of Contents
Introduction to
Case taking
GPE of patient
Built
Nutrition
Icterus
Pallor

Clubbing
Tongue
Cyanosis
Oedema
Pigmentation
Lymphadenopathy
Temperature
Respiratory rate
Blood pressure

INTRODUCTION
Case taking is a unique art of getting into
conversation observation and collecting
information from patient as well as from
bystanders to define the patient as a person
and the disease.
The history obtained thus makes the basis
for a physician to go further into the
physical examination and laboratory studies
in order to define the problem accurately.

 Each case is unique in all respects only true

individualized approach can explore the
true picture and help a physician to arrive
at a totality in its true sense. Every
individual is different in health as well as
in disease and hence every case has to be
examined individually giving importance to
its unique expressions during health and
disease.

General Physical
Examination Of a Patient
Many patients are apprehenive about
being examined, the environment is
unfamiliar, they may feel exposed
and are likely to have anxieties about
the findings.

The examination should be done

in a warm , private, quiet area.
Daylight is preferable to
artifical light.
And give a brief explanation to
the patient as to what you will
do.

BUILT/ PHYSIQUE
Certain observations that can be made
from the general inspection of the
patients physique are If the patients appearance is consistent
with his chronological age
Body proportions and obvious deformities
The somatotype of the patient

Somatotypes
Body types, otherwise known as
somatotypes can be split into 3
different types:
1. Endomorph (Fat)
2.Mesomorph (Muscular)
3.Ectomorph (Thin)

A somatotype number of three digits is

determined for an individual classified by the
system, with the first digit referring to
endomorphy, the second to mesomorphy, and the
third to ectomorphy; each digit is on a scale of 1
to 7. Hence, the extremeendomorphhas the
somatotype 711, the extreme mesomorph171,
and the extremeectomorph117. In practice,
extreme types (711, 171, 117) are rare or
nonexistent, and the person of normal build has
a somatotype approaching 444, evenly balanced
between extremes.

Endomorph (711)
A pear shaped body
A rounded head
Wide hips and shoulders
Wider front to back rather
than side to side.
A lot of fat on the body,
upper arms and thighs

Mesomorph (171)
A wedge shaped body
A cubical head
Wide broad shoulders
Muscled arms and legs
Narrow hips
Narrow from front to
back rather than side to
side.
A minimum amount of
fat

Ectomorph (117)
A high forehead
Receding chin
Narrow shoulders and
hips
A narrow chest and
abdomen
Thin arms and legs
Little muscle and fat

NUTRITION
The nutritional status of an individual is often
the result of many inter-related factors.
It is influenced by food intake, quantity &
quality, & physical health.
The spectrum of nutritional status spread from
obesity to severe malnutrition

NUTRITION
ASSESSMENT

DIET HISTORY
Nutritional intake of humans is assessed by:
1. 24 hours dietary recall
All foods & beverages

Time of day eaten

Amounts consumed

Food preparation

2. Food frequency questionnaire

In this method the subject is given a list of around 100 food items to

indicate his or her intake (frequency & quantity) per day, per week & per
month.
3. Dietary history since early life
4. Observed food consumption
- The meal eaten by the individual is weighed and contents are exactly calculated

INTERPRETATION OF
DIETARY DATA
Quantitative and qualitative
analysis using the food pyramid.
The amount of energy & specific
nutrients in each food consumed
can be calculated & then compared
with the recommended daily intake.

ANTHROPOMETRY
METHODS
Anthropometry is the measurement of body
height, weight & proportions.
It is an essential component of clinical
examination of infants, children & pregnant
women.
It is used to evaluate both under & over nutrition.
The measured values reflects the current
nutritional status & dont differentiate between
acute & chronic changes .

