The general examination

Chapter 2 The general examination


The examination really begins from the moment you set eyes on the patient. Facial expression, tone of voice and body attitude may signal depression, even if the patient does not complain of feeling depressed.


The formal physical examination follows on from the history and calls on your major senses of sight, touch and hearing. Inspection, palpation, percussion and auscultation form the foundation of the physical examination and this formula is repeated each time you examine an organ system.


The physical examination begins with a general examination and is followed by examination of the skin, head and neck, heart and lungs, abdominal organs, musculoskeletal and neurological systems.



GENERAL EXAMINATION: FIRST IMPRESSIONS


At the first encounter, decide whether the patient looks well or not and whether there is any striking physical abnormality. Observe the posture, gait and character of the stride. You should quickly recognise the slow shuffling gait and ‘pill-rolling’ tremor of Parkinson’s disease or the unsteady broad-based gait of the ataxic patient. Patients with proximal muscle weakness may have difficulty rising from the waiting room chair and their gait may have a waddling appearance. Take note if the patient walks with a stick or other physical support.




imageSymptoms and signs: Observation of general appearance



• Does the patient look comfortable or distressed?

• Is the patient well or ill?

• Is there a recognisable syndrome?

• Is the patient well nourished?

• Is the patient well hydrated?

Short stature may reflect constitutional shortness, a distinct genetic syndrome or the consequence of intrauterine, childhood or adolescent growth retardation.


Posture may provide helpful information. Patients with acute pancreatitis find some relief lying with knees drawn towards the chest. Patients with peritonitis lie motionless, as any abdominal wall movement causes intense pain. In acute pericarditis, the patient finds modest relief by sitting forward; in left ventricular failure, patients breathe more easily when lying propped up on 3 or 4 pillows (orthopnoea).



FORMAL EXAMINATION


The examination requires full exposure.


Begin with a global inspection of overall appearance. When inspecting the face, you might be struck by a single sign such as a red eye or the characteristic facies associated with discrete syndromes.



THE EYE




imageSymptoms and signs: Quick testing of visual acuity



• Assess ability of each eye to read newspaper print

• Pinhole test

• Snellen chart


imageDifferential diagnosis: Main causes of red eye



• Conjunctivitis (infective, allergic, toxic)

• Keratitis (infective, foreign body, sicca syndrome)

• Acute closed-angle glaucoma

• Iritis

• Reiter’s syndrome


imageSymptoms and signs: Penlight inspection of the red eye



• Does the pupil react to light?

• Is the pupil smaller than expected or pinpoint?

• Is there a purulent discharge?

• What is the pattern of the redness?

• Is there a corneal ‘white spot’?

• Is there hypopyon or hyphaema?


imageRed flag – urgent referral: Indications for emergency referral to ophthalmology



• Unilateral red eye which is painful with nausea and vomitting (e.g. acute glaucoma)

• Associated loss of vision

• Corneal infiltrate or hypopyon


RECOGNISABLE SYNDROMES AND FACIES


Genetic or chromosomal syndromes that may present to clinicians caring for adults include Down’s syndrome, Turner’s syndrome, Marfan’s syndrome, tuberous sclerosis, albinism, the fragile X chromosome, Peutz–Jeghers syndrome, Waardenburg’s syndrome, familial hypercholesterolaemia and neurofibromatosis.




imageSymptoms and signs: Down’s syndrome (trisomy 21)



• Facies – oblique orbital fissures, epicanthic folds, small ears, flat nasal bridge, protruding tongue, Brushfield’s spots on iris

• Short stature

• Hands – single palmar crease, curved little finger, short hands

• Heart disease (endocardial cushion defects)

• Gap between first and second toes

• Learning difficulties


ENDOCRINE SYNDROMES


It is practical to consider the examination of the endocrine glands in the context of the overall general examination.


Distinct clinical syndromes occur in diseases of the thyroid, parathyroid, adrenal and pituitary glands.



Clinical examination of the thyroid gland




imageQuestions to ask: Hyperthyroidism



• Have you lost weight recently?

• Has your appetite changed (e.g. increased)?

• Have you noticed a change in bowel habit (e.g. increased)?

• Have you noticed a recent change in heat tolerance?

• Do you suffer from excessive sweating?

• Does your heart race or palpitate?

• Have you noticed a change in mood?


imageSymptoms and signs: Hyperthyroidism



• Weight loss, increased appetite

• Recent onset of heat intolerance

• Agitation, nervousness

• Hot, sweaty palms

• Fine peripheral tremor

• Bounding peripheral pulses

• Tachycardia, atrial fibrillation

• Lid retraction and lid lag

• Goitre, with or without overlying bruit

• Brisk tendon reflexes


GRAVES’ DISEASE




imageSymptoms and signs: Graves’ disease (autoimmune hyperthyroidism)



• Diffuse goitre with audible bruit

• Pretibial myxoedema, finger clubbing

• Onycholysis (Plummer’s nails)

• Lid retraction, lid lag

• Proptosis, exophthalmos

• Conjunctival oedema (chemosis)


Hypothyroidism


Hypothyroidism presents insidiously; the diagnosis may be readily apparent on general examination.




imageQuestions to ask: Hypothyroidism



• Has your weight changed?

