Chapter Outline
- ■ Aims and Objectives
- ■ Doctor-Patient Interrelationship
- ■ Case History
- ■ General Examination
- ■ Pulse
- ■ Respiration
- ■ Blood Pressure
- ■ Temperature
- ■ Clinical Examination
- ■ Examination of Skin
- ■ Examination of Face
- ■ Constitution
- ■ Stature
- ■ State of Nutrition
- ■ Oedema
- ■ Examination of Mouth and Pharynx
- ■ Examination of Neck
- ■ Examination of Hands and Fingers
- ■ Differential Diagnosis
- ■ Investigations
- ■ Diagnosis
- ■ Treatment
- ■ Prognosis
- ■ Follow-up
Aims and Objectives
The term general medicine is implied to learn and analyze the health of the patient in totality, thus the knowledge of general medicine is very important for dental graduates in order to come to relevant diagnosis and treatment planning.
- Aims: The aim of the dental student should be:
- To identify the disease and determine its diagnosis if any underlying systemic condition.
- To make appropriate referrals to a concerned speciality if required.
- To render timely treatment or should be in a capacity to suggest or organize the same.
- Objectives: The following objectives will help him in achieving his aim:
- Complete detailed history
- Complete clinical evaluation
- Complete investigation
- Differential diagnosis.
Doctor-Patient Interrelationship
To understand the importance of doctor-patient interrelationship, one must recall the statement of Dr Francis Peabody, ‘the significance of intimate personal relationship between physician and patient cannot be too strongly emphasized, for in an extraordinary large number of cases both the diagnosis and treatment are directly dependent on it. One of the essential qualities of clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient ’. If you listen to your patient long enough without interrupting, they will tell you what is wrong with them. Eighty per cent of accurate final diagnosis could be arrived at the end of carefully listening to the patient and only 20% more refined by physical examination and investigations. We must remind our younger generation that ‘cure rarely, comfort mostly, but console always’. Even before going into the patient's complaints, important facts can be glanced from the following data that is asked as a routine from every patient and help the consulting doctor to arrive at a most probable conclusion to the patient's problems.
Case History
- Name: It gives a clue of the country, state and religion to which the patient may belong.
- Age: Diseases occurring in childhood are occasionally congenital in origin. Degenerative, neoplastic and vascular disorders are more common in the middle aged or elderly. In women beyond the menopausal age group, the incidence of problems like ischaemic heart disease (IHD) increases in equal proportion as that in their male counterparts.4
- Sex: Males are prone to inherit certain conditions that are transmitted as X-linked recessive disorders, e.g. haemophilia. They are more prone to develop conditions like IHD, bronchogenic carcinoma and decompensated liver disease, as they are habituated to smoking and consumption of alcohol, in larger numbers than their female counterparts.Females are more prone for developing autoimmune disorders like systemic lupus erythematosus (SLE), thyroid disorders, etc.
- Religion: Jews practice circumcision soon after birth, and thus, development of carcinoma of penis is rare in them. Muslims do not consume alcohol and are less prone to develop problems related to its consumption, e.g. decompensated liver disease. Sikhs do not smoke and are less likely to develop problems related to smoking, e.g. carcinoma of lung. Certain sects of Hindus do not consume meat products and consume a high fibre diet and are therefore protected from developing carcinoma of the colon.
- Address: People hailing from the urban region are prone to develop problems related to urbanization like exposure to constant stress and atmospheric pollutants (industrial and vehicular) and problems developing consequent to this, e.g. IHD, chronic obstructive pulmonary disease (COPD), interstitial lung disease, etc. Inhabitants of mountains or hilly regions may develop problems like primary pulmonary hypertension, may have a persistent patent ductus arteriosus (PDA) (from childhood) or may be goitrous secondary to iodine deficiency. The particular place from which the patient hails may be endemic for certain diseases, e.g. fluorosis prevalent in certain pockets in Andhra Pradesh.
- The presenting complaint (Table 1.1): Allow the patient to tell his complaints in his own words. Do not ask leading questions to the patient. The current complaints and their duration should be noted in a chronological order.
- History of present illness: Allow the patient to elaborate on the story of his illness from its onset to its present state. Take care so as not to ask any leading questions to the patient which may distort the patient's history. The doctor may, however, interrupt the patient to ask for the presence of ‘positive’ or ‘negative’ symptoms pertaining to patient's current problems. In analysis of the symptoms, it is important to consider the mode of onset of the illness (acute, subacute, or insidious) and the progression of the illness to the present state (gradually deteriorating, getting better, remaining the same or having remissions and exacerbations). A review of all the systems can be made by asking the patient on the presence or absence of symptoms pertaining to a particular system. Clinician should record the history of pain such as onset, type, severity and, aggravating and relieving factors.
