Essentials of Medicine for Dental Students Anil K Tripathi, Kamal K Sawlani
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Clinical MethodsChapter 1

Clinical methods form the basis of the approach to a patient by which a proper diagnosis is achieved. The skill of a clinician depends on his knowledge of theoretical as well as practical aspects of the clinical methods. This skill is acquired and refined with experience.
History is the physician's abstraction of certain facts developed in the course of the patient's interview and arranged in a manner that facilitates diagnosis.
Proper history is important for making a correct diagnosis. A careful evaluation by competent clinicians reveals that 82% of diagnoses are made by history, 9% by physical examination and 9% by the laboratory tests. A history is not simply a collection of facts. It must also contain information. Facts are the true statements made by the patient while information consists of facts arranged in useful manner. A general format is followed while taking a history of the patient. The contents of history are recorded in the patient's version and no part in the history should be distorted or omitted. However, the focus and contents may vary from patient to patient and also with the experience of the clinician.
The standard format used for history taking is as follows;
  1. Patient's details (name, age, sex, marital status, occupation, address)
  2. Presenting complaints with duration
  3. History of present illness
  4. History of past illnesses
  5. Treatment history
  6. Personal history
  7. Family history
  8. Menstrual history (in females)
Presenting Complaints
This is also known as chief complaints. The patient is asked about the main problems for which he has come to the doctor. These main symptoms/problems are listed in a chronological order (noted in the order of their appearance). Generally the patient is allowed to tell by himself. Leading questions are avoided. The list should not be too long.
History of Present Illness
The patient is then asked to narrate individual symptoms in details. Once this is over with, leading questions are asked to clarify certain points or associations related to different symptoms. For example, if the patient is complaining of pain, details should be recorded about the site, severity, character, radiation, duration and timing, relieving and aggravating factors.
  1. Site: The exact site of pain is noted. Whether it is localized or diffuse pain.
  2. Severity: Does the pain interfere with routine daily activities or keep the patient awake at night? Is the patient in severe agony or is he shouting?
  3. Character: Description of character of pain such as burning, stabbing, pricking, colicky, and dull ache are helpful. Colicky pain is the waxing and waning type of pain and may cause the patient to roll about. Colicky pain suggests obstruction of hollow structure like intestine, ureter or common bile duct.
  4. Timing and duration: When does it start and when does it stop?
  5. Relieving factors and aggravating factors: Cardiac pain occurs on exertion and is relieved by rest and nitrates. Pain of duodenal ulcer is relieved by eating. Musculoskeletal pain may be relieved by change in the 2posture and by simple analgesics. Anginal pain is relieved by sublingual nitrates.
The typical anginal (ischemic) pain is described in Table 1.1.
Symptoms pertaining to different systems are asked. Important symptoms regarding disorders of various systems are given in Table 1.2.
History of Past Illness
A detailed account is noted about any illness which occurred in the past. A disease or symptom which has occurred in the past could be a part of the present disease process or related to the present problem.
For example, a patient with liver cirrhosis may give a history of jaundice or blood transfusion.
TABLE 1.1   Characteristics of chest pain in stable angina
Site of the pain
Retrosternal or precordial
Squeezing, constricting, piercing, feeling of heaviness or pressure
Precipitating factors
Physical exertion, cold exposure, heavy meals, emotional stress, anemia, thyroid disease, vivid dreams (nocturnal angina)
Associated features
Feeling of impending death, breathlessness, apprehension, nausea, vomiting
Relieving factors
Rest, sublingual nitroglycerin
Left shoulder, both arms, jaw, neck
Typically 2-10 minutes (>30 minutes suggests infarction)
TABLE 1.2   Common symptoms in various systemic disorders
Fever, weight loss, weakness, bodyache, headache
Respiratory system
Cough, sputum, hemoptysis, dyspnea, chest pain and wheezing
Cardiovascular system
Chest pain, dyspnea, orthopnea, palpitation, edema, cough
Gastrointestinal system
Anorexia, nausea, vomiting, heart burn, dysphagia, diarrhea, constipation, jaundice, pain in abdomen
Hematological system
Pallor, weakness, fever, dyspnea, bleeding, lymph gland enlargement
Urinary system
Dysuria, hematuria, polyuria, oliguria, anuria, retention
Nervous system
Headache, seizures, stroke
Treatment History
The details of medications taken are noted. History of any adverse effects of drugs is also asked. It is imperative to know what drugs the patient is taking currently so that drug interactions may be avoided. The history of intake of certain drugs may help in knowing the cause of disease. For example, steroids and NSAIDs can cause gastric erosion and hematemesis.
It is noted whether the patient has been compliant or not. If not, the reason for the drug non-compliance is discussed.
