Clinical

examination
Plan of Conduction & Scheme of Recording

Chiranjeevi Kumar
Department of Physiology
AIIMS Bhopal
 Three sections

• Vital data.

• General examination.

• Systemic examination.
 Vital Data

• Name Of The Institution : • Sex :

• Name Of The Doctor: • Religion :
• Ward No: • Caste :
• Cot No :
• Married Or Single :
• Case No :
• Children :
• Date:
• Occupation :
• Name Of The Patient :
• Income
• Age :
• Address
 General History
• The general history is organized into the following
sections:
• Identifying data (ID)
• Chief complaint (CC)
• History of the present illness (HPI)
• Past medical history (PMHx)
• Family history (FHx)
• Medications (MEDS) and Allergies (ALL)
• Social history (SHx)
• Review of systems or functional inquiry (ROS/FI)
 History of Present Illness
• Symptom characterization:
• 0 =Onset and duration
• P = Provoking and alleviating factors
• Q = Quality of pain (e.g. sharp, dull, throbbing)
• R = Does the pain radiate?
• S = Severity of pain ("on a scale from 1 to 10, 10 being the
most severe")
• T =Timing and progression ("Is the pain constant or
intermittent? Worse in the morning or at nighttime?")
• U = "How does it affect 'U' in your daily life?“
• V = Deja vu ("Has this happened before?")
• W ='What do you think it is?
 General examination
• General examination is actually the first step of physical
examination and Key component of diagnostic approach.
• Inspection is the major method during general
examination, combining with palpation, auscultation,
and smelling.
• Aims to
– Assess patient's general condition
– Detect manifestations of internal & systemic diseases
• 3 components:
– History taking – Clues are the symptoms
– Physical exam - Clues are the signs
– Investigations - Clues are test results
Instruments And Equipment :
• Stethoscope
• Sphygmomanometer
• Thermometer
• Torch
• Wooden tongue depressors
• Measuring tape
• Note:-
• Exam begins the minute you first see the patient
• Exam continues throughout your patient interaction
Prerequisites:
• Examination environment
• Hand Washing
• Proper light
• Privacy & Confidentiality
• 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
General examination
– General Appearance
– Hands and arms
– Skin
– Face
– Eyes
– Mouth
– Neck
– Oedema
– Lymph nodes
– Vital Signs
• Temperature
• Pulse
• Respiration Rate
• Blood Pressure
General Appearance
• General state of health: Healthy/ill/comfortable/Distressed
• Body Built and Nutritional status
– Height
– Weight
– BMI
– Obese/lean
– Tall/short
– Muscular/Asthenic/Cachexic
• State of awareness or level of consciousness
• Facial feature/expression/ Mood/Attitude
• Speech （ tone/voice)
• Position/posture and Gait
• Personal Hygiene
• Breath/Odor
• General state of health:
Healthy/ill/comfortable/Distressed
• Body Built
I. Sheldon's Anthropometric Types.
• ENDOMORPHIC - in whom viscera and abdomen tend to
dominate the body.
• MESOMORPHIC - in whom the muscular tissue
dominates the
body
• ECTOMORPHIC - in whom the skin, bones and the head
dominate the body..

II. Clinical types.

• Asthenic or hyposthenic has a slender or a weak figure.

• Sthenic or Hypersthenic has a broad and muscular

figure.
Gigantism

Dwarfism
Malnutrition
• State of awareness or level of consciousness
Facial feature/expression/ Mood/Attitude
 Acromegaly

Alveolar bone
growth causes the
teeth to separate

The enlargement of the Growth of

frontal and maxillary mandible leads to
sinuses results in an a jutting jaw
prominent brow and long (prognathism).
face
 Acromegaly

Macroglossia. There is Broadening and enlargement

also generalized visceral of the hands and feet due to
enlargement increased periosteal growth as
well as thickening of the skin
 Graves’ disease

Ocular involvement is mediated by

one or more distinct but still poorly
characterised orbital-stimulating
immunoglobulins:Proptosis, due to
increased volume and edema of
retrobulbar fat. Shortened
extraocular muscles, because of the
muscle infiltration and fibrosis result
in upper lid retraction. Conjunctival
erythema, and periorbital edema are
evident.

