General physical examination for ug students

1. GENERAL PHYSICAL
EXAMINATION OF GIT, RS, CVS
AND CNS

2. GENERAL PHYSICAL
EXAMINATION OF GASTRO
INTESTINAL SYSTEM

3. BUILT AND NOURISHMENT
• INCREASED – NASH
• DECREASED – MALIGNANCY
• WT. MONITORING – TO CHECK INCREASE OR DECREASE IN VOLUME
OVERLOAD STATUS AND RESPONSE TO DIURETICS ( 0.8 TO 1 KG
DECREASE PER DAY ; DIURETIC RESISTANT IF NO RESPONSE TO 400MG
SPIRONOLACTONE AND 160 MG FUROSEMIDE)

4. PULSE
• Tachycardia—anemia, hypovolemia
• Bradycardia—obstructive jaundice
• High volume pulse—cirrhosis of liver

5. Blood pressure
• Wide pulse pressure—cirrhosis
• Low blood pressure—sepsis, UGI bleed, Diuretics

6. Fever
• SBP
• Hepatoma
• Cirrhosis
• Hepatitis
• Abscess
• Pancreatitis
• Inflammatory bowel disease

7. Respiratory Rate
Increases in
• Ascites
• Pleural Effusion
• HepatoPulmonary Sundrome
Pattern
• Becomes ThoracoAbdominal in Ascites

8. ELEVATED JVP
• Anemia leading to Hyperdynamic circulation
• CHF is a DD in an ascitic and edematous pt

9. Pallor
• GI bleed
• Anemia of chronic disease
• Macrocytic anemia—liver disease, B12 and folate deficiencies
• Splenic sequestration
• Alcohol depressed bone marrow
• Alcohol can lead to haemolytic anemia (Zeive’s syndrome)

10. Icterus
• HEPATIC CAUSE – usually not seen in cirrhosis, if present it might be
due to superimposed infection, recent alcohol consumption or
malignancy
• POST HEPATIC/OBSTRUCTIVE CAUSE

11. Cyanosis
• Hepatopulmonary syndrome
• Pleural effusion

12. Clubbing
• Primary biliary cirrhosis
• Inflammatory bowel disease
• HCC

13. Lymphadenopathy
• Tuberculosis
• HIV
• Lymphoma
• Hepatocellular carcinoma

14. Pedal edema
• Cirrhosis – pitting edema with rapid recovery
Occurs due to portal hypertension and hypoproteinemia
Grading of Pitting Edema
1+ 2-mm depression, immediate rebound
2+ 4-mm deep pit, a few seconds to rebound
3+ 6-mm deep pit, 10–12 seconds to rebound
4+ 8-mm deep pit, >20 seconds to rebound

16. Peripheral Signs of Chronic Liver Disease
• Hair- alopecia and thin and brittle hair due to deficiencies
• Eyes- KF ring in Wilson disease
• Oral Cavity- stomatitis, cheilitis, ulcers due to deficiencies; bleeds due to
coagulopathy
• Palmar erythema (blotchy appearance over the thenar and hypothenar
eminence) – due to hyperdynamic circulation
• Bruising – deranged coagulation by liver, thrombocytopenia due to less
thrombopoietin by liver, thrombocytopenia due to splenic sequestration
• Scratch marks (cholestatic jaundice)

17. • Neck and upper chest and back - Spider nevi (telangiectatic superficial
blood vessels with central feeding vessel)
Size: Vary from pinhead to 0.5 mm in diameter
Clinical demonstration: Applying pressure over the body of spiders with
a glass slide (diascopy) or pin head leading to pallor with refilling
following the release of pressure
Significance: They are a strong indicator of liver disease but can be
found in other conditions - Viral hepatitis, Alcoholic hepatitis,
Hepatocellular carcinoma, Treatment with sorafenib, Third trimester of
pregnancy, Rheumatoid arthritis, Thyrotoxicosis, Also normally seen in
2% of healthy population.

19. Endocrine—due to estrogen excess
• Gynecomastia ( palpable nodule )
• Atrophy of testis ( decreased size and loss of testicular sensation)
• Loss of axillary and pubic hair

20. • Dupuytren’s contracture (sign of alcoholism)
seen in the 3rd and 4th finger

21. • Asterixis/Flapping tremors
Tremors is a misnomer(to and fro movt)
Type of negative myoclonus where brief loss of muscle tone in agonist
muscles followed by compensatory jerk of antagonists

23. • Parotid and lacrimal gland swelling (alcoholic liver disease)
• Fetor hepaticus (characteristic sweet smelling breath due to dimethyl
sulphide)

24. Nail Changes
• White/Terry’s/ Leukonychia
• Muehrcke’s nails – white transverse lines that disappear on pressure
but not as the nail grows

25. GENERAL PHYSICAL
EXAMINATION OF RESPIRATORY
SYSTEM

26. Built and Nourishment
Respiratory diseases associated with emaciation:
• HIV
• Pulmonary tuberculosis
• Malignancy.
Respiratory diseases associated with obesity:
• OSA
• Pickwikian syndrome (obesity hypoventilation syndrome)