Personal History
The patient is asked about the consumption of alcohol, tobacco, or smoking. His occupation should also be noted. Certain occupations are associated with a higher incidence of a particular disease, e.g. persons working in a silica factory are prone to develop silicosis. A history of stress at home and office should also be recorded. Financial status of the patient is also an important fact to be noted in the history.
Family History
Any history of genetic disorders in the family is enquired about. Any history of similar illness in other family members and cause of death of immediate relative should be recorded. History of hypertension, diabetes mellitus, tuberculosis, cardiovascular diseases, and bleeding diastheses in other family members should be noted.
Menstrual History
Women should be asked about menstruation. Regularity of the cycle, duration of cycle, and amount of bleeding are noted. Obstetric history is also important. Many drugs are contraindicated or avoided during pregnancy. Migraine can be triggered by menstruation and heart failure may become worse during pregnancy. Excessive bleeding during menstruation (menorrhagia) may be due to bleeding disorder and amenorrhea can occur in certain diseases.
  • Proper physical examination needs cooperation of the patient.
  • The patient should be comfortable and relaxed.3
  • The nature and need of such an examination should be explained to him.
  • Examination is performed in a quiet and well-lit room. Day light is always better than artificial light as changes in skin color may be masked in the latter.
  • Examination is carried out as gently as possible.
    The examination is carried out in a routine manner. However, the information from the history may suggest which part or system should be particularly examined in greater detail.
The examination is customarily divided into general and systemic examination. Systemic examination is described in specific chapters.
General Physical Examination
General examination of the patient starts even as the history is being taken. A standard scheme should be followed to avoid any omissions. Points that should be noted are given in Table 1.3.
Mental and Emotional Status
History taking and simple observations can assess the mental, emotional status and intelligence of the patient. State of consciousness is noted.
  • In a confusional state, the patient is subdued, drowsy and physically inactive. He is also disoriented about time, place and person.
  • Delerium is a confusional state accompanied by agitation, hallucination and illusion. These always indicate disease of the nervous system.
    TABLE 1.3   Points for general physical examination
    • Mental and emotional state
    • Built of the body
    • Temperature
    • Pulse
    • Blood pressure
    • Respiration
    • Anemia
    • Jaundice
    • Cyanosis
    • Oral cavity and throat
    • Neck veins
    • Thyroid
    • Lymphadenopathy
    • Clubbing
    • Peripheral edema
    • Skin and mucous membrane
  • Stupor state is lesser degree of altered consciousness from which patient can be awakened by vigorous stimuli.
  • Coma is a deep sleep-like state from which the patient cannot be aroused. The patient does not respond to external stimulus or to inner needs.
  • In dementia, there is a loss of previously acquired intellectual functions but in the absence of impairment of consciousness. Memory is the most common intellectual function lost in dementia.
Built of the Body
This can be assessed by general inspection. The physique may be short, tall, obese, muscular, thin or asthenic.
  • Dwarfism is found in hypopituitarism, hypothyroidism, and achondroplasia.
  • Height is increased in Marfan's syndrome and hyperpituitarism (Gigantism).
  • Weight loss may occur in malnutrition, malabsorption, thyrotoxicosis, chronic infections (tuberculosis), diabetes mellitus, malignancies, depression, anxiety, and anorexia nervosa. Weight loss despite normal or increased food intake suggests diabetes mellitus, thyrotoxicosis or malabsorption.
  • Weight gain may occur due to hypothyroidism or fluid retention.
    The most widely used method to measure obesity is body mass index (BMI). BMI is calculated as weight in kg divided by the square of height in meters (kg/m2). BMI upto 25 is normal, 25-29.9 is overweight and above 30 is obesity. Abdominal obesity (increased waist-hip ratio: >0.9 in females, >1.0 in males) is an important risk factor for coronary artery disease.
Temperature is measured with a thermometer. Thermometer is placed in the mouth or in the axilla in adults while it is placed in the fold of the groin with thigh flexed or in the rectum in case of small children.
  • Mouth temperature is 0.5C° higher than that of groin or axilla. Rectal temperature is about 0.4°C (0.7°F) higher than mouth temperature.
  • The evening (pm) temperature may be up to 0.5°C or 0.9°F higher than the morning (am) temperature in normal persons.4
  • The maximum normal is 37.2°C (98.9°F) at 6 am and 37.7°C (99.9°F) at 4 pm.
  • A fever of more than 41.5°C (106.7°F) is known as hyperpyrexia. A temperature less than 35°C (95°F) is called hypothermia.
The fever may be continued, remittent or intermittent. These classical patterns of fever are less commonly seen due to early initiation of treatment with antipyretics and antibiotics.
  1. Fever which at no time touches the normal and does not fluctuate more than 1°C during 24 hours is called continued fever.