- History of previous illnesses: This should include all important previous illnesses, operations, or injuries that the patient might have suffered since birth. The mode of delivery and the timing of attainment of the various developmental milestones in infancy may be important in some cases. It is always wise to be cautious while accepting readymade diagnosis from the patient like ‘typhoid fever’, ‘malaria’, etc. unless the patient has records of the mentioned illness. Tactful enquiry about sexually transmitted diseases and their treatment, when considered of being possible relevance to the patient's problem, should be made.
- The menstrual history: Following should be enquired:
- Age of menarche
- Duration of each cycle
- Regular or irregular cycles
- Approximate volume of blood loss in each menstrual cycle
- Age of attainment of menopause
- Postmenopausal bleeding.
- Obstetric history: Following should be enquired:
- Number of times the patient conceived.
- Number of times pregnancy was carried to term.
- Number of abortions (spontaneous or therapeutic)
- Number of living children, their ages and the age of the last child delivered.
- The time interval between successive pregnancies/ abortions.
- Mode of delivery (vaginal, forceps assisted, or caesarean).
- Development of oedema in legs, HTN, seizures in the antenatal or postnatal period (seizure within 48 hours of delivery is due to pregnancy-induced HTN, beyond 48 hours may be due to cerebral sinus thrombosis).
- Presence of impaired glucose tolerance in the course of pregnancy or history of having given birth to a large baby may give a clue to the presence of diabetes mellitus (DM) in the patient.
- Family history: Enquire about the presence of consanguinity in the patient's parents, any disease states in the patient's parents, brothers, sisters and close relatives (presence of disease states like HTN, DM, IHD in the above may make the patient more prone to develop a similar problem). Presence of a hereditary disorder prevalent in the family should be enquired for. Marital status of the patient and the number of children that the patient has should also be enquired (Infertility in a patient may give a clue to the presence of immotile cilia syndrome, cystic fibrosis or Young's syndrome).
- Social history: Enquire about the patient's family lifestyle, daily habits and diet; about the nature of the patient's work (hard work or sedentary), the possibility of overcrowding at home (overcrowding aids in the spread of communicable diseases) and the sanitation in and around the house; about the presence of pets in the house; about the use of alcohol (number of days in a week and also the quantity consumed each day), tobacco (whether chewed or smoked) and betel nut.
- Treatment history: This should include all previous medical and surgical treatments and also any medication that the patient is continuing till date. Details of drugs taken, including analgesics, oral contraceptives, psychotropic drugs, previous surgery and radiotherapy are particularly important to find out if the patient had been allergic or had experienced any untoward reactions to any medication that he may have consumed previously. It may be helpful as the same medication can be avoided in the patient in future and the patient is also appraised of the same. Knowledge of any current therapy that the patient may be taking is necessary in order to avoid adverse drug reactions, when new drugs are introduced by the consulting doctor.
Chewing betel nut or tobacco is a habit common with people living in the rural areas, and this increases the risk of developing oral malignancies. Inquire about history of travels abroad or other places within the country, as it may give a clue to the import of a disease by the patient endemic in the place visited.
- Occupational history: Enquiry must be made on all previous and present occupations, as it may give a clue to the presence of an occupational disease in the patient and also in planning the rehabilitation, e.g:
- Mesothelioma: Exposure to asbestos.
- Carcinoma of the urinary bladder: Exposure to aromatic amines in dye stuff industry.
- Silicosis: Occurs in mine workers.On the other hand, the presence of disease in an individual may make him unfit for his occupation by proving to be hazardous to him as well as to others, e.g:
- Salmonella infection or carrier state in food handlers.
- Epilepsy in drivers of public transport vehicles.
General Examination
General examination of the patient is done with an objective to get an overall impression about the general state of health and draws attention to the system that is maximally deranged so that the physician can start systematic examination with that system first.6
Pulse
The radial pulse should be examined and its rate, rhythm and character should be noted. The right radial pulse is palpated with the tips of three fingers of the left hand. Normal pulse rate is 60–100 beats per minute. Tachycardia refers to pulse rate above 100 beats per minute and may occur due to anxiety, after exercise, fever and hyperthyroidism. Bradycardia refers to pulse below 60 beats per minute and is seen in trained athletes or may be a sign of heart block.
Respiration
Respiratory rate is counted by watching the movement of the abdomen. Normal respiratory rate is 14–18 breaths per minute. Increase in respiratory rate occurs in pneumonia, pulmonary oedema, asthma, pulmonary embolism and metabolic acidosis. Respiratory rate decreases in narcotic poisoning, raised intracranial tension and in deep coma.
Blood Pressure
The patient is seated comfortably or in lying down position, blood pressure (BP) cuff of adequate size is tied properly permitting introduction of one finger (Fig. 1.1). The cuff is tied in a way so that it is 2–3 cm above the elbow joint. The hand should be kept in a position to ensure that the cuff remains at the level of heart.