BMI Classification
BMI < 18.5 = Under Weight
BMI 18.5-24.5= Healthy weight range
= Overweight (grade 1
BMI 25-30
obesity)
BMI >30-40 = Obese (grade 2 obesity)
=Very obese (morbid or
BMI >40
grade 3 obesity)

ICTERUS
Icterus is ayellowishpigmentation of the skin, the
conjunctivalmembranes over thesclerae(whites of the
eyes), and othermucous membranescaused
byhyperbilirubinemia(increased levels ofbilirubinin the
blood).
This hyperbilirubinemia subsequently causes increased levels
of bilirubin in theextracellular fluid.
Concentration of bilirubin inblood plasmais normally below
1.2mg/dL(<25mol/L).
A concentration higher than approx. 3mg/dL (>50mol/L)
leads to jaundice.

Sites:
Upper bulbar
conjunctiva
(sclera)
Palate
Under surface
of tongue
Palms and soles
General skin
surface

Scleral icterus

In people with scleral icterus, the body's processing

system forbilirubin breaks down. The pigment
circulates in the blood, and becomes deposited in
theconjunctiva, the membrane that covers the whites
of the eye. It can also be present in the skin, causing
it to turn yellow along with the eyes.

SHADES OF JAUNDICE
Reddish shade (Rubin jaundice):Hepatitis
Lemon yellow with a reddish hue (Flavin
jaundice):Hemolysis
Greenish yellow (Verdin
jaundice):Obstructive jaundice
Grayish or blackish green (Melas
jaundice):Prolonged obstructive jaundice

PALLOR
Pallor is the paleness of skin and mucous
membranes, due to the reduced amount of
oxyhemoglobin or decreased peripheral perfusion.
Assessment of pallor for anaemia is an important
part of general physical examination of every
patient.
To detect anaemia, pallor at sites where capillaries
are superficial is looked for. The usual sites are
lower eyelid conjunctiva, nailbed and palm.

A. Technique of exminaing for pallor in lower

palpebral conjunctiva
B. Normal conjunctiva (Note the demarcation
shown by arrow)
C. Pale conjunctiva (Loss of demarcation)

Pallor in the
palm of the
patient

Pallor in nailbeds: Press

the nail and note the color
of nailbed after releasing
the digital pressure.

CAUSES OF PALLOR
1) Anemia (can be appreciated clinically when hemoglobin
<8-9 g/dl)
2) Pallor without anemia:
Physiologic (fair skinned)
Shock
Hypoglycemia and other metabolic derangements
Respiratory distress
Skin edema
Pheochromocytoma

CLINICAL GRADING OF
ANAEMIA
Mild: Pallor of conjunctiva and/or
mucous membrane
Moderate: Above + Pallor of skin
Severe: Above + Pallor of palmar
creases

CLUBBING
Clubbing (also known as drumstick
fingers and watch-glass nails)is a
deformity of thefingers andfinger
nailsassociated with a number of
diseases, mostly of
theheartandlungs.

STAGING
Clubbing may be present in one of five stages:
Fluctuation and softening of the nail bed
(increased ballotability)
Loss of the normal <165 angle ( Lovibond angle)
between the nail bed and the fold ( cuticula)
Increased convexity of the nail fold
Thickening of the wholedistal(end part of the)
finger (resembling a drumstick)
Shiny aspect andstriationof the nail and skin

SCHAMROTHS
WINDOW TEST
When the distal phalanges(bones nearest
the fingertips) of corresponding fingers of
opposite hands are directlyopposed (place
fingernails of same finger on opposite
hands against each other, nail to nail), a
small diamond-shaped "window" is normally
apparent between the nail beds. If this
window is obliterated, the test is positive
and clubbing is present.

DISEASE
ASSOCIATIONS
Clubbing is associated with:
Lung disease:

Lung cancer, mainly non-small-cell (54% of all cases), not

seen frequently in small-cell lung cancer (< 5% of cases)
Interstitial lung disease
Complicatedtuberculosis
Suppurative lung disease:lung
abscess,empyema,bronchiectasis,cystic fibrosis
Mesotheliomaof the pleura
Arteriovenous fistula or malformation

 Heart disease:
Any disease featuring chronichypoxia
Congenitalcyanotic heart disease(most
common cardiac cause)
Subacute bacterial endocarditis
Atrial myxoma (benign tumor)
Tetralogy of Fallot

Gastrointestinal and hepatobiliary:

Mal-Absorption
Crohn's diseaseandulcerative colitis
Cirrhosis, especially inprimary biliary
cirrhosis
Hepatopulmonary syndrome, a
complication of cirrhosis.