  2. When the daily fluctuation in the temperature is more than 2°C, the fever is of the remittent type.
  3. Fever which occurs only for several hours during 24 hours is called intermittent fever. Intermittent fever can be quotidian (occurs daily), tertian (occurs on alternate days) or quartan (occurs every third day). Infection with P. falciparum causes intermittent quotidian fever, P. vivax and P. ovale cause tertian fever and P. malariae causes quartan fever.
Arterial pulse should be examined mainly for following things:
  1. Rate
  2. Rhythm
  3. Volume
  4. Character
  5. Radio-femoral delay
The rate and rhythm are assessed by palpating the radial artery (Fig. 1.1). The character of the pulse is better assessed by palpating the carotid artery (Fig. 1.2). Other peripheral arteries like brachial, popliteal, posterior tibial and dorsalis paedis can also be palpated. The pulse may be absent or weak in obstruction in the proximal part of the artery due to thromboembolism and atherosclerosis.
Rate: The pulse rate is determined by counting it for at least 30 seconds. The normal pulse rate varies from 60-100 per minute.
  • Bradycardia is defined as pulse rate <60/min. Important causes are raised intra-cranial pressure, heart blocks and sinus node disease, cholestatic jaundice, hypothyroidism and drugs (beta blockers, verapamil, digoxin). Bradycardia may also be present in athletes.
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    FIGURE 1.1: Palpation of the radial artery; the forearm of the patient is in semiprone position with wrist semiflexed
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    FIGURE 1.2: Palpation of the left carotid artery with the right thumb
  • Tachycardia (pulse rate >100/min) occurs due to fever, exercise, anxiety, thyrotoxicosis, anemia, tachyarrhythmias, shock and drugs.
  • Pulse is slower than would be expected from the height of fever in typhoid fever (relative bradycardia).
Rhythm: Normally the rhythm of the pulse is regular. An irregular rhythm is seen in atrial fibrillation (irregularly irregular) and frequent ectopic beats (regularly irregular).5
  • A low volume and slow rising pulse (parvus et tardus) is found in aortic stenosis (AS).
  • A large bounding pulse (hyperkinetic pulse) is seen in hyperkinetic states (anemia, fever, anxiety, exercise), patent ductus arteriosus, ventricular septal defect, and aortic regurgitation (AR).
  • Bisferiens pulse which has two systolic peaks is found in mixed lesion of AS and AR.
  • Alternating strong and weak pulse (pulsus alternans) is present in severe left ventricular failure.
  • Normally there is a fall in systolic arterial pressure of <10 mmHg during inspiration. An accentuation in this phenomenon can lead to weakening or disappearance of pulse during inspiration (paradoxical pulse). This is found in cardiac tamponade and obstructive airway disease.
Radio-femoral delay: The femoral pulse is weak and delayed as compared with the radial pulse (radio-femoral delay) in coarctation of aorta.
Blood Pressure (BP)
Blood pressure is measured with the help of a sphygmomanometer. A mercury sphygmomanometer is more accurate than aneroid one.
  • BP should be measured in both arms and also in the lower limb. In coarctation of aorta, the arterial pressure in the upper limb is much higher than in the lower limbs.
  • The patient should be sitting at ease.
  • The cuff should be applied closely to the upper arm; it should not be loose or tight. The lower border of the cuff must be one inch (2.5 cm) above the cubital fossa.
  • The instrument should be placed at the same level as the cuff on the patient's arm and the observer's eye.
  • The standard cuff width for adults is 12.5 cm. The size of cuff is also important since a small cuff may record false high blood pressure.
  • The blood pressure must be recorded when the patient is resting quietly as anxiety, exertion, excitement, smoking and intake of coffee and tea within last half an hour will give rise to false readings.
  • In elderly and patients on drugs (for hypertension) BP should be recorded in standing and lying down position to detect the occurrence of postural hypotension.
Initially the assessment of systolic BP is made by palpatory method. The radial or brachial artery is palpated while the cuff is inflated to raise pressure about 30 mm Hg above the level at which radial/brachial pulse disappears The stethoscope is placed over the brachial artery and cuff is deflated slowly (Figs 1.3A and B). The level at which Korotkoff sounds appear (phase 1) is the systolic pressure and the level at which they disappear completely (phase 5) is the diastolic pressure. When the pulse pressure (the difference between systolic and diastolic blood pressure) is increased as in cases with hyperdynamic circulation (aortic regurgitation, pregnancy, thyrotoxicosis, anemia, arteriovenous fistula) the sounds may not disappear completely even at 0 level.
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FIGURES 1.3A and B: (A) Localization of brachial artery (B) Measurement of blood pressure; note the position of cuff and the stethoscope
In such cases the level at which sounds become suddenly muffled (phase 4) is taken as diastolic blood pressure.