Diastolic pressure closely corresponds to phase V. However, in aortic regurgitation, the disappearance point is extremely low, sometimes 0 mm Hg and so phase IV is taken as diastolic BP in adults as well as children. Normal BP in adults is 100–120 mm Hg systolic and 70–84 mm Hg diastolic. Normal BP differs with age and during pregnancy. Elevation of BP is seen in systemic HTN, increased intracranial tension, and several other disease. In shock, the BP decreases below 80/40 mm of Hg.
Temperature
By placing the dorsum of the hand on the forehead, temperature can be easily assessed if the patient is febrile or not. But the exact temperature has to be recorded by using a clinical thermometer.
The normal diurnal variation is 1°F. The normal body temperature is more towards the evening because of increased basal metabolic rate (BMR) and increased skeletal muscle activity. Rectal temperature is 0.6°C (1°F) higher than oral temperature. Oral temperature is 0.6°C (1°F) higher than temperature recorded in the axilla.
Fever
It is an elevation of body temperature above the normal circadian variation as a result of the change in the thermoregulatory centre, located in the hypothalamus.
Normal | 37–37.6°C (98.6–99.6°F) |
Febrile | Above 37.8°C (100°F) |
Hyperpyrexia | > 41°C (>06°F) |
Hypothermia | 35°C (95°F) |
Febrile Convulsions
It occurs in infants and children less than 5 years old. Convulsions are common at temperatures more than 40°C. It may not be a sign of cerebral disease.
Patterns of Fever
Continuous Fever
The temperature remains elevated above normal without touching the baseline and the fluctuation does not exceed 0.6°C (1°F) (diurnal variation), e.g. lobar pneumonia, infective endocarditis, enteric fever, etc.
Remittent Fever
The temperature fluctuation exceeds 0.6°C (1°F), but does not touch the baseline.
Intermittent Fever
The elevated temperature touches the baseline in between. In hectic or septic type of intermittent fever, the diurnal variation is extremely large (as in septicaemia). Quotidian fever is a hectic fever occurring daily.
Relapsing Fever
Febrile episodes are separated by normal temperature for more than 1 day, e.g. borrelia infection, rat bite fever.
- Tertian fever occurs on the 1st and 3rd day, e.g. Plasmodium vivax, P. ovale, falciparum.
- Quartan fever occurs on 1st and 4th day, e.g. P. malariae.
- Pel-Ebstein fever: Lasts for 3–10 days followed by afebrile period of 3–10 days, e.g. Hodgkins lymphoma and other lymphomas.
- Saddle back fever: In which initially fever lasts for 2–3 days, followed by a remission lasting for 2 days and the fever reappears and continues for 2–3 days, e.g. dengue fever.
- In cyclic neutropenia fever occurs every 21 days.
Hyperpyrexia
It is an elevation of body's core temperature, above 41°C (106°F), due to inadequate dissipation of heat. It is a medical emergency, since the patient is prone to sudden cardiorespiratory arrest.
Causes of Hyperpyrexia
- Heat stroke
- Thyroid storm
- Pontine haemorrhage
- Rheumatic fever
- Meningococcal meningitis
- Drugs (atropine)
- Septicaemia
- Cerebral malaria.
Treatment
It is treated with parenteral antipyretics to set the elevated thermostat point to a lower level. Physical cooling aids in reducing the body temperature are employed. Chlorpromazine is sometimes helpful in reducing the body temperature.
Hyperthermia
In hyperthermia, the body temperature is raised with normal setting of thermoregulatory centre and the diurnal variation is absent. There is an uncontrolled increase in body temperature that exceeds body's ability to lose heat.
Causes
- Heat stroke
- Malignant hyperthermia
- Thyrotoxicosis
- Pheochromocytoma
- Hypothalamic fever
- Drugs: Amphetamine, atropine.
Pyrexia of Unknown Origin
Pyrexia of unknown origin (PUO) is defined as the presence of persistent high temperature greater than 101.2°F (38.4°C) on several occasions accompanied by more than 3 weeks of illness and failure to reach a diagnosis despite week of impatient investigations.
Investigations
- Erythrocyte sedimentation rate (ESR)-platelet correlation: If ESR is more than 100 mm/hour with thrombocytosis, think of:
- Tuberculosis
- Malignancy
- Connective tissue disease.
Erythrocyte sedimentation rate more than 100 mm/hour without thrombocytosis, think of viral infections.
- Alkaline phosphatase may be elevated in biliary tract infections, alcoholic hepatitis and primary and secondary cancer of liver.
- Blood culture
- Serological tests (fourfold rise significant): Useful in:
- Enteric fever
- Hepatitis
- Cytomegalovirus (CMV) infection
- Amoebiasis
- Human immunodeficiency virus (HIV).
- Imaging techniques
- Chest X Ray (CXR): In all patients with PUO, when initial X-ray of chest is normal, a second X-ray must be taken after 3 weeks to rule out miliary tuberculosis (time taken for radiological opacity to appear).
