Introduction to Clinical ExaminationPractical No. 1

History taking: Collecting detail information about the subject/patient and his illness.

General examination of the subject: Different physical signs are elicited in general examination which direct towards the source of disease process (like examining for pallor, jaundice, edema, etc.).

Systemic examination: After completing general examination a thorough and detail examination of different systems is completed which gives an idea about the system which may be diseased giving rise to various signs and symptoms. Systemic examination is done with the help of inspection, palpation, percussion and auscultation.

Differential diagnosis: After completing systemic examination, the doctor tries to analyze the signs and symptoms observed and arrives at differential diagnosis.

Final diagnosis: If required, doctor takes help of special investigations like X-ray, blood examination, endoscopy etc. for arriving at final diagnosis, which is followed by treatment and follow-up or progress of the patient.

History of present illness: Detail history of complaints, i.e. what are his chief complaints; since when he is suffering from these complaints; what type of pain it is; extent of pain; whether relieved by certain positions and so on.

History of past illness: It includes review of past illness related or unrelated to present illness, any treatment received for the similar complaints in past or any other illness in past.

Family history: History of similar complaints in any other family members, any other illness any family member is/was suffering from.

Personal history: Make enquiries of personal habits, addictions, occupational history, residential history or social history. Also enquire about food habits, urine, bowel habits, appetite, sleep, etc.

General appearance.

Mental state and intelligence.

Consciousness and co-operation.

Built (height, weight).

State of nutrition.

Pallor (anemia).

Jaundice.

Cyanosis.

Clubbing.

Edema.

Lymphadenopathy.

Skin.

Vital data and signs.

General appearance: Look for the appearance of the subject/patient and observe whether he looks healthy, ill or very ill.

Mental state and intelligence: An idea about the patients level of intelligence is one of the most important information to be obtained from the interview. It helps to determine the suitable treatment. The educational status and occupation can give idea about his intelligence.

Consciousness and co-operation: The level of consciousness of the patient should be noted i.e. fully conscious, drowsy, semicoma, comatose. If fully conscious, note whether he is co-operative or not.

Built: It is skeletal structure of a person. It should be observed whether the subject is tall or short, lean or fat, muscular or asthenic. Height should be measured (vertical, arm span, etc), weight should be ascertained that it is normal for his age, sex. Also assess the development of secondary sexual characteristics like pubertal changes, development of breast, hair lines, etc.

State of nutrition: Assessment of the nutritional status of a patient is an important part of general examination. Along with dietary history, physical examinations like measuring bulk of muscles, skin fold thickness, anthropometric measurements (Height/Weight) is also recorded. It is performed to ascertain whether the patient is well nourished or malnourished. Malnourishment may be due to starvation, maldigestion of food, malabsorption of nutrients, etc.

Pallor: It is paleness of the skin. It depends on thickness of skin and also on amount and quality of blood in the capillaries. Thus it is seen when blood flow in capillaries is decreased as in anemia, shock. The sites to look for pallor are lower palpable conjunctiva, tip of tongue, soft palate, palm and nails. It's degrees can be + (mild), ++(moderate), +++(severe) anemia.

Jaundice: It is yellowish discoloration of the skin, mucus membrane and conjunctiva, due to presence of excess amount of bilirubin in the blood. Normal serum bilirubin is 0.2–0.8 mg percent. When the levels exceed 2 mg percent jaundice appears clinically. Bilirubin levels between 0.8–2 mg percent is called subclinical or latent jaundice.

Cyanosis: It is defined as the bluish discoloration of the skin and mucus membrane due to presence of reduced hemoglobin more than 5 gm percent in the blood. Normally Hb is 95 percent saturated in arterial blood, so out of 15 gm percent Hb, 14.25 gm percent is oxyhemoglobin while remaining 0.75 gm percent is reduced hemoglobin in arterial blood. The same values in venous blood are 10.5 g percent and 4.5 gm percent as venous Hb is 75 percent saturated with oxygen. The capillaries have mean of arterial and venous blood oxygen saturation. Thus in normal person capillaries have [(0.75 + 4.5)/2 = 2.6 gm percent] of reduced Hb. Therefore the color of normal skin is pink. When concentration of reduced Hb is more than 5.0 gm percent, the skin, mucous membrane becomes blue because of the dark color of reduced hemoglobin. Thus patients having severe anemia (Hb less than 5 gm percent may not exhibit cyanosis. Even in ‘CO’ (carbon monoxide) poisoning, there may not be cyanosis as ‘CO’ prevents reduction of oxyhemoglobin.

Clubbing: Bulbous enlargement of soft parts of the terminal phalanges with over curving of nails is called as clubbing.

Edema: Swelling of the skin and subcutaneous tissues due to accumulation of excess of free fluid in interstitial tissue spaces is called as edema. It can be localized, generalized, pitting or nonpitting type.

It is usually in dependant parts of the body. Dyspnea at rest is one of the associated features. The pathophysiology of edema in heart failure is:

Right sided cardiac failure results in building up of back pressure in venous system first, then liver and lastly in lower extremities thus resulting in edema over feet and abdomen.7

In renal diseases, edema first appears on face. Puffiness of lower eyelid in the morning is a characteristic feature. Nephrotic syndrome is commonest cause of edema. It's pathophysiology is:

Anemia along with severe pallor is associated with generalized edema. The pathophysiology is

Cirrhosis of liver, hepatic malignancies result in decreased synthesis of proteins by liver, hypoproteinemia and edema.

Lymphadenopathy: Lymph nodes in neck, axilla, inguinal region on either sides should be palpated for enlargement or any other abnormality as follows:

Skin: Skin should be examined in good day light to see for color, pigmentation, features like pallor, cyanosis, jaundice, albinism pustules, maculae, fissures, ulcers, scales, crusts, etc.