The patient is said to be hypertensive if the systolic BP is >140 mmHg and/or diastolic BP is >90 mmHg (Table 1.4). Sometimes the blood pressure recorded by the clinician at clinic or hospital is high while normal readings are obtained at home or when BP is measured under casual circumstances. This is known as white coat hypertension and is the result of the anxiety upon visiting a physician or a hospital.
Jugular Venous Pulse
Pulsations and pressure in internal jugular vein in the neck are noted (Fig. 1.4).
  • Venous vs arterial pulsation: Venous pulsations must be differentiated from carotid artery pulsations. Venous pulsations are better seen while arterial pulsations are better palpable. The upper level of venous pulsation varies with the change in posture and phases of respiration.
  • Jugular veins are distended and pulsatile in congestive heart failure and pericardial effusion. Neck veins are also distended in cases of mediastinal tumors and retrosternal goiter but these are not pulsatile.
  • Normally there is fall in the jugular venous pressure (JVP) during inspiration. There may be a paradoxical rise in the JVP during inspiration in constrictive pericarditis and cardiac tamponade (Kussmaul's sign).
    The venous pulse has three positive waves, a, c, and v, and two negative waves or descents, x and y. The a wave is due to atrial contraction. This is followed by x descent (due to descent of tricuspid valve ring) which is interrupted by a small c wave. The v wave is due to passive filling of blood from veins into the right atrium during ventricular systole.
TABLE 1.4   Classification of blood pressure for adults (>18 yrs)
Systolic blood pressure (mmHg)
Diastolic blood pressure (mmHg)
  • Stage 1
  • Stage 2
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FIGURE 1.4: Prominent jugular vein
This is followed by y descent due to rapid flow of blood from the right atrium to the right ventricle when the tricuspid valve is open.
The “a” wave is absent in atrial fibrillation while it is prominent in tricuspid stenosis (TS). Prominent “Y” descent is seen in tricuspid regurgitation.
Normal rate of respiration is 12-16 per minute in adults. The causes of fast breathing (tachypnea) are given in Table 1.5. Dyspnea is an abnormally uncomfortable awareness of breathing. This could be due to respiratory diseases, cardiac diseases, anemia, acidosis, and psychogenic. Dyspnea, orthopnea and paroxysmal nocturnal dyspnea are described in detail in Chapters 4 and 5.
  • Noisy breathing may occur due to obstruction of the respiratory passages at various levels. Obstruction at the level of larynx and trachea causes inspiratory stridor and obstruction in bronchi and bronchioles produces wheezing.
  • Rapid and deep respiration (Kussmaul's breathing) is present in metabolic acidosis while rapid shallow breathing is a feature of restrictive lung disease.
  • Cheyne-Stokes respiration is characterized by cyclical waxing and waning of rate and depth of respiration intervened with periods of apnea.
    TABLE 1.5   Causes of tachypnea
    • Recent exertion
    • Anxiety
    • Fever
    • Metabolic acidosis
    • Hysterical over-breathing
    • Pulmonary and cardiac conditions causing hypoxia
    • Cerebral disturbance
    It is observed in narcotic overdose and severe left heart failure.
  • The presence of pallor depends on the thickness and quality of the skin, amount of blood in the capillaries and quality of the blood in the capillaries.
  • The evidence of pallor is looked at palpebral conjunctiva and mucous membrane of the mouth (Fig. 1.5). Other sites are nailbed and palmar creases (Fig. 1.6).
  • Generalized pallor is present in anemia. Pallor can also be found in hypopituitarism, thick or opaque skin, and diminished capillary blood flow as in shock, syncope, left heart failure.
A yellowish discoloration of the skin and mucous membrane due to deposition of bilirubin is known as jaundice (icterus). The deposition of bilirubin in tissues occurs when the serum bilirubin level is raised (hyperbilirubinemia). Sclerae have a high affinity for bilirubin due to their rich elastin content.
  • The normal total serum bilirubin level is 0.3-1.0 mg/dL. Jaundice is clinically apparent in sclera when the bilirubin level is raised above 3 mg/dL (Fig. 1.7).
  • The clinical detection of jaundice is difficult in artificial light. Hence, it should be examined preferably in day light. Besides sclera, other sites to be looked for the evidence of jaundice are mucosa of oral cavity underneath the tongue and skin.
  • Yellow discoloration of the skin can also occur in carotenemia (carotenoderma) and exposure to quinacrine or phenols. Sclera is typically not involved in carotenemia.