Facial expression
The stare in
hyperthyroi
dism
Hypothyroidism
• The most common cause is
the Hashimoto’s thyroiditis,
affects appr. 1% of adult
population
This woman demonstrates
the typical hypothyroid facies.
She also had a slow, hoarse,
deep voice and lassitude
(state of feeling very tired in
mind or body).
• Dull, puffy facies. Edema does
not pit with pressure. The
lateral eyebrows are thin.
Speech And Language
 Position & Posture
• It refers to patient’s body status and the general way of
holding the body
• Divided into:
• Active
• Passive
• Compulsive

• Active position
The patient can move his/her body freely, without any
restriction
It can be seen in normal adult, patients with mild diseases
or at earlier stage of the diseases

• Passive position
The patient can’t adjust or move his/her body
It occurs in extremely sick or patients with
• Compulsive supine position
The patient lie down on the beck, with two legs bending.
Acute peritonitis
Compulsive prostrate position
Rachis disease - in order to relief the tenderness of
back muscles.
Compulsive side down position
in patients with one sided pleurisy or pleurorrhea
Orthopnea
An abnormal condition in which a person must keep the head
elevated (sit or stand) to breathe deeply or comfortably (orthopnea) or
wakes up suddenly in the middle of the night short of breath. It can be
seen in patients with lung or heart disease
Squar down position
It has been seen in patients with congenital heart disease
• Compulsive rest position
When patient suffers an angina attack it will force them to rest.
The heart is then able to return to it’s normal working level
• Toss & turn position (alternative position)

• Opisthotonos
It is an abnormal posturing condition characterized by
rigidity and severe aching of the back, with head thrown
backwards
The typical position of COPD patients

An elderly patient who looks chronically ill. He is unable to speak more than two or
three words at a time due to shortness of breath. He has intercostal muscle
retraction when breathing and sits upright. Hi is thin with diffuse muscle wasting.
Gait : a way or manner of walking
Gait abnormalities describe unusual and uncontrollable
problem with walking
Personal Hygiene
Personal Hygiene
Breath/Odor
HANDS and ARMS
• Nails
– Clubbing
– Koilonychia
– Leuconychia
• Palmar erythema
• Dupuytren’s contractures
• Hepatic flap
 Nicotine Staining Onycholysis: Separation of Nail
from Underlying Bed

Onychomycosis: Fungal Paronychia: Infection of skin adjacent

Infection of the Nail to nail of middle finger
 HANDS

Palmar erythema Dupuytren’s contractures

 ARMS
• Spider naevi (telangiectatic lesions)
• Bruising
• Wasting
• Scratch marks (chronic cholestasis)
 FACE, EYES …
• Conjuctival pallor (anaemia)
• Sclera: jaundice, iritis
• Cornea: Kaiser Fleischer’s rings (Wilson’s disease)
• Xanthelasma (primary biliary cirrhosis)
• Parotid enlargement (alcohol)
Jaundice
Pale Conjunctiva, due to severe anemia
Parotid enlargement

Xanthelasma
fat builds up under
the surface of
the skin.
Evaluation of Frontal and Maxillary Sinuses
 MOUTH
• Breath (fetor hepaticus)
• Lips
– Angular stomatitis
– Cheilitis
– Ulceration
– Peutz-Jeghers syndrome
• Gums
– Gingivitis, bleeding
– Candida albicans
– Pigmentation
• Tongue
– Atrophic glossitis
– Leicoplakia
– Furring
Atrophic glossitis Thrush
 NECK AND CHEST
• Cervical lymphadenopathy
• Left supraclavicular fossa (Virchov’s node)
• Gynaecomastia
• Symmetry of the chest
 Skin
• The skin is the largest organ of the body
• One of the best indicators of general health
• The examination of the skin is dependent on inspection, but
palpation of a skin lesion must also be performed
• The color changes include
– Pallor
– Cyanosis
– Yellow skin (Icterus)
– Redness
– Pigmentation
– Discoloration
Cyanosis
 Discoloratio
Vitiligo n
• It is a skin condition in which there is loss of pigment
from areas of skin resulting in irregular white patches
with normal skin texture
• Associated with pernicious anemia, hyperthyroidism,
Addison’s disease
 Discoloration
Leukoplakia
• A precancerous lesion that develops on the tongue or
the inside of the cheek as a response to chronic
irritation
• Occasionaly, leukoplakia patches develop on the female
external genitalia
 Rashes
• Skin rashes are frequently one of the manifestation of systemic
diseases, and hence, they are important for the diagnosis of
some special diseases
• The different rashes may occur in infectious disease,
dermentological disease, drug or other allergic materials
• The rashes have some special regular patterns and
sharps
• Types of rashes
– Macule
– Roseola
– Papules
– Maculopapulae
 Macule
• A macule is small, flat, distinct colored area of skin