THE TONGUE
General examination involves examination
of the anterior two-thirds of the tongue
(oral tongue) visible on routine
examination.

On physical examination, there are several characteristics

of the tongue that should be noted:
Color
Pink-red on dorsal and ventral surfaces. The ventral
surface may have some visible vasculature.
Texture
Rough dorsal surface owing to papillae, which have three
types. There should be no hairs, furrows, or ulceration.
Size
Should fit comfortably in mouth, tip against lower
incisors. Sublingual glands should not be displaced.

In general, the examination of the tongue should

occur in the following steps:
Have the patient touch the tip of the tongue to
the roof of their mouth and inspect the ventral
surface.
Have the patient protrude the tongue straight out
and inspect for deviation, color, texture, and
masses
With gloved hands, hold the tongue with gauze in
one hand while palpating the tongue between the
thumb and index finger of the other, noting
masses and areas of tenderness

CLINICAL FINDINGS
A classic smooth, beefy
red tongue from vitamin
B12 deficiency

A black, hairy tongue

consistent
withaspergillus
overgrowth

Geographic tongue is a benign

condition in which discolored,
painless patches of the tongue
appear and then reappear
from atrophy, often in a
different distribution.
White hairs along the sides
of the tongue are the classic
appearance of oral hairy
leukoplakia.

CYANOSIS
The namecyanosis, literally means "the blue
disease" or "the blue condition." It is derived
from the colorcyan, which comes fromkyanos,
the Greek word for blue
Cyanosisis the appearance of a blue or purple
coloration of theskinormucous membranesdue
to the tissues near the skin surface having low
oxygen saturation.
The onset of cyanosis is classically described as
occurring if 5.0 g/dL ofdeoxyhemoglobin or
greater is present.

TYPES OF CYANOSIS
Cyanosis is divided into two main
types:
1.Central(around the core, lips, and
tongue)
2.Peripheral(only the extremities or
fingers).

CAUSES OF CENTRAL
CYANOSIS
Central cyanosis may be due to the following causes:
1.CENTRAL NERVOUS SYSTEM(impairing normal ventilation):
Intracranial hemorrhage
Drug overdose(e.g.Heroin)
Tonicclonic seizure(e.g. grand mal seizure)
2.RESPIRATORY SYSTEM
Pneumonia
Bronchiolits
Bronchospasm (e.g.Asthma)
Pulmonary Hypertension
Pulmonary embolism
Hypoventilation
Chronic obstructive pulmonary disease, or COPD (emphysema)

3.CARDIOVASCULAR SYSTEM
Congenital heart disease(e.g.Tetralogy of Fallot,Right to
left shunts in heart or great vessels)
Heart failure
Valvular heart disease
Myocardial infarction
4.BLOOD
Methemoglobinemia* Note this causes "spurious" cyanosis,
in that, since methemoglobin appears blue,the patient can
appear cyanosed even in the presence of a normal arterial
oxygen level.
Polycythaemia
Congenital cyanosis (HbM Boston) arises from amutationin
the -codon which results in a change ofprimary sequence,
H Y.Tyrosinestabilises the Fe(III) form
(oxyhaemoglobin) creating a permanent T-state of Hb.

CAUSES OF
PERIPHERAL CYANOSIS
All common causes of central cyanosis
Reduced cardiac output (e.g.heart
failure,hypovolaemia)
Cold exposure
Arterial obstruction (e.g.peripheral
vascular disease,Raynaud phenomenon)
Venous obstruction (e.g.deep vein
thrombosis)

OEDEMA
Edema(American English)
oroedema(British English) (from
theGreekodma, "swelling"),
formerly known asdropsyorhydropsy, is
an abnormal accumulation of fluid in
theinterstitium, which are locations
beneath the skin or in one or more cavities
of the body.