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FIGURE 1.5: Palpebral conjunctivae showing pallor
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FIGURE 1.6: A. Pallor of the palm; compare with palm of normal person (left) B. pale tongue
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FIGURE 1.7: Jaundice visible over sclera
The enlargement of the distal portion of the fingers and toes, due to proliferation of connective tissues, is known as clubbing (Fig. 1.8A). The clubbing is graded as follows;
  • Grade I: There is thickening of tissues at the nail base.
  • Grade II: In addition to the features of grade I, the angle between nail base and the adjacent skin fold of the finger is obliterated. There is reduction in the space between thumb nails when placed in apposition (Schamroth's window test).
  • Grade III: In addition to the features of grade I and grade II, the shape of the nail becomes convex in both horizontal and vertical directions. In severe cases there is bulbous enlargement of the distal segment of the fingers (drumstick appearance) (Fig. 1.8B).
  • Grade IV: Along with the clubbing, there may be swelling above the wrist and ankles due to periosteitis of long bones (hypertrophic osteoarthropathy).
    The exact mechanism of clubbing is clearly not known. However, it is thought to be due to some humoral substances leading to increased vascularity in the nailbed.
Clubbing may be present since birth (congenital), or acquired. Acquired causes of clubbing are given in Table 1.6.
Cyanosis is bluish discoloration of the skin and mucous membrane caused by an increased quantity of reduced hemoglobin (> 4g%) in superficial blood vessels. The bluish discoloration can also be seen in methemoglobinemia and sulfhemoglobinemia where the patient is cyanosed but not breathless. A cherry red discoloration is caused by carboxyhemoglobin in carbon monoxide poisoning (not true cyanosis).
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FIGURES 1.8A and B: (A) Marked digital clubbing (B) Severe clubbing (drum stick appearance)
Cyanosis is looked for at lips, nailbeds, malar area, ear lobes and mucous membrane of the oral cavity (Fig. 1.9).
Cyanosis is classified into central and peripheral types (Table 1.7).
  1. The imperfect oxygen saturation or abnormal hemoglobin derivatives lead to central cyanosis which is seen in both the mucous membrane (tongue) and skin and also nailbeds of the limbs. The extremities are warm.
  2. Peripheral cyanosis is due to excessive extraction of oxygen from the capillaries when the flow of blood is slow. The extremities are cyanosed and cold while mucous membrane of the oral cavity and tongue are spared. Warming of the cyanotic extremity may increase blood flow and abolish peripheral (but not central) cyanosis.9
    TABLE 1.6   Causes of clubbing
    Respiratory disease
    • Chronic suppurative lung diseases
      • Lung abscess
      • Bronchiectasis
      • Empyema
    • Bronchogenic carcinoma
    • Mesothelioma (pleural neoplasm)
    • Pulmonary tuberculosis
    • Fibrosing alveolitis
    Cardiac diseases
    • Congenital cyanotic heart diseases
      • Fallot's tetralogy
      • Eissenmenger syndrome
    • Subacute bacterial endocarditis
    Gastrointestinal diseases
    • Inflammatory bowel diseases
      • Ulcerative colitis
      • Crohn's disease
    • Hepatic cirrhosis
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    FIGURE 1.9: Central cyanosis
  3. Cyanosis due to heart failure is of mixed type, both central and peripheral.
TABLE 1.7   Causes of cyanosis
Central cyanosis
  • High altitude
  • Respiratory diseases (COPD, extensive pneumonia, pulmonary edema, massive pulmonary embolism)
  • Cardiac diseases (congenital cyanotic heart diseases, Eisenmenger syndrome, heart failure)
  • Abnormal hemoglobin (methemoglobinemia, sulfhemoglobinemia)
Peripheral cyanosis
  • Cold exposure
  • Heart failure (reduced cardiac output)
  • Arterial obstruction
  • Venous obstruction
Edema is the presence of an excess of fluid in interstitial space causing swelling of the tissues.
  1. Edema may be localized or generalized. Generalized edema is known as anasarca, in which the fluid may also accumulate in the pleural cavity (hydrothorax) and peritoneal cavity (ascites). Edema over feet is known as pedal edema. Causes of pedal edema are given in Table 1.8.
  2. Edema may be of the pitting or non-pitting type. Pitting edema means formation of an indentation or pit following the application of firm pressure for a sustained period over the area of swelling (Figs 1.10A and B).
