Physical examination Flashcards
Physical examination: end of the bed
Look at the patient.
Are they well or in extremis? what makes you think so?
Are they in pain? does the pain make them lie still (e.g. peritonitis) or writhe about (e.g. colic)?
What is the pattern of breathing- laboured, rapid, shallow, irregular, distressed?
Are they obese or cachectic?
Is their behaviour appropriate?
Can you detect any unusual smell, e.g. hepatic fetor, cigarettes, alcohol?
Take a moment to look around the bed for other clues, e.g. inhalers, insulin administration kit, walking aids, etc.
Physical examination: face and body habitus
Does the patient’s appearance suggest any particular diseases, e.g. acromegaly, thyrotoxicosis, myxoedema, Cushing’s syndrome, or hypopituitarism?
Is there an abnormal distribution of body hair, e.g. bearded female or hairless male, suggestive of endocrine disease?
Is there anything about the patient to trigger thoughts about Paget’s disease, Marfan’s, myotonia, or Parkinson’s syndrome\?
Look for rashes, e.g. malar flush of mitral disease and butterfly rash of SLE.
Physical examination: peripheral stigmata of disease
Specific signs are associated with different diseases: consider the nails (koilonychia = iron deficiency), subcutaneous nodules (rheumatoid, neurofibroma?), and look for lymph nodes (cervical, axillary, inguinal).
Skin colour:
- blue/purple = cyanosis, can also be central only.
- yellow = jaundice (yellow skin can be caused by uraemia, pernicious anaemia, carotenaemia- check the sclera).
- pallor: non-specific, anaemia is assessed from the palmar creases and conjunctivae, usually pale if Hb <80-90g/L.
- hyperpigmentation = Addison’s, haemochromatosis (slate grey), and amiodarone, gold, silver, and minocycline therapy.
Charts: temperature, blood pressure and pulse trends, urine (urinalysis and input/output charts).
Physical examination: fluid status
When admitting an unwell patient, don’t forget to assess their hydration, check skin turgor and mucous membranes, look for sunken eyes, and check capillary refill (if well perfused <2s) and JVP.
Signs: cyanosis
Dusky blue skin (peripheral- of the fingers) or mucosae (central- of the tongue) representing 50g/L of Hb in its reduced (hence hypoxic) form, it occurs more readily in polcythaemia than anaemia.
Causes:
- lung disease with inadequate oxygen transfer, e.g. luminal obstruction, asthma, COPD, pneumonia, PE, pulmonary oedema- may be correctible by increased inspired O2.
- congenital cyanotic heart disease, where there is a mixture, e.g. transposition of the great arteries or right-to-left shunt (e.g. VSD with Eisenmenger’s syndrome)- cyanosis is not reversed by increasing inspired oxygen.
- rare causes = methaemoglobinaemia, a congenital or acquired red cell disorder.
Acute cyanosis is an emergency.
Is there asthma, an inhaled foreign body, a pneumothorax or pulmonary oedema?
Peripheral cyanosis will occur in causes of central cyanosis, but may also be induced by changes in the peripheral and cutaneous vascular systems in patients with normal oxygen saturations.
It occurs in the cold, in hypovolaemia, and in arterial disease.
Signs: pallor
May be racial or familial, or from anaemia, shocks/faints, Stokes-Adams attack (pale first, then flushing), hypothyroidism, hypopituitarism, and albinism.
Anaemia is haemoglobin concentration <130g/L in men and <120g/L in non-pregnant women.
It may be assessed from the conjunctivae and skin creases.
Koilonychia and stomatitis suggest iron deficiency.
Anaemia with jaundice suggests haemolytic.
If pallor just one limb or digit, think of emboli.
Signs: skin discolouration
Generalised hyperpigmentation may be genetic (racial) or due to radiation, raised ACTH (cross-reacts with melanin receptors, e.g. Addison’s disease, Nelson’s syndrome, ectopic ACTH in bronchial carcinoma), chronic kidney disease (raised urea), malabsorption, chloasma (seen in pregnancy or with the oral contraceptive pill), biliary cirrhosis, haemochromatosis, carotenaemia, or drugs e.g. chlorpromazine, busulfan, amiodarone, gold.
Signs: obesity
BMI >30kg/m^2.
Higher waist to hip ratio, indicating central fat distribution, is commoner in males and is associated with greater health risks, including T2DM, IHD, dyslipidaemia, HTN, osteoarthritis of weight-bearing joints, and cancer (breast and bowel).
The majority of cases are not due to specific metabolic disorders.
Lifestyle change is key to treatment, to increase energy expenditure and reduce intake.
Medication ± surgery may be considered if the patient fulfils strict criteria (BMI >40kg/m^2, or >35kg/m^2 with other significant disease that could improve with weight loss, non-surgical measures have been tried and failed, patient receives intensive management in a tier 3 service, and fit for anaesthesia and surgery.
Conditions associated with obesity include: genetic (Prader-Willi syndrome, Lawrence-Moon syndrome), hypothyroidism, Cushing’s syndrome, and hypothalamic damage (e.g. tumour or trauma causing damage to satiety regions).
Signs: lymphadenopathy
Causes of lymphadenopathy are either reactive or infiltrative.
Reactive, infective, bacterial causes: e.g. pyogenic, TB, brucella, syphilis.
Reactive, infective, viral causes: EBV, HIV, CMV, infectious hepatitis.
Reactive, infective, others: toxoplasmosis, trypanosomiasis.
Reactive, non-infective causes: sarcoidosis, amyloidosis, berylliosis, connective tissue disease (e.g. rheumatoid, SLE), dermatological (eczema, psoriasis), drugs (e.g. phenytoin).
Infiltrative, benign: histiocytosis, lipoidoses.
Infiltrative, malignant, haematological: lymphoma or leukaemia, ALL, CLL, AML.
Infiltrative, malignant, metastatic carcinoma: from breast, lung, bowel, prostate, kidney, or head and neck cancers.
Signs: pitting oedema
Fluid can either be squeezed out of the veins (increased hydrostatic pressure, e.g. DVT, right heart failure) or diffuse out because of reduced oncotic pressure (low plasma proteins, e.g. cirrhosis, nephrotic syndrome, protein-losing enteropathy) leading to an osmotic gradient with the issues.
Signs: periorbital oedema
The eyelid skin is very think so periorbital oedema is usually the first sign- think of allergies (contact dermatitis, e.g. from eye makeup, stings), angioedema (can be hereditary), infection (orbital cellulitis can be life-threatening; EBV; sinusitis).
If there is proptosis, think Graves’ disease, connective tissue diseases (e.g. dermatomyositis, SLE, sarcoid, amyloid).
Signs: non-pitting oedema
Non-indentable lymphoedema due to poor lymphatic drainage.
Can be due to radiotherapy, malignant infiltration, infection, filariasis, or rarely primary lymphoedema (Milroy’s syndrome).
Signs: weight loss
Feature of chronic disease, depression, malnutrition, malignancy, chronic infections (e.g. TB, HIV/enteropathic AIDS), diabetes mellitus, and hyperthyroidism (with increased appetite).
Severe generalised muscle wasting is also seen as part of a number of degenerative neurological diseases and in cardiac failure (cardiac cachexia), although in the latter, right heart failure may not make weight loss a major complaint.
Do not forget anorexia nervosa as an underlying cause of weight loss.
Signs: cachexia
General muscle wasting from famine, or decreased eating (dementia, stroke, MND, anorexia nervosa), malabsorption (enteropathic AIDS/slim disease/Cryptosporidium, Whipple’s) or increased catabolism (neoplasia, CCF, TB, chronic kidney disease, increased leptin).