CLASSIFICATION
A.GENERALISED-It is often due to
disorder of heart,kidneys,liver,gut or
diet.
B.LOCAL- It is due to lymphatic or
venous obstruction,allergy or
inflammation.

GRADING OEDEMA
GRADE
Absent
Grade +
Grade ++
Grade +++

DEFINITION
Unilateral
Mild
Moderate
Severe

MECHANISM OF
OEDEMA
Six factors can contribute to the formation of edema:
increasedhydrostatic pressure;
reducedoncotic pressurewithin blood vessels;
increased tissue oncotic pressure;
increased blood vessel wall permeability
e.g.inflammation;
obstruction of fluid clearance in thelymphatic system;
changes in the water retaining properties of the
tissues themselves. Raised hydrostatic pressure often
reflects retention of water and sodium by the kidney.

Pitting oedema

PIGMENTATION
Normal skin contains varying amounts of
brown melanin pigment. Brown pigmenation
due to deposited haemosiderin is always
pathological.
Albinism is an inherited generalised
absence of pigment in the skin.
Patches of white and darkly pigmented
skin are due to local and complete absence
of melanocytes.

HYPERPIGMENTATION
Facial Acanthosis Nigricans

Butterfly patches-Systemic
Lupus erythematous

LYMPHADENOPATHY
Lymphadenopathyrefers tolymph
nodeswhich are abnormal in size,
number or consistencyand is often
used as a synonym for swollen or
enlarged lymph nodes. Common causes
of lymphadenopathy
areinfection,autoimmunedisease,
ormalignancy.

TYPES OF
LYMPHADENOPATHY
Localized lymphadenopathy: due to
localized spot of infection e.g., an infected
spot on the scalp will cause lymph nodes in
the neck on that same side to swell up
Generalized lymphadenopathy: due to a
systemic infection of the body e.g.,
influenza or secondarysyphilis

 Dermatopathic
lymphadenopathy:
lymphadenopathy associated with
skin disease.
Persistent generalized
lymphadenopathy(PGL):
persisting for a long time,
possibly without an apparent
cause

Cervical enlargement

CAUSES
Lymph node enlargement is recognized as a common sign
of infectious, autoimmune, or malignant disease.
Examples may include:
Reactive: acuteinfection(e.g.,bacterial, orviral), or
chronic infections (tuberculous lymphadenitiscatscratch disease
The most distinctive sign ofbubonic plagueis
extreme swelling of one or more lymph nodes that
bulge out of the skin as "buboes." The buboes often
becomenecroticand may even rupture.
Infectious mononucleosisis an acute viral infection
caused byEpstein-Barr virusand may be
characterized by a marked enlargement of
thecervical lymph nodes

 It is also a sign ofcutaneous

anthraxandHuman African
trypanosomiasis

Toxoplasmosis, aparasitic disease, gives

a generalized lymphadenopathy
(Piringer-Kuchinka lymphadenopathy).
Plasma cell variant of Castleman's
disease- associated withHVV8
infection andHIVinfection
Mesenteric lymphadenitisafter viral
systemic infection (particularly in
theSALTin the appendix) can commonly
present likeappendicitis.

 Tumoral:
Primary:Hodgkin lymphomaandnon-Hodgkin
lymphoma give lymphadenopathy in all or a few
lymph nodes.
Secondary:metastasis,Virchow's
Node,neuroblastoma andchronic lymphocytic
leukemia.
Autoimmuneetiology:systemic lupus erythematosus
andrheumatoid arthritismay have a generalized
lymphadenopathy.

 Immunocompromised etiology:AIDS. Generalized

lymphadenopathy is an early sign of infection
withhuman immunodeficiency virus(HIV), the
virus that causes acquired immunodeficiency
syndrome (AIDS)."Lymphadenopathy syndrome"
has been used to describe the first symptomatic
stage ofHIV progression, preceding a diagnosis
of AIDS.
Bites from certain venomous snakes such as
thepit viper
Unknown etiology:Kikuchi disease,progressive
transformation of germinal
centers,sarcoidosis,hyaline-vascular variant of
Castleman's disease,Rosai-Dorfman
diseaseKawasaki diseaseKimura disease

TEMPERATURE
Normal human body temperature,
also known
asnormothermiaoreuthermia,
depends upon the place in thebodyat
which the measurement is made, the
time of day, as well as the activity
level of the person.