- Ultrasound: Excellent imaging is procured in thin individuals and poor imaging in obese individuals.
- Computed tomography (CT) scan: It gives excellent imaging in obese patients also.
- Magnetic resonance imaging (MRI) scan: It gives the best resolution of tissue planes of differing intensity. It has an advantage over CT scan when studying bone, brain, pelvis, spinal cord and large vessels in thorax. MRI is contraindicated when metal clips are present.
- Radionuclide scans: 99mTc-sulphur colloid is used for scanning liver and spleen. 111Indium–labelled leucocytes are used for detection of intra-abdominal abscess.
Ninety percent of PUOs are diagnosed by proper evaluation. The rest recover under a watchful non-interference. The duration of fever increases the likelihood of infection as the cause of PUO is remote.
Clinical Examination
Inspection
Inspection is through visualization of the patient with naked eye. During inspection all the external signs appearance, weight, skin colour, breathing pattern, walking style (Gait) and manner of speaking; and gross deviations—scars, visible lumps, swelling, postural deviations and tremor are noted.
Palpation
Palpation is the examination of body by hand. It is performed to determine the shape, size and texture of the tissues. It is very important in diagnosing conditions like enlargement of liver, gall bladder, and other causes of abdominal pain. Anatomical landmarks are also located by palpation for various therapeutic procedures.
Percussion
Percussion is the examination of body by tapping on the surface to determine the underlying structures. Percussion can be performed by two methods: directly and indirectly. Direct method is used to percuss bony areas, in which finger is directly tapped over area. In indirect method to middle finger of one hand is placed over the area to be examined and is tapped with middle finger of other hand by wrist flexion.
Auscultation
Auscultation is derived from the latin word ‘auscultare’ meaning ‘to listen’. It is the method of listening internal sounds of the body with the help of stethoscope. This method is mainly used to listen heart sounds, breath sounds and gastrointestinal (GI) sounds. It takes substantial clinical experience to learn the skill of auscultation. Auscultating plays an important role in making provisional diagnosis of heart and lung conditions. When auscultating heart, one should look for abnormal heart sounds like heart murmur, gallops and any other sound coinciding with normal heart sounds. When auscultating lungs, one should look for breath sounds like wheezes, crackles and crepitations. Bowel sounds are listened during auscultating of GI system.
Examination of Skin
Prerequisites for Skin Examination
Accessibility
An examination room where patient can be clothed only in an examination gown. If thats not possible, at least, the affected part should be properly exposed.
Adequate Illumination
Sunlight or a bright overhead fluorescent lighting is preferred. Penlight is used in side lighting to determine if a lesion is subtly elevated and for examining the oral cavity. A complete cutaneous examination should be made that includes:
- Skin from head to toe
- Mucous membrane, mouth and genitals
- Hair and nails.
The examination includes inspection and palpation, besides percussion and auscultation.
Inspection of Skin
- Pigmentation: Pigmentation of the skin varies from dark skinned to fair individuals, depending on the race to which they belong.
- Generalised absence of skin pigmentation suggestive of albinism.
- Patchy absence of skin pigmentation may be due to vitiligo. In the presence of vitiligo, suspect presence of DM or other autoimmune disorders (Fig. 1.2).
- Circumscribed hypopigmented lesions of the skin may occur in Hansen's disease (tuberculoid or borderline tuberculoid types) and tinea versicolor.
- Generalised hyperpigmentation of the skin is seen in haemochromatosis, Addison's disease, Cushing's syndrome, ectopic, adrenocorticotropic hormone (ACTH) production.
- Patchy hyperpigmentation of the skin is seen in pellagra (in parts exposed to sunlight), café-au-lait spots (Fig. 1.3), butterfly rash over face in SLE, chloasma and acanthosis nigricans.10
- Abnormal skin pigmentation and the condition in which they are found are given in Table 1.2.
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Examination of Hair
While examining hair, one should look for presence and colour of scalp hair. Presence and distribution of hair over body (secondary sexual character: axillary and pubic region) should also be noted.
Shape
Shape of hair varies depending on the race.
- Asians—straight hair
- Mongoloids—sparse facial and body hair
- Negroids—curly hair
- Europeans—wavy hair.
Colour
- White hair: Albinism (due to absence of pigment)
- Grey hair: A sign of ageing
- Flag sign: Brownish discolouration of hair with interspersed normal colour of hair, seen in protein-energy malnutrition (PEM).
Growth
- Baldness: Temporal recession and baldness are common in males and the process is androgen dependent. Temporal recession in females may suggest virilisation. Frontal baldness is a marker for myotonic dystrophy and also seen in some cases of SLE.
- Hypertrichosis: It refers to excess hair which could be familial or due to sexual precocity, hypothyroidism, adrenal hyperplasia or neoplasm and virilising ovarian tumours.