The mechanisms of edema can be described as follows:
  1. The hydrostatic pressure in vascular system and tissue colloid oncotic pressure tend to drive fluid from the vascular to the extravascular space. On the contrary, colloid oncotic pressure maintained by plasma proteins in the vascular system and hydrostatic pressure in the interstitial fluid promote the movement of fluid in the vascular compartment. The development of edema is a result of the imbalance between these “Starling forces”. For example, the edema in congestive heart failure is due to an increase in the vascular hydrostatic pressure. A decrease in the plasma colloid oncotic pressure is the cause of edema in hypoalbuminic states like nephrotic syndrome, malnutrition, and liver disease. The edema is of the pitting type.10
    TABLE 1.8   Causes of pedal edema
    Bilateral pedal edema
    Pitting type
    • Congestive heart failure
    • Nephrotic syndrome, acute nephritis
    • Liver cirrhosis
    • Malnutrition
    • Epidemic dropsy
    • Drugs (calcium channel blockers, NSAIDs, steroids)
    Non-pitting type
    • Myxedema
    Unilateral edema
    • Filariasis
    • Thrombophlebitis
    • Cellulitis
    • Trauma
    • Regional lymph node resection
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    FIGURES 1.10A and B: (A) Pressure applied over edematous limb (B) pitting edema
  2. Edema may result from damage to the capillary endothelium which causes exudation of fluid and protein due to increased permeability. Injury to capillary endothelium may occur due to drugs, infections, and trauma. Capillary permeability is also increased in hypersensitivity reactions. This type of edema is usually localized, non-pitting and may be accompanied by other signs of inflammation.
  3. In many forms of edema, the effective arterial blood volume is reduced. This in turn initiates physiological mechanisms to restore the volume by renal salt and water retention, which further adds up to the edema. Compensatory physiological responses are activation of rennin-angiotensin-aldosterone system, and increased secretion of vasopressin.
Edema generally appears first over the periorbital area and is more marked in the mornings, in nephrotic syndrome and acute nephritis (see Fig. 6.1). In heart failure, the edema is more marked during the evenings and present over the ankles and dorsum of the feet. In these conditions, edema may become generalized later on. In bed-ridden patients, the edema first appears in the presacral region.
Localized edema in a single limb is generally due to either venous or lymphatic obstruction. For example, edema of the leg may occur due to thrombosis of the popliteal or femoral vein. Compression of axillary vein due to malignant lymph nodes may cause edema of the arm.
Lymphatic obstruction due to resection of regional lymph nodes or in filariasis leads to non-pitting edema. Generalized non-pitting edema is found in myxedema.
Lymph Nodes
Palpation of lymph nodes is an important part of general examination (Fig. 1.11). Lymph nodes are examined for;
  • size
  • number
  • texture
  • tenderness
  • mobility
  • signs of inflammation over the nodes
Important groups of lymph nodes which must be examined are submental, submandibular, preauricular, postauricular, cervical (anterior and posterior chains), supraclavicular, axillary and inguinals. For other details, see Chapter 3.11
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FIGURE 1.11: Palpation of the submandibular lymph nodes
Halitosis is an unpleasant odor or smell emerging from the mouth or nostrils that is detected by the patient or others. It is also referred as bad breath, breath malodor, puppy breath, and dragon mouth. About 35% of world population is suffering from bad breath problem. Important causes of halitosis are given in Table 1.9.
Types of Halitosis
  1. Physiologic bad breath: This affects all normal healthy persons and is caused by anaerobic bacterial overgrowth mainly on the tongue deep in the papillae.
  2. Pathologic bad breath: Occurs due to oral infections including carious teeth.
  3. Halitophobia: Some patients may complain of bad breath in spite of treatment being given to them. It may be due to psychiatric illness.
  4. Transitory bad breath: This type occurs after consumption of certain foods like garlic, onions, and certain medications. It usually lasts for hours/days.
Pathophysiology of Halitosis
Anaerobic bacteria are responsible for bad breath. These bacteria are abundantly present in the oral cavity, tonsils and throat. Bacteria react with food, medications in the presence of acidic environment and produce volatile sulphur compounds (VSC) such as hydrogen sulphide (HS) which smells like rotten eggs, methyl mercaptans (smells like gym. socks), putrescine and cadverin (smells like old garbage).
TABLE 1.9   Causes of halitosis
Dental causes
  • Dental decay-carries, exposed teeth
  • Gum diseases
  • Oral infections-abscess
  • Oral cancer
  • Xerostomia (dry mouth)
  • Mouth breathing habit
  • Tongue coating
Medical causes
  • Sinus infections, cough and cold
  • Allergies, post nasal drip
  • Lung abscess
  • Diabetic ketoacidosis (sweet and fruity)
  • Renal failure (ammonical, urinary)
  • Hepatic failure (fishy, mousy)
  • Hiatus hernia
  • Menstruation
  • Medications
  • Certain foods- fish, dairy products, garlic, eggs
  • Smoking
  • Alcohol
  • Stress
  • Certain professions
  • High protein diets (Atkins diet)
Foods Causing Bad Breath
  1. Sugars: bacteria cause breakdown of sugar and produce acidic environment.
  2. Dense proteins/milk products: Cheese, yoghurt, ice cream stay on the tongue and between teeth. Anaerobic bacteria break down the proteins and produce VSC.