• Has your bowel habit changed (e.g. constipation)?

• Is your hair falling out?

• Have you noticed a change in weather preference (e.g. cold intolerance)?

• Has there been a change in your voice (e.g. hoarse)?

• Do you suffer from pain in your hands (e.g. carpal tunnel syndrome)?


imageSymptoms and signs: Hypothyroidism



• Constipation, weight gain

• Hair loss

• Angina pectoris

• Hoarse, croaky voice

• Dry flaky skin

• Balding and loss of eyebrows (beginning laterally)

• Bradycardia

• Xanthelasmas (hyperlipidaemia)

• Goitre (especially with iodine deficiency)

• Effusions (pericardial or pleural)

• Delayed relaxation phase of tendon reflexes

• Carpal tunnel syndrome


imageDifferential diagnosis: Hypothyroidism



Congenital



• Congenital absence

• Inborn errors of thyroxine metabolism


Acquired



• Iodine deficiency (endemic goitre)

• Autoimmune thyroiditis (Hashimoto’s disease)

• Postradiotherapy for hyperthyroidism

• Postsurgical thyroidectomy

• Antithyroid drugs (e.g. carbimazole)

• Pituitary tumours and granulomas


Hyperparathyroidism


Hyperparathyroidism is usually detected by finding an abnormally high serum calcium level on routine blood testing. The clinical syndrome may be difficult to recognise, because the symptoms (‘moans’) dominate the signs (‘stones and bones’). The patient complains of tiredness and lethargy, excessive thirst and symptoms of increased urine output. There may be profound changes in the mental state and, in severe cases, drowsiness and even coma may occur. Renal stones are common and the patient may present with severe acute unilateral abdominal pain radiating towards the groin. There may be proximal muscle weakness (due to a myopathy), a thin opaque ring around the limbus of the cornea, and bone pain or radiological evidence of hyperparathyroidism.



Hypoparathyroidism


Surgical damage or removal of three of four parathyroid glands during neck surgery (usually thyroidectomy) is the most common cause of hypoparathyroidism. The serum calcium level is low (in the presence of a normal serum albumin). The major symptoms of acute hypoparathyroidism are paraesthesiae around the mouth, fingers and toes. Abnormal nerve and muscle irritability can be elicited with Chvostek’s (Fig. 2.1) and Trousseau’s signs (Fig. 2.2).


image

Fig. 2.1 Chvostek’s sign. Tap over the facial nerve in front of the ear. This causes a momentary twitch of the corner of the mouth on the same side as the irritable facial muscles contract.


image

Fig. 2.2 Trousseau’s sign. Inflate a sphygmomanometer cuff to above systolic pressure. Within approximately 4 min, there is characteristic carpopedal spasm of the hand. There is opposition of the thumb, extension of the interphalangeal joints and flexion of the metacarpophalangeal joints. This posture reverses spontaneously when the cuff is deflated.



Biochemical assessment of thyroid function


Thyroxine (T4) has a number of important metabolic effects and over- and underactivity results in characteristic clinical syndromes that may readily be recognised. Diagnosis of hyperthyroidism is confirmed by measuring the serum levels of T4 and triiodothyronine (T3), whereas in hypothyroidism the serum thyroid-stimulating hormone (TSH) level is elevated and T4 is subnormal.



Hyperadrenalism (Cushing’s syndrome)


Excessive glucocorticoids (either endogenous or exogenous) cause a significant change in body appearance which can be readily recognised as Cushing’s syndrome.



imageDifferential diagnosis: Hyperadrenalism



• Iatrogenic, exogenous steroids

• Bilateral adrenal hyperplasia

• Benign autonomous adrenal adenoma

• Malignant adrenal adenocarcinoma

• Non-metastatic tumour effect (e.g. lung cancer producing adrenocorticotrophic hormone (ACTH)-like peptide)

• Alcoholism causing pseudo-Cushing’s syndrome


imageSymptoms and signs: Cushing’s syndrome



• Round, moon-shaped, plethoric facies

• Hirsutes

• Acne

• Hypertension

• Buffalo hump on neck (fatty deposit)

• Central distribution of fat

• Proximal muscle weakness and wasting

• Purple skin striae


Hypoadrenalism and Addison’s disease


In acute adrenal failure, the clinical features may be non-specific and puzzling. The most helpful physical sign is the profound drop



imageSymptoms and signs: Presenting features of acute adrenal (Addisonian) crisis



• Profound dehydration, postural hypotension, shock

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Apr 20, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on The general examination

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