Examination of Face
Type of Facies
- Acromegalic facies: Prominent lower jaw, coarse features, large nose, lips, ears, prominent forehead, cheekbones and widespread teeth.
- Hypothyroid face: Puffy face with a dull expression and swollen eyelids and loss of hair over eyebrows (Fig. 1.12A).
- Leonine facies: Seen in leprosy, and shows thickening of the skin and ear lobes with a flattened nasal bridge and loss of hair over the lateral aspect of eyebrows and eyelashes (madarosis) (Fig. 1.12B).
- Cushing's syndrome: Rounded ‘moon face’ with excessive hair growth (Fig. 1.12C).
- Face in SLE: Butterfly rash is seen over the face encompassing the upper cheeks and nasal bridge (Fig. 1.12D).
- Hyperthyroid face: Anxious look, widely opened eyes with the upper and lower limbus being visible, associated with infrequent blinking and absence of wrinkling of the forehead (Fig. 1.12E).
- Parkinsonian face: Immobile, fixed, expressionless face with infrequent blinking of the eyes. Normal rate of blinking is about 20 blink per minute. In parkinsonism, the rate of blinking is reduced to 10 blink per minute (Fig. 1.12F).
- Bell's palsy: Absence of wrinkling of forehead on the side of the lesion, along with inability to close the eyes and on attempting to do so the eyeball is seen to move upwards and outwards (Bell's phenomenon). There is also loss of the nasolabial fold on the side of lesion and deviation of the angle of the mouth to the opposite healthy side on smiling. However, in long-standing Bell's palsy, when contractures of the facial muscles develop, prominent nasolabial grooves may be seen on the affected side, creating confusion as to the side of lesion (Fig. 1.12G).
Eyes
Look for the following features when examining the patient's eyes:
- Ptosis (unilateral or bilateral) (Figs 1.13A and B)
- Hypertelorism (Fig. 1.14)
- Pallor
- Cyanosis
- Icterus
- Bitot's spots (Vitamin A deficiency).
- Any corneal opacities, cataract, subconjunctival haemorrhage and corneal ulcers (seen in Bell's palsy and in trigeminal nerve palsy).
- Kayser-Fleischer ring (KF ring) is seen in Wilson's disease (disorder of copper metabolism), primary biliary cirrhosis, cryptogenic cirrhosis and intraocular copper foreign body (uniocular KF ring).
- Blue sclera as seen in osteogenesis imperfecta (disorder of bone metabolism) (Fig. 1.15).
Constitution
Constitution indicates the body type or habitus. Human race can be classified into the following somatotypes.
Clinical Classification
- Normosthenic: Normal average body build.
- Sthenic: Broad, short, fat neck, muscular chest and large stumpy fingers. They have horizontal heart.
Anthropometric Classification
- Endomorph: Soft, round contours with well-developed cutaneous tissues and short stature.
- Mesomorph: Wide, stocky, muscular individual with normal stature.
- Ectomorph: Long narrow hands, long feet, shallow thorax, small waist and tall stature.
Stature
Stature is total height measured from vertex of head to soles of feet. It is a sum total of upper segment measurement (from vertex of head to the upper border of symphysis pubis) + lower segment measurement (from top of symphysis pubis to soles of feet).
State of Nutrition
The state of nutrition depends mainly on the distribution of adipose tissue in the body. On this basis, individuals can be classified as normal, overweight (fat or obese) and underweight. The state of nutrition can be assessed in the following ways:
- Ideal body weight (IBW) = 22.5 × (height in metres)2. In women, the IBW is calculated as follows 0.94 × 22.5 × (height in metre)2. If the body weight more than 10% of IBW, the individual is overweight. If the body weight more than 20% of IBW, the individual is obese.
- Body mass index is calculated as follows:BMI = Weight in kg/(height in metre)2.
- The amount of subcutaneous fat can be estimated by measuring the skinfold thickness over the triceps, biceps, subscapular region and suprailiac region, by using a special pair of calipers. Normal triceps skinfold thickness: adult males—12.5 mm, adult females—16.5 mm.
- Rough calculation of body weight (Broca's index) can be done provided the height of the individual is more than 100 cm and so is possible in adults only.
Height in cm–100 = desired body weight (in kg)
E.g. 160 cm–100 = 60 kg
Height in inches = body weight (in kg)
E.g. 66 inches = 66 kg.
Obesity
A person is said to be obese, if his body weight more than 20% of IBW and his BMI more than 30.
Types of Obesity
- Generalised obesity: There is excess fat deposition uniformly throughout the body. Overeating is the most common cause. It is characterised by the presence of a ‘double chin’.
- Android obesity: It is a type of obesity, which is characterised by excess deposition of fat over the region of the waists (Fig. 1.16A).
- Gynoid obesity: It is a type of obesity, which is characterised by excess deposition of fat over the hips and thighs (Fig. 1.16B).