27. ORIENTATION
• ANXIOUS - RF1
• DROWSY AND COMATOSE – RF2, pneumonia spread to brain as
encephalitis

28. Pulse:
• Rate—tachycardia (any pneumonia, febrile illness, hypoxia)
• Bounding pulse—CO2 retention
• Pulsus paradoxus ( inspiratory drop in bp > 10mm Hg)—acute
exacerbation of COPD/asthma, pneumothorax

29. Respiratory Rate
Tachypnea
>20 cpm
Bradypnea
<10 cpm

30. Abdominothoracic
• Due to well-developed abdominal muscles
• Seen in males
Thoracoabdominal
• Well-formed internal intercostal muscles
• Seen in females

32. • Pursed Lip Breathing Seen with chronic obstructive pulmonary
disease (COPD)
• Mechanism of auto-positive end-expiratory pressure (PEEP)
• The purpose of this breathing is to slow down the air flow during the
exhalation to build up back pressure in the airway to avoid a sudden
drop in intrapulmonary pressure resulting in alveolar and airway
collapse.

33. Blood pressure:
• Wide pulse pressure—in hypercapnia
• Low blood pressure—seen with hypoxia, acute respiratory distress

34. Jugular venous pressure:
• Elevated: In cor pulmonale, tricuspid regurgitation due to Pulm HTN
• Nonpulsatile jugular venous pressure (JVP): Superior vena cava (SVC)
obstruction

35. Temperature:
• Evening rise of temperature: Tuberculosis
• High spiking fevers: Lung abscess, empyema, pneumonias.

36. Pallor:
• Tuberculosis
• Malignancy
• Any cause of massive hemoptysis.

37. Polycythemia
• Chronic respiratory diseases are usually associated with polycythemia
RUDDY CYANOSIS- BLUISH RED EYES

38. Icterus:
• Hepatitis secondary to antitubercular (ATT) drugs
• Atypical pneumonias (hemolytic jaundice)
• As a part of multiple organ dysfunction syndrome (MODS)
• Rarely metastasis to liver from lung Ca
• Alpha 1 antitrypsin deficiency affects liver and lungs
• Cor pulmonale can cause liver congestion

39. CLUBBING
• Malignancies- Bronchogenic carcinoma, Mesothelioma
• Suppurative diseases- Bronchiectasis, Lung abscess, Empyema
• Interstitial lung disease (ILD)
• Tuberculosis Seen in 30% cases as a sequelae to complications
• Sarcoidosis

40. CYANOSIS
• Asthma
• Chronic obstructive pulmonary disease (COPD)
• Cor pulmonale
• Respiratory failure of any cause like pneumonia, tension
pneumothorax, massive pleural effusion, and acute pulmonary
edema

41. LYMPHADENOPATHY
• Bacterial Disseminated TB
• Malignancy
• Pneumonia

42. Edema:
• Cor pulmonale
• Bronchiectasis leading to hypoproteinemia (due to loss of protein in
the sputum and nephrotic syndrome secondary to amyloidosis)—100
mL of sputum can cause 3–4 g of protein loss.
• Hypercapnia-induced dilation of the precapillary sphincters.

43. Oral cavity examination:
• Halitosis seen in suppurative lung diseases
• Tobacco staining of the teeth
• Poor oral hygiene
• Oral markers of malignancy—leukoplakia, erythroplakia, submucous
fibrosis.
• Cyanosis or polycythemia.
• Oral candidiasis—due to inhaled steroids.

44. MARKERS OF TB
• Matted lymph nodes
• Erythema nodosum
• Phlyctenular conjunctivitis
• Choroid tubercle
• Discharging sinuses
• Scrofuloderma
• Lupus vulgaris
• Beaded vas deferens
• Positive Mantoux test
• Generalized tinea versicolor
• Uveitis.

45. MARKERS OF MALIGNANCY
• Cachexia
• Grade IV clubbing (HPOA)
• Hard lymph nodes
• Acanthosis nigricans
• Horner’s syndrome
• SVC obstruction features—non-pulsatile, dilated JVP, facial flushing
and edema, conjunctival suffusion, papilledema, dilated veins on the
chest wall

46. Features of respiratory failure:
RESP TYPE 1
• NORMAL Pco2
• High RR
• FEEBLE PULSE
• LOW BP
• CYANOSIS
• ANXIOUS PT
• CAUSES - ARDS
Pneumonia Acute
severe asthma Tension
pneumothorax
RESP TYPE 2
• LOW Pco2
• BOUNDING PULSE
• HIGH PULSE PRESSURE
• ANXIOUS PT
• ASTERIXIS PRESENT
• Causes - COPD Obesity
Respiratory paralysis

47. Features of Cor Pulmonale
• Raised JVP
• Pedal edema
• Tender hepatomegaly
• Ascites
• Sustained abdominojugular reflux is first sign of RVF

48. GENERAL PHYSICAL
EXAMINATION OF
CARDIOVASCULAR SYSTEM

49. PULSE

52. • Pulse deficit (Apex-pulse deficit) (Fig. 2B.2) is the difference between
the heart rate (counted by auscultation) and pulse rate when counted
simultaneously for one full minute by two individuals.

