General Physical Examination

          General Physical Examination :

                                        

History

Introductory information

• Introduce, shake hands.
• Name, age, sex, residence, occupation, DOA.

Presenting complaint

• What is the problem lately. Alternatively: What is the problem that brought you to hospital [record in pt's own words].

History of presenting complaint

SOCRATES:

• Site: where, local/ diffuse, "Show me where it is worst".
• Onset: rapid/ gradual, pattern, worse/ better, what did when symptom began.
• Character: vertigo/ lightheaded, pain: sharp/ dull/ stab/ burn/ cramp/ crushing.
• Radiation [usually just if pain].
• Alleviating factors, "What do you do after it comes on?"
• Time course: when last felt well, chronic: why came now.
• Exacerbating factors, "What are you doing when it comes on?".
• Severity: scale of 1-10.
• Associated symptoms.
• Impact of symptoms on life: "Does it interrupt your life".

• "Were you referred here by your GP, or did you come in through casualty?" 

Past medical, surgical history

• Past illnesses, operations.
• Childhood illness, obs/gyn.
• Tests and treatment prescribed for these.
  • Drugs remaining relevant: corticosteroids, OCP, anti-HTN, chemotherapy, radiotherapy.
• Checklist of dz's:
  MJ THREADS:
  MI, Jaundice, TB, HTN, Rheumatic fever, Epilepsy, Asthma, Diabetes, Stroke
• Problems with the anesthetic in surgery.

  Gynecological history

• Time of menarche, if periods regular, menopause.
• Possibility of pregnant, number of children, number of miscarriages (GPAL).
• Length of cycles, length of period, first day of your last period.

Family history

• The current complaint in parents/ siblings: health, cause of death, age of onset, age of death [eg: heart dz,  bowel CA, breast CA].
• Health of parents/ siblings/ children: "Are your parents still alive?" "How is the health of your..."
• Hereditary dz suspected: do a family tree.

Social, personal history

• Birthplace, residence.
• Race and migration [if relevant].
• Present occupation [and what do they do there], level of education.
• Any others at workplace with same complaint.
• Social habits [if relevant].
• Smoking: "Ever smoked, how many per day, for how long, type [cigarette, pipe, chew]".
• Alcohol: do you drink. If yes: type, how much, how often.
• Travel: where, how lived when there, immunization/ prophylactic status when went [if relevant].
• Marital status [and quality], health of spouse/ children, sex activity [discretely, if relevant].
• Other household members, pets [if infections/ allergies], social support, whether patient can manage at home: "Who's with you there at home".
• Diet, physical activity.
• Community care: home help, meals on wheels. 
• "Is there some things that worry you about the symptoms you are having?"

Drug history

• Prescriptions currently on [don't trust their written doses, do your own when re-prescribe].
• Over-the-counters.
• OCP.
• Supplements, HRT.
• Alternative medications.
• Recreational drugs.
• Allergies: drugs [and what was reaction], dyes. Pt. often will confuse side effect with a reaction.

Systems review

• See Systems.

Examination

Environment

General appearance

• Pre-exam checklist: WIPE:
  • Wash your hands
  • Introduce yourself to pt
  • Position pt
  • Expose the area
• Always examine from the R side of the pt.
• Ask pt. if tenderness anywhere, before start touching them.
• Skin colors. See Skin Colors Reference.

Posture, weight, body shape

• If pt. enters, examine gait.
• Posture, stature, height..
• Obesity [BMI = kg/m^2. Normal <25].
• Limb amputations, deformities.
• Physique expected for age.

Hydration

• Sunken orbits.
• Mucus membrane dryness.
• Axillae.
• Skin turgor [pinch skin: normal returns immediately].
• Postural hypotension [less BP when sit, stand].
• Peripheral perfusion [press nose, time capillary return].
• Examine weight loss over hours.

Vital signs

·         Often logged on ward chart.