  3. Acidic foods: Anaerobic bacteria multiply very fast in acidic medium and produce high levels of VSC. Acidic foods include coffee, tomato juice, citrus fruit juices aerated drinks.
  4. Onion, garlic, cabbage: When taken raw, smell comes from mouth because of sulphur compounds present in them.
Examination/Tests for Halitosis
These are following scientifically proven ways to check breath:
  1. Using Halimeter: It measures the concentration of sulphides in the breath. Reading above 75 ppb (parts per billion) indicates bad breath.
  2. Using bad breath detective: It measures the amount of VSC coming from the tongue by simply swabbing the 12back of tongue and placing it into the test tube that comes with bad breath detective.
  3. Other methods used to detect halitosis are:
    1. Lick the back surface of hand, let it dry and smell after 15-20 seconds.
    2. Use floss interdentally and smell it.
    3. If the back surface of tongue is whitish it indicates that person has bad breath.
    4. If friends, colleagues and relatives, move away or offer mint while person is talking to them.
Myth about Halitosis
Bad breath comes from stomach is myth. There is no open tube connecting the stomach or intestines to mouth as there are valves, sphincters and muscles etc, that keep digested food at its place.
Tongue and Bad Breath
Tongue is responsible for almost 85% of bad breath that comes from the mouth. Tongue has glossy surface so the food gets accumulated here and bacteria utilize the food to produce the volatile sulphur compounds (VSC). Tongue cleaning is more effective than brushing in stopping bad breath. Tongue cleaning reduces oral bacteria thereby decreasing chances of bad breath and plaque formation. It also improves taste sensitivity and quality.
Treatment of Bad Breath
Treatment of bad breath is possible if the cause is removed. It can be done in multiple visits to dental clinic (fresh breath clinics). It includes following:
  • Thorough dental and oral checkup
  • Medical history to rule out any medical cause
  • Dietary analysis and counseling
  • Bad breath testing using halitometer
  • Oral hygiene instructions and techniques
Mouth wash: Sugar, saccharin and alcohol containing mouth washes should be avoided. Alcohol causes dryness of mouth. Special mouthwashes are used which release oxygen that kills the anaerobic bacteria.
Xylitol chewing gums: sugar free xylitol chewing gums are also useful.
General Physical Examination
General appearance
Mental state
Height and weight
  • Pulse
    Rate and rhythm (radial)
    Character and volume (carotids)
  • Blood pressure
  • Temperature
  • Respiration
  • Exophthalmos, ptosis, eye movements
  • Conjunctiva—pallor, icterus
  • Pupils—size, reaction to light and accommodation
Face: Symmetry, puffiness, cyanosis, parotid gland
Oral cavity: odour, lips, tongue, teeth, gum, buccal mucous membrane
  • Lips: color, eruption
  • Teeth: denture, other abnormalities
  • Gums: swelling, bleeding, inflammation, ulcers
  • Tongue: color, appearance, ulcers
  • Buccal mucosa: color, ulcers
Pharynx: tonsils, oropharynx.
  • JVP
  • Thyroid
  • Lymph nodes (cervical)
Upper limbs:
  • Nails-clubbing, koilonychia, pallor, cyanosis
  • Pulse
  • Blood pressure
  • Lymph nodes (axillary)
Lower limbs:
  • Edema of feet, ankles13
Certain terms are frequently used in clinical medicine. These have profound effects on presentations. Some important terms are defined below.
Diagnosis is an act or process of identifying or determining the nature of a disease by way of examination and assessment of the symptoms and signs.
Diagnosis is an art wherein scientific methods are applied to the elucidation of problems presented by a patient. A concept is formed about the etiology, pathology, and organ dysfunctions which constitutes the patient's disease.
Diagnosis provides a firm basis for the treatment and prognosis of the individual patients.
Clinical Diagnosis
Diagnosis made by bedside methods without the help of laboratory tests.
Differential Diagnosis
The recognition of a particular condition from amongst others which closely resemble it in certain aspects.
Prognosis is a considered opinion of the probable development and outcome of the disease based upon all the relevant available facts of the case.
Treatment is the course of action adopted to deal with illness and control of the patient.
Illness is defined by the totality of effects, predicaments, and repercussions of the disease, deformity, or circumstances produced in the patient.