 Different parts of the body have

different
temperatures.Rectalandvaginalmeasurem
ents, or measurements taken directly
inside the body cavity, are typically
slightly higher than oral measurements,
and oral measurements are somewhat
higher than skin temperature.

 The commonly accepted average core body

temperature (taken internally)
is37.0C(98.6F). The typical oral (under
the tongue) measurement is slightly cooler,
at 36.8 0.4C (98.2 0.7F), and
temperatures taken in other places (such
as under the arm or in the ear) produce
different typical numbers.

Methods Of Measurement
Taking a person'stemperatureis an initial part of a
fullclinical examination. Sites used for measurement
include:
In the anus (rectal temperature)
In the mouth (oral temperature)
Under the arm (axillary temperature)
In the ear (tympanic temperature)
In thevagina(vaginal temperature)
In thebladder
On the skin of the forehead over thetemporal artery

MEDICAL THERMOMETER

RESPIRATORY RATE
The respiration rate is the number of breaths a
person takes per minute. The rate is usually
measured when a person is at rest and simply
involves counting the number of breaths for one
minute by counting how many times the chest
rises. Respiration rates may increase with fever,
illness, and with other medical conditions. When
checking respiration, it is important to also note
whether a person has any difficulty breathing.
Normal respiration rates for an adult person at
rest range from 12 to16 breaths per minute.

PULSE
The pulse rate is a measurement of the heart
rate, or the number of times the heart beats per
minute. As the heart pushes blood through the
arteries, the arteries expand and contract with
the flow of the blood. Taking a pulse not only
measures the heart rate, but also can indicate the
following:
Heart rhythm
Strength of the pulse

 The normal pulse for healthy adults ranges

from 60 to 100 beats per minute. The
pulse rate may fluctuate and increase with
exercise, illness, injury, and emotions.
Females ages 12 and older, in general, tend
to have faster heart rates than do males.
Athletes, such as runners, who do a lot of
cardiovascular conditioning, may have
heart rates near 40 beats per minute and
experience no problems.

How to check pulse ?

As the heart forces blood through the arteries,
you feel the beats by firmly pressing on the
arteries, which are located close to the surface of
the skin at certain points of the body. The pulse
can be found on the side of the neck, on the inside
of the elbow, or at the wrist. For most people, it
is easiest to take the pulse at the wrist.If you
use the lower neck, be sure not to press too hard,
and never press on the pulses on both sides of the
lower neck at the same time to prevent blocking
blood flow to the brain. When taking your pulse:

 Using the first and second fingertips, press firmly but

gently on the arteries until you feel a pulse.
Begin counting the pulse when the clock's second hand is on
the 12.
Count your pulse for 60 seconds (or for 15 seconds and then
multiply by four to calculate beats per minute).
When counting, do not watch the clock continuously, but
concentrate on the beats of the pulse.
If unsure about your results, ask another person to count
for you.
If yourdoctor has ordered you to check your own pulse and
you are having difficulty finding it, consult yourdoctor or
nurse for additional instruction.

BLOOD PRESSURE
Blood pressure(BP), sometimes
referred to asarterial blood
pressure, is thepressureexerted by
circulating bloodupon the walls
ofblood vessels, and is one of the
principalvital signs.

 Blood pressure varies depending on

situation, activity, and disease states,
and is regulated by thenervousand
endocrinesystems. Blood pressure
that is pathologically low is
calledhypotension, and pressure that
is pathologically high ishypertension.

CLASSIFICATION
Systolic
The top number, which is also the higher of the
two numbers, measures the pressure in the
arteries when the heart beats (when the heart
muscle contracts)
Diastolic
The bottom number, which is also the lower of the
two numbers, measures the pressure in the
arteries between heartbeats (when the heart
muscle is resting between beats and refilling with
blood).