- Superior or central type of obesity: In this type, there is excess fat deposition over face, neck and upper part of the trunk and the arms are thin. This is seen in Cushing's syndrome.
Type of obesity | Waist-hip ratio | Prognosis |
---|---|---|
Pear-shaped | 0.8 or less | Good |
Apple-shaped | 0.9 or greater | Greater risk for complications of obesity |
Figs 1.16A and B: Pattern of obesity: (A) Android type (apple-shaped) and (B) Gynoid type (pear-shaped)
Waist-hip Ratio
Recent evidence suggests that regional distribution of fat may be of greater prognostic significance than absolute degree of obesity. This is assessed by measuring waist-hip ratio. Take maximal measurement of the hip over the buttocks. Take the narrowest measurement between the rib cage and the iliac crest. Calculate the waist-hip ratio.
Oedema
Oedema is a collection of excess fluid in the body interstitium, from the intravascular compartment.
The normal body fluid compartments are given in Table 1.4.
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Types
Oedema may be generalised or localised.
- In generalised oedema (synonym: anasarca), there is retention of excessive fluid in tissues resulting in increase in total body fluids. This excessive fluid is due to transudation of fluid into the tissue spaces, increase in fluid in cells and increase of fluid volume in the venous and capillary sides of the circulation. Along with the retention of water, there is retention of sodium and chloride.
- Localised oedema: Unlike generalised oedema, there is no accumulation of fluid in the entire body but there is accumulation in localised area with oedema confined to that region.
The causes of generalised and localised oedema are listed in Table 1.5.
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Clinical Features
The patient complains of tightness of the part and unusual heaviness. The skin is stretched and shiny and the normal wrinkles are obliterated. Superficial veins become less prominent. The confirmatory sign of oedema is pitting on pressure, i.e. pressure over the oedematous part displaces the fluid and this leads to the formation of a dimple (Fig. 1.17). The test is performed by exerting gentle pressure with the flat of the thumb for 10 seconds over a bony area (shin of the tibia, medial malleolus, and sacrum), and looking for pitting.
Characteristic Features
- Cardiac oedema: In right-sided heart failure, there is systemic venous congestion and generalised16 oedema. The oedema is dependent in nature, i.e. it is most prominent in those parts which are the lowest. In ambulant subjects, the oedema is maximal over the ankles and feet (pedal oedema) and it is worse towards the end of day. It clears up with recumbency. In bedridden patients, oedema is most prominent over the sacrum. An early symptom of generalised fluid retention is nocturnal polyuria. The fluid which accumulates during the day is cleared at night due to improvement in cardiac output. As the condition progresses, the oedema becomes established at all times. Cardiac oedema is accompanied by other signs of cardiac failure such as exertional dyspnoea, engorged jugulars and hepatic enlargement.
- Renal oedema: Renal oedema characteristically involves the loose connective tissue, especially over the periorbital region. It is more prominent when the patient wakes up in the early morning, as the patient with renal oedema are able to lie down flat (comfortably).
- Hepatic oedema: The pathophysiology of this oedema is that the collection of fluid occurs characteristically first in the peritoneal cavity (ascites), because of the increased portal venous pressure (portal HTN). Tense ascites leads to increased intra-abdominal pressure, thereby decreasing venous return from the lower limbs and hence development of pedal oedema.
- Nutritional oedema: It is a generalised oedema. Causes of nutritional oedema are:
- Decreased ingestion of proteins leading to hypoalbuminaemia and therefore, oedema.
- Thiamine deficiency leading to beri-beri.
- Idiopathic oedema: This constitutes the periodic episodes of oedema occurring exclusively in women. Diurnal variation of weight occurs with orthostatic retention of salt and water. This suggests an increase in capillary permeability on erect posture.
Examination of Mouth and Pharynx
Examination should be done with the help of torch and tongue depressor. The following things need to be examined.
- Color of lips, tongue and buccal mucous membrane
- Angle of mouth
- Appearance of teeth and gum
- Pigmentation of mucous membrane
- Halitosis or bad breath typically emanates from oral cavity or nasal passages. Bacterial decay of food and cellular debris release volatile sulphur compounds resulting in halitosis. Poorly-fitting dentures, oral infections, and tongue coating are usual causes. Pockets of decay in the crypts of tonsils, oesophageal diverticulum, stasis of food due to achalasia or stricture can cause halitosis. Psychiatric illness can cause pseudo-halitosis or halitophobia in the absence of objectively detectable bad odour and is also indicative of certain diseases, e.g. in hepatic failure, breath has a fishy odour, in renal failure ammoniacal or urinary odour and in diabetic ketoacidosis fruity odour.
Examination of Neck
The neck should be examined for:
- Thyroid gland: Size, shape, enlargement if any.
- Neck veins: Normal or engorged, jugular venous pressure, carotid pulse.