Multiple Choice Questions
  1. Rate and rhythm of the pulse is best appreciated by palpating:
    1. Brachial artery
    2. Radial artery
    3. Popliteal artery
    4. Femoral artery
  1. Following is not true in pulsus paradoxus:
    1. Found in cardiac tamponade
    2. Disappears during expiration
    3. Inspiratory fall in blood pressure
    4. May be present in bronchial asthma
  1. Following conditions are associated with bradycardia except:
    1. Hypothyroidism
    2. Athletes
    3. Hypotensive shock
    4. Raised intracranial tension
  1. Edema in both lower limbs can occur in:
    1. Filariasis
    2. Cellulitis
    3. Nephrotic syndrome
    4. Popliteal vein thrombosis
  1. Cyanosis in CHF is of following type:
    1. Central
    2. Peripheral
    3. Both, central and peripheral
    4. Not found
  1. Which of the following is not matched correctly:
    1. Pulsus Parvus et tardus — aortic stenosis
    2. Pulsus besferiens—severe mitral stenosis
    3. Water hammer pulse—aortic regurgitation
    4. Hyperkinetic pulse—thyrotoxicosis
  1. Clubbing can be found in the following except:
    1. Bronchiectasis
    2. Lung abscess
    3. Pneumonia
    4. Bronchogenic carcinoma
  1. Yellowish discoloration of sclera and skin occurs in the following:
    1. Carotinemia
    2. Hyperbilirubinemia
    3. Quinacrine ingestion
    4. Both A and B
    5. All of the above
  1. Cyanosis is seen in:
    1. Fallot's tetralogy
    2. Methemoglobinemia
    3. Sulfhemoglobinemia
    4. All of the above
  1. All of the following is true in peripheral cyanosis except:
    1. It improves on warming
    2. Best seen in oral mucous membrane
    3. Occurs in cases with low cardiac output
    4. May occur following exposure to cold
  1. Following is not matched properly:
    1. CHF _______ pedal edema
    2. Thyrotoxicosis _______ tachycardia
    3. High arterial CO2 _______ cyanosis
    4. Orthopnea _______ mitral stenosis
  1. Early morning periorbital edema suggests the disease of following system:
    1. Cardiac
    2. Renal
    3. Hepatic
    4. All of the above
  1. “a” wave in JVP is absent in:
    1. Pericardial tamponade
    2. Complete heart block14
    3. Atrial fibrillation
    4. Hypotension
  1. Distended but nonpulsatile neck veins are found in:
    1. Right heart failure
    2. Tricuspid stenosis
    3. Mediastinal tumor
    4. Constricitive pericarditis
  1. JVP is best examined in:
    1. External jugular vein
    2. Internal jugular vein
    3. Subclavian vein
    4. Any one of the above
  1. Sweet fruity odour is found in the oral cavity in case of:
    1. Renal failure
    2. Hepatic failure
    3. Diabetic ketoacidosis
    4. All of the above
  1. Blood pressure is generally measured by auscultating over following artery:
    1. Radial artery
    2. Brachial artery
    3. Carotid artery
    4. Any of the above
  1. The diastolic BP corresponds best with:
    1. First appearance of Korotkoff sound
    2. Disappearance of Korotkoff sound
    3. Muffling of Korotkoff sound
    4. In between appearance and disappearance of korotkoff sound
  1. The following can be measured by sphygmo-manometer and palpating the artery:
    1. Systolic blood pressure
    2. Diastolic blood pressure
    3. Both
    4. None
  1. In coarctation of aorta, following is true:
    1. BP in lower limbs is higher than in upper limbs
    2. BP is equal in lower and upper limbs
    3. BP in upper limb is higher than in lower limbs
    4. BP is generally not recordable in upper limbs
  1. Cyanosis is accompanied with clubbing in the following except:
    1. Eisenmenger's syndrome
    2. Fallot's tetralogy
    3. Interstitial lung disease
    4. Conditions with peripheral cyanosis
  1. Clubbing may be present in the following except:
    1. Lung cancer
    2. Crohn's disease
    3. Infective endocarditis
    4. Left to right cardiac shunts
  1. Following is not properly matched:
    1. Clubbing_______Fallot's tetralogy
    2. Cyanosis_______pulmonary edema
    3. Eisenmenger's syndrome_______cardiac shunts with left to right flow
    4. Pulmonary osteoarthropathy_______lung cancer.
Fill in the Blanks
  1. Radio-femoral delay is found in _______.
  1. Pulsus alternans is present in _______.
  1. Cyanosis appears when amount of reduced Hb exceeds _______ g/dL.
  1. Rise in JVP during inspiration in constrictive pericarditis is called _______ sign.
  1. Prominent Y descent in JVP is seen in _______.
  1. Bradycardia is defined as pulse rate less than _______ per minute.
  1. Tachycardia is defined as pulse rate more than _______ per minute.
  1. Normal respiratory rate in adults is ______ per minute.
  1. Regularly irregular pulse is found in _______.
  1. Fishy mousy odour in the oral cavity suggests ______.
  1. Cherry red discoloration of skin is found in _______.
  1. Waxing and waning respiration with intervening periods of apnea is called _______.