MEASUREMENT OF
BLOOD PRESSURE
Sphygmomanometer
Position: supine, seated, standing.
In seated position, the subject's arm
should be flexed.
The flexed elbow should be at the level of
the heart.
If the subject is anxious, wait a few
minutes before taking the pressure.

Procedures
To beginblood pressure measurement, use a
properly sized blood pressure cuff. The length of
the cuff's bladder should be at least equal to 80%
of the circumference of the upper arm.
Wrap the cuff around the upper arm with the
cuff's lower edge one inch above the antecubital
fossa.
Lightly press the stethoscope's bell over the
brachial artery just below the cuff's edge. Some
health care workers have difficulty using the bell
in the antecubital fossa, so we suggest using the
bell or the diaphragm to measure the blood
pressure.

 Rapidly inflate the cuff to 180mmHg.

Release air from the cuff at a
moderate rate (3mm/sec).
Listen with the stethoscope and
simultaneously observe the
sphygmomanometer. The first knocking
sound (Korotkoff) is the subject's
systolic pressure. When the knocking
sound disappears, that is the diastolic
pressure (such as 120/80).

 Record the pressure in both arms and note

the difference; also record the subject's
position (supine), which arm was used, and
the cuff size (small, standard or large adult
cuff).
If the subject's pressure is
elevated,measure blood pressuretwo
additional times, waiting a few minutes
between measurements.
A BLOOD PRESSURE OF 180/120mmHg OR
MORE REQUIRES IMMEDIATE
ATTENTION!

PRECAUTIONS> Don't place the cuff over clothing.

Flex and support the subject's arm.
In some patients the Korotkoff sounds disappear
as the systolic pressure is bled down. After an
interval, the Korotkoff sounds reappear. This
interval is referred to as the "auscultatory gap."
This pathophysiologic occurrence can lead to a
marked under-estimation of systolic pressure if
the cuff pressure is not elevated enough. It is for
this reason that the rapid inflation of the blood
pressure cuff to 180mmHg was Aneroid and
digital manometers may require periodic
calibration.

 Use a larger cuff on obese or heavily muscled

subjects.
Use a smaller cuff for pediatric patients.
For pediatric patients a lower blood pressure
may indicate the presence of hypertension.
recommended above. The "auscultatory gap" is
felt to be associated with carotid
atherosclerosis and a decrease in arterial
compliance in patients with increased blood
pressure.

PALPATORY METHOD
-The relaxed subject sits on a chair. The cuff of
the sphygmomanometer is wrapped firmly around
the right arm above the elbow. The lower arm
should be resting on a table-top or bench.
- The radial pulse (the pulse at the radial artery
in the wrist) is palpated with the fingers of the
left hand. The number of beats in 30 seconds is
counted, and the heart rate in beats per minute is
recorded

- The valve on the inflating bulb of the

sphygmomanometer is turned fully
clockwise so that it is closed. The cuff is
inflated slowly (10 mm Hg/sec) by pumping
the inflating bulb until the radial pulse is
no longer felt. The cuff is inflated
further until the pressure is about 30 mm
Hg higher.

- The valve on the inflating bulb is opened slightly

by turning it in the counter clockwise direction,
allowing the pressure to drop slowly by about 5
mm Hg/sec. At some point, one will be able to
feel the radial pulse once again.
- The pressure indicated on the gauge when the
pulse reappears is noted. This is the systolic
pressure. Now the pressure in the cuff is quickly
released, so as not to cause undue discomfort to
the subject.

2.

1.

3.

BIBLIOGRAPHY
http://www.hopkinsmedicine.org/healthlibrary/co
nditions/cardiovascular_diseases/vital_signs_bod
y_temperature_pulse_rate_respiration_rate_blo
od_pressure_85,P00866/ dated on 20.9.2014
www.wikipedia.com dated on 21.9.2014
Hutchisons clinical methods dated on 24.5.2014
www.ncbi.nlm.nih.gov dated on 25.9.2014
www.onlinelibrary.wiley.com dated on 25.9.2014
www.wisegeek.org dated on 25.9.2014
www.epomedicine.com dated on 25.9.2014