- Lymph nodes: Site, size, number of nodes enlarged, consistency, tenderness, mobility, fixity to skin, lesions in area of drainage, lymphoedema.
Lymph Nodes
Cervical nodes may be broadly divided into superficial and deep groups with reference to their relation with the deep fascia. Superficial group consists of the occipital, retro-orbital, parotid, buccal, submandibular, submental and anterior and posterior cervical nodes. Supraclavicular nodes are situated above the medial ends of the clavicles. Pretracheal (scalene) nodes are situated behind the origin of the sternal head of the sternocleidomastoid muscle, usually palpated in between the two heads of this muscle (Fig. 1.18).
Lymphadenopathy
Lymph nodes are normally just palpable as small firm nontender masses less than 0.5 cm in diameter, especially in children or they are not palpable at all. Any palpable lymph node anywhere in the body is significant. In general, nodes larger than 2 cm, any lymph node in the supraclavicular region, scalene node or generalised lymphadenopathy are significant. The causes of generalised lymphadenopathy are given in Table 1.6.
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Examination of Hands and Fingers
- The hands should be examined for general appearance, muscle wasting, any contracture, etc.
- The fingers should be examined for their number, webbed fingers (syndactyly), absence of digits and clubbing (Table 1.7).
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Clubbing of Fingers
It is a selective bulbous enlargement of the distal portion of the digit due to increased subungual soft tissue. The normal angle between the nail and the nail-bed is 160° and is known as the Lovibond angle (Fig. 1.21A). When the dorsum of the distal phalanges of the fingers of both hands are approximated to each other, a diamond-shaped gap is made out due to the presence of the Lovibond angle (Shamroth's sign). This gap disappears with obliteration of this angle, as that occurs with clubbing. The minimum duration required for clubbing to manifest is 2–3 weeks. Clubbing first appears in the index finger (Figs 1.21B and C). The causes of clubbing are given in Table 1.8.
Figs 1.21A to C: Clubbing: (A) Normal nail-bed angle; (B) Testing for fluctuation and (C) Clubbing of finger
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Examination of Nails
The various nail changes and their causes are given in Table 1.9.
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Differential Diagnosis
It is the method of reaching the diagnosis by rulling out other candidate diseases (having almost same sign and symptoms) with the help of advanced investigations.
Investigations
Investigation for a patient depends on the presenting complaints. Various type of investigations are as follows:
- Haematological investigations:
- Complete blood count
- Serum electrolytes
- Serum creatinine
- Coagulation studies
- Blood grouping and typing
- ABG
- Radiological examinations:
- X-ray scan
- CT scan
- MRI
- Electrocardiogram (ECG)
- Echocardiogram
- Treadmill test (TMT)
- Angiography
- Electroencephalography (EEG)
- Endocrine study.
Diagnosis
It is the process of reaching a conclusion about the cause and the nature of disease after taking detailed history, examination and investigations.
Provisional Diagnosis
It is the process of making a tentative diagnosis with the help of history, examination and differential diagnosis.21
Confirmed Diagnosis
When provisional diagnosis is confirmed with the help of investigation, it is called confirmed diagnosis.
Treatment
Once the diagnosis is made, treatment for the diagnosed condition is started. Treatment can be symptomatic or treatment of the underlying cause/pathology. Choice of treatment depends on the type of disease, e.g. a tooth pain can be treated for its symptoms with analgesics or can be treated removing its underlying etiology.
Prognosis
Prognosis is the prediction of likely outcome of the course of a disease. A complete prognosis includes expected duration, function and a description of course of disease (progressive, relapsing, etc.). It is an important part of modern medicine as it helps in deciding course of treatment. It also helps patient's relative to take important decisions related to patient, e.g. decision to wean-off a patient from ventilator can be taken by the relatives in the light of prognosis.
Follow-up
It is the process of monitoring the progress of a patient after active treatment. Follow-up is a very important part of modern medicine. It helps in developing better doctor-patient or hospital-patient relationship with better patient satisfaction.
