General examination (2) — Past Paper OmpathStudy

General Examination — Complete Study Notes All 35 slides were processed. This is a clinical examination lecture, not a numbered question paper. Visual-only slides and clinical photographs remain available in the attached original page images. General examination Dr Okanga N. MKU University. 3rd year class Outline of general exam 1. Posture and gait 9. Axilla 2. Speech and interaction 10. Skin 3. Physique and nutrition 11. Pulses 4. Temperature 12. Blood pressure 5. Hands 13. Leg and feet 6. Odour 14. Breast 7. Face and Neck 8. Lymph nodes The setting Make your patients comfortable – (They are in unfamiliar environment, they feel exposed, are anxious about the findings) Introduce your self politely, ask for permission and explain what you are about to do; I am a “student doctor” from Maseno University, I need to examine you from head to toe, could you please remove your shirt/blouse and trousers, remain with your inner wear, cover your self with this sheet. Warm private, quiet area. Chaperone when a male doctor is examining a female patient and for intimate exam ( rectum, vagina, breast) Setting Examine from the right side of the bed, ideally patient should be lying semi-recumbent at 45 degrees. Left handed examiners should strive to master this approach ( easier to examine JVP, apex beat and abdominal organs from the right side of the bed/couch) Ensure patient is comfortable at all times – look at their face for signs of discomfort, adjust pillow, cover them up, etc as required. How ill is your patient ? Looks well, mildly ill or severely ill. If severely ill full examination may not be possible, sort out the acute emergency first. Posture and gait Observe the patient from the moment you meet in the waiting area. Does he rise easily from a chair? Does he walk freely, stiffly or with a limp; confidently or apparently fearful of falling; aided or unaided? Stroke patients – hemiplegic gait, Parkinson’s disease – Parkinsonian gait Painful joint – atalgic gait. Sensory ataxia – High stepping gait Cerebellar gait – Veers towards side of lesion. Proximal muscle weakness – Difficulty rising from seated position Posture and gait Left side heart failure – Propped up in bed, they develop difficulty in breathing on lying horizontally. Peritonitis – Lie supine, quiet and still sometimes with legs drawn up. Renal colic – restless, rolls around in a futile attempt to find a position free from pain. Meningitis – Neck bent backwards. Page 7 — visual slide See the attached original page image. Page 8 — visual slide See the attached original page image. Speech and interaction Face shows real feelings better than words. Did your patient smile when you introduced yourself? Was it symmetrical or was there obvious facial weakness? Did he make eye contact? Was the face animated or expressionless as in Parkinson’s disease? Hoarse voice – laryngeal disease, recurrent laryngeal nerve palsy or myxoedema? Pressured speech - thyrotoxicosis or mania. Monotonous speech and expressionless face – severe depression? Slurred speech - cerebellar disease or a previous stroke? Physique and nutrition note if the patient is cachectic, slim, plump or obese Indicators of poor nutrition – temporalis muscle wasting, cracked skin, loss of scalp and body hair and poor wound healing. Atrophic glossitis – B 12 def, tongue is smooth with loss of papillae, Angular stomatitis – Softening of skin on the angles of mouth followed by cracking, usually indicates vit B or Fe def. Pellagra – Photosensitive dermatitis, niacin deficiency. Page 11 — visual slide See the attached original page image. Temperature Diurnal variation exists – lowest values morning, Highest between 6pm and 10pm. In women, ovulation is associated with a 0.5°C rise in temperature. Normal oral temp 35.8 to 37 degrees Celsius, axillary 35.3 to 36.5 Celsius, Rectal 36.3 – 37.5 celcius. Hands Strength of hand shake – Weak in neurological or musculoskeletal disorders. Tremor – Fine in thyrotoxicosis, recent Beta adrenergic therapy, Pill rolling tremor occurs in parkinsonism, jerky tremor occurs in hepatic or uremic encephalopathy, intention tremor in cerebellar disease. Dupuytren’s contracture - thickening of tissue over the flexor tendon of the ring finger at the level of the distal palmar crease. Risk factors include family hx, alcoholism, diabetes, liver disease, With time flexion contracture of the metacarpophalangeal and proximal interphalangeal Joints occurs. Flexion contracture of the other fingers may follow
Hands Clubbing – nails are convex both longitudinally and transversely. Occurs in heart, lung, GI conditions - cyanotic heart disease, bronchiectasis, empyema, bronchial carcinoma, fibrosing alveolitis, inflammatory bowel disease and infective endocarditis. Lovibond’s angle Increased in clubbing Page 17 — visual slide See the attached original page image. Hands Osler’s nodes – transient, tender swellings due to dermal infarcts from septic cardiac vegetations. Splinter hemorrhages – Tiny blood spots un