• Does not include a change in skin texture or thickness

 Rosela
• Rosela is a skin lesion that is small, solid, and
raised. It may be seen in measles, drug rashes,
eczema
 Papule
• A papule is defined as a small (5 millimeters
or less), solid lesion slightly elevated above
the surface of the skin.
 Maculopapulae
• It is plate lesion with redness around the
papules
• It can be seen in scarlet fever and drug-
induced rashes
 Urticaria
• Urticaria (hive) are raised red welts of variuos
size on the surface of the skin, often itchy, which
come and go. It is associated with allergic
reaction
 Herpes zoster

• Vesicles in a unilateral dermatomal pattern are typical of herpes zoster

 Subcutaneous hemorrhage
• Bleeding into the skin & subcutaneous tissues
• According to the size of bleeding, it may be subdivided
as follows:
petechia
<2mm purpura
3~5 mm
ecchymosis
>5mm

• A hematoma is a large collection that forms a lump

 Spider angioma
• Spider angioma is a group of abnormal blood vessel that
produces the appearance of a spider-web on the surface
of the skin
• A spider angioma lesion typically has a red dot in the
center with reddish extensions radiating out for some
distance around it
• Liver palms
 Spider angioma

From very small to 2 cm; pulsatility is often demonstrable, when pressure

with a glass slide is applied. Distribution: upper trunk, face, arms.
 Edema
• Excessive build up of fluid in the tissues

• Either occurs throughout the body (generalized

swelling) or limited to a specific part of the body

(localized swelling)
• It can be either pitting edema or non-pitting edema
• Mild : facial edema, peripheral edema
• Moderate: generalized edema
• Severe: generalized severe edema
Grading Edema
Protruded eyeballs and periorbital edema
 Lymph nodes
• The lymph nodes are distributed all over the body
• The general physical examination can only palpate the
superficial lymph notes
Palpating Anterior Cervical Lymph Nodes
Lymph nodes of the head and neck
 Cervical adenopathy

Massive right side cervical adenopathy due to

metastatic, intraoral squamous cell cancer.
Palpation of Epitrochlear Lymph
Nodes
Palpation of the Axilla
Left Axillary Adenopathy
 Lymph nodes
• Lymph node enlargement either localized or systemically

• Localized : lymphadenitis

tuberculosis

malignant metastasis

(gradually and painless)

• Systemically: lymphadenitis

lymphoma

leukemia
 Vital signs---pulse

60~100 /min
Childhood
Emotion
Aged
Night
Vital signs---blood pressure
• Clinical Examination
• Personal information
• Name: Age: Sex: Address:
• 1. General Findings
• • General appearance - Normal/ Healthy
• • Mental state/ intelligence/ consciousness–Patient conscious, co-operative, well
oriented in time, place and person
• • Body Build
• o Height -
• o Weight -
• o BMI -
• o Nutritional Status– Normal or average
• • Gait - Normal
• • Pallor - Absent
• • Icterus - Absent
• • Cyanosis - Absent
• • Clubbing - Absent
• • Edema(foot)- Absent
• • Lymph nodes – Not palpable
• • JVP– Not visible
• • Vitals
• o Temperature– ….measured/febrile/afebrile
• o Pulse -
• o Respiration -
• o BP -
 The systemic examination
• The various systems to be examined are :
• 1. Cardio - vascular system.
• 2. Respiratory system.
• 3. Digestive system .
• 4. Hemopoietic system .
• 5. Excretory system.
• 6. Reproductive system .
• 7. Endocrine system .
• 8. Nervous system .
• 9. Special senses.
Thank You