Protocol for Recording Case History/Sample Format for Case History
Name | ……………………………………………………………………………………………………………………………………………………… |
Age/Sex | ……………………………………………………………………………………………………………………………………………………… |
Occupation | ……………………………………………………………………………………………………………………………………………………… |
Marital Status | ……………………………………………………………………………………………………………………………………………………… |
Address: | ……………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………… |
Provisional Diagnosis: | ……………………………………………………………………………………………………………………………………………………… |
Chief Complaint: | ……………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………… |
Present Medical History | ……………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………… |
Past Medical History | ……………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………… |
Family History | ……………………………………………………………………………………………………………………………………………………… |
Social History | ……………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………… |
Physical Examination
General Examination
General Appearance ………………………………………………………………………………………………………………………………………………………
Built | ……………………………………………………………………………………………………………………………………………………… |
Dehydration | ……………………………………………………………………………………………………………………………………………………… |
Anaemia | ……………………………………………………………………………………………………………………………………………………… |
Cyanosis | ……………………………………………………………………………………………………………………………………………………… |
Clubbing | ……………………………………………………………………………………………………………………………………………………… |
Jaundice | ……………………………………………………………………………………………………………………………………………………… |
Purpura | ……………………………………………………………………………………………………………………………………………………… |
Oedema | ……………………………………………………………………………………………………………………………………………………… |
Exophthalmus | ……………………………………………………………………………………………………………………………………………………… |
Puffiness | ……………………………………………………………………………………………………………………………………………………… |
Pulse | ……………………………………………………………………………………………………………………………………………………… |
Blood Pressure | |
Fever | ……………………………………………………………………………………………………………………………………………………… |
Lymph Nodes | ……………………………………………………………………………………………………………………………………………………… |
Skin | ……………………………………………………………………………………………………………………………………………………… |
Teeth and Gums | ……………………………………………………………………………………………………………………………………………………… |
Tonsil and Pharynx | ……………………………………………………………………………………………………………………………………………………… |
Ear | ……………………………………………………………………………………………………………………………………………………… |
Systemic Examination
Chest
Inspection | |
Respiratory Rate | ……………………………………………………………………………………………………………………………………………………… |
Shape of Chest | ……………………………………………………………………………………………………………………………………………………… |
Movement | ……………………………………………………………………………………………………………………………………………………… |
Palpation | ……………………………………………………………………………………………………………………………………………………… |
Percussion | ……………………………………………………………………………………………………………………………………………………… |
Auscultation | ……………………………………………………………………………………………………………………………………………………… |
Heart Sounds Murmur
………………… …………………………
Abdomen | |
Inspection | ……………………………………………………………………………………………………………………………………………………… |
Contour | ……………………………………………………………………………………………………………………………………………………… |
Movement of Abdominal Wall | ……………………………………………………………………………………………………………………………………………………… |
Veins | ……………………………………………………………………………………………………………………………………………………… |
Umbilicus | ……………………………………………………………………………………………………………………………………………………… |
Scar | ……………………………………………………………………………………………………………………………………………………… |
Palpation | |
Superficial | ……………………………………………………………………………………………………………………………………………………… |
Deep | ……………………………………………………………………………………………………………………………………………………… |
Liver | ……………………………………………………………………………………………………………………………………………………… |
Spleen | ……………………………………………………………………………………………………………………………………………………… |
Kidney | ……………………………………………………………………………………………………………………………………………………… |
Gall Bladder | ……………………………………………………………………………………………………………………………………………………… |
Bowels | ……………………………………………………………………………………………………………………………………………………… |
Lymph Nodes | |
Other Mass | ……………………………………………………………………………………………………………………………………………………… |
Fluid Thrill | ……………………………………………………………………………………………………………………………………………………… |
Percussion | |
Upper Border of Liver | ……………………………………………………………………………………………………………………………………………………… |
Shifting Dullness | ……………………………………………………………………………………………………………………………………………………… |
Auscultation | |
Bowel Sounds | ……………………………………………………………………………………………………………………………………………………… |
Bone and Joints | |
Limbs | ……………………………………………………………………………………………………………………………………………………… |
Skull | ……………………………………………………………………………………………………………………………………………………… |
Spine | ……………………………………………………………………………………………………………………………………………………… |
Sternum | ……………………………………………………………………………………………………………………………………………………… |
Ribs | ……………………………………………………………………………………………………………………………………………………… |
Nervous System | |
Mental State | |
Consciousness | ……………………………………………………………………………………………………………………………………………………… |
Memory | ……………………………………………………………………………………………………………………………………………………… |
Intelligence | ……………………………………………………………………………………………………………………………………………………… |
Mood | ……………………………………………………………………………………………………………………………………………………… |
Fear, Anxiety, etc. | ……………………………………………………………………………………………………………………………………………………… |
Delusions/Illusions | ……………………………………………………………………………………………………………………………………………………… |
Temperament | ……………………………………………………………………………………………………………………………………………………… |
Other | ……………………………………………………………………………………………………………………………………………………… |
Orientation | |
Time | ……………………………………………………………………………………………………………………………………………………… |
Place | ……………………………………………………………………………………………………………………………………………………… |
Person | ……………………………………………………………………………………………………………………………………………………… |
Behaviour Speech | ……………………………………………………………………………………………………………………………………………………… |
Involuntary Movement | ……………………………………………………………………………………………………………………………………………………… |
Differential Diagnosis | ……………………………………………………………………………………………………………………………………………………… |
Investigations | ……………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………. |
Diagnosis | ……………………………………………………………………………………………………………………………………………………… |
Provisional Diagnosis | ……………………………………………………………………………………………………………………………………………………… |
Confirmed Diagnosis | ……………………………………………………………………………………………………………………………………………………… |
Treatment | ……………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………. |