·         See Taking Vital Signs Reference

1.      Temperature

·         Types:
• Axillary: worst
• Oral
• Aural
• Rectal: best

·         Timing:
• Continued
• Intermittent
• Remittent
• Relapsing

·         Nomenlature:.
• Hyperpyrexia: >41.6°C
• Hypothermia: <35°C

2.      Pulse

v  Shake hands: Dr's L to pt's L.

v  During handshake grip Dr's R hand takes pulse.

v  Measure for 15 seconds, then multiple by 4 to get rate/min.

v  Assess rhythm, character, delays.

3.      Respiratory rate

·         Don't announce measuring it, since under pt's control.

·         Adult normal: 14-20/min.

4.      Blood pressure

·         Pt's anticubital fossa level with heart, arm slightly bent.

·         Proper-sized cuff over brachial a. 2cm above anticubital fold.

·         Inflate cuff until pulse disappears to tell systolic
• If HTN, then need to palpate radial as inflate.

·         Stethoscope over brachial a., inflate cuff 30mmHg more.

·         Release pressure, when hear pulse, tells diastolic.

.

Nails

• Clubbing.
• Nail signs.
• Nail fold.
• See Nails Reference.

Hands

• Palms:
  • Palmar erythema (cirrhosis, polycythaemia, pregnancy).
  • Pigmentation of crease (Addison's, but normal in asians, blacks).
  • Pallor of palmar crease. Better results if hyperextend fingers, or stretch skin on either side of crease (anemia).
  • Dupuytren's contracture [fibrosis, contracture of palm's fascia] (liver dz, epilepsy, trauma, elderly).
• Joints:
  • Herberdens, Bouchards (OA).
  • Swollen PIP, distal PIP spared (RA).

Head

• Hair: deficiency, excess.
• Facial hallmarks (Down's, Grave's, acromegaly, Cushing's, etc).
• Teeth: nicotine stains.

Examination tips

• Initial examination is from the foot of the bed.
• Always ask if any part tender, before touching pt.
• Watch pt's head as palpate, to look for pain flinches.
• Percussion is R middle finger hitting middle of middle phalynx of L middle finger.
• To measure circumference of limbs, choose the bony landmark on each, measure down the correct distance, then take the circumference at that point.

General Systems Review

Cardiovascular

• Chest pain, pressure
• Shortness of breath, exertion required
• Lie flat or use pillows, how many pillows
• Awoke breathless at night
• Noticed heart racing, aware of heartbeat
• Ankle swelling
• Cold/ blue hands, feet

Pulmonary

• Cough: sputum, blood
• Shortness of breath, wheeze
• Snore loudly, apnea
• Fever, night sweats
• Recent chest X-ray
• Breast: lumps, bleeding, masses, discharge

Alimentary

• Weight, appetite changes
• Abdominal pain or discomfort
• Bloating, distention
• Indigestion
• Nausea, vomiting: contents
• Bowel habits: change, number
• Incontinence, constipation/ diarrhea
• Stool: colour, blood/ black, consistency, mucous

Nervous

• Headaches
• Vision, hearing, speech troubles
• Dizziness, vertigo
• Faints, seizures, blackouts
• Weakness, numbness
• Sleep disturbances
• Ataxia, tremors
• Concentration, memory

Genitourinary

• Incontinence
• Frequency, dysuria, nocturia
• Genitourinary pain, discomfort
• Hesitancy, dribbling
• Changes to quantity, colour
• Blood in urine
• Genital rashes, lumps
• Sex life problems
• Pain, bleeding in periods

Endocrine

• Prefer hot or cold weather
• Sweating
• Fatigue
• Hand trembling
• Neck swelling
• Skin, hair, voice changes
• Thirst

Integumental

• Itchiness
• Rashes
• Bruising
• Swelling
• Colour changes

Hematological

• Bruise easily, difficulty stopping bleeds
• Lumps under arms, neck, loin
• Clots in legs, lungs
• Fevers, shakes, shivers

Rheumatoid

• Joints: pain, stiffness, swollen
• Variation in joint pain during day
• Fingers painful/ blue in cold
• Dry mouth, red eyes
• Skin rash
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