57. Radio-Radial Delay
Proceed to palpate both radial pulses simultaneously to detect any
inequality in timing.
This is known as radio-radial delay.
Causes include: Presubclavian coarctation Thoracic inlet syndrome:
Cervical rib Takayasu’s disease Aortic arch aneurysm.
Radio-Femoral Delay
If the femoral pulse is appreciated at the same time as the radial pulse,
the patient is said to have radiofemoral delay.
This is a sign of coarctation of aorta.

58. Condition of vessel wall
• Osler Sign: seen in Monckeberg’s Sclerosis of arteries – palpable and
pulseless radial artery while BP cuff is inflated above systolic pressure
is a positive osler sign

59. Blood Pressure
JNC 8 Guidelines
SBP DBP
Normal <120 and <80
PreHTN 120-139 or 80-89
Stage I HTN 140-159 or 90-99
Stage II HTN ≥160 or ≥100

60. Hypotension
• BP ≤ 90/60 mm Hg
• Causes : Vasovagal syncope, autonomic failure, dysrrhythmias, carotid
sinus syndrome, diuretic use, haemorrhage, etc

61. JVP
• The normal JVP is less than 4 cm above the sternal angle; or is just visible above the clavicle
in 45° position.
Causes of Raised JVP - Cardiac causes:
• Right heart failure
• Congestive cardiac failure
• Chronic constrictive pericarditis
• Cardiac tamponade
• Complete heart block
• Restrictive cardiomyopathy
• Superior vena cava (SVC) obstruction
• Tricuspid stenosis

65. • ABDOMINOJUGULAR (AJR) REFLUX OF RUNDOTT (PREVIOUSLY KNOWN AS
HEPATOJUGULAR REFLUX)
• consistent abdominal pressure , preferably over the right hypochondrium
• Historically pressure was applied for 15 seconds; however, recent studies
suggest 10 seconds is adequate
• Normal response: Transient rise of around 4 cm for about 4–5 cardiac
cycles (approximately 5 sec)
• Sustained response/positive response: Earliest sign of right heart failure
(RHF), also seen in tricuspid regurgitation (TR)
• Absent response/negative response: Obstruction/thrombosis of inferior
vena cava (IVC) or hepatic veins as seen in Budd-Chiari syndrome

66. • Kussmaul Sign of JVP
• Normally when the patient inspires there is fall in the height of JVP
due to increased negative intrathoracic pressure.
• Kussmaul sign is the paradoxical elevation of JVP during inspiration.
• Seen in: Constrictive pericarditis, Severe heart failure ,Right
ventricular infarction, Restrictive cardiomyopathy.

67. TEMPERATURE
• IE
• ACUTE RHEUMATIC FEVER

68. PALLOR
• LHF
• AORTIC STENOSIS
• IE
• CARDIOGENIC SHOCK
• ANEMIA LEADING TO HEART FAILURE

69. ICTERUS
• MICROANGIOPATHIC HEMOLYTIC ANEMIA BY PROSTHETIC HV
• COXSACKIE VIRUS
• CONGESTIVE HEPATITIS

70. CYANOSIS
• HEART PATHOLOGIES CAUSE CENTRAL CYANOSIS

71. CLUBBING
• Subacute bacterial endocarditis
• Atrial myxoma
• Cyanotic heart disease
• Acyanotic heart disease with Eisenmengerization
• Differential clubbing: Upper limb (N) Lower limb (clubbing):
Patent ductus arteriosus (PDA) with reversal of shunt
• Reverse differential clubbing: Upper limb (clubbing) Lower limb (N):
PDA + transposition of the great arteries (TGA) + reversal of shun

72. Lymphadenopathy
• IE

73. EDEMA
• PITTING TYPE WITH SLOW RECOVERY RATE I.E. > 40 SECONDS IN CHF,
PERICARDITIS, TRICUSPID VALVE DISORDERS

74. Nails in CHF
• White nails
• Red ½ moon nails

75. Markers of RHD
• Fever
• Arthritis
• Erythema marginatum
• Subcutaneous nodules
• Tachycardia.

76. MARKERS OF IE

77. MARKERS OF CAD
• Xanthoma
• xanthelasma
• Skin tags
• Arcus senilis
• Nicotine staining
• Frank’s sign
• Locomotor brachialis

78. Stigmata of congenital heart disease
• Down syndrome-ECD, VSD -Cataract ,Hypotonia ,Hypothyroidism,
Increased gap between 1st and 2nd toe (sandal gap), Duodenal atresia,
Hirschsprung’s disease,, Simian crease, Mental retardation, Micrognathia
Atlantoaxial instability, Nystagmus, Protruding tongue, Poor hearing, Round
face ,Respiratory infections ,Occiput is flat, Oblique palpebral fissure,
Brushfield spots, Brachycephaly, Low nasal bridge, Language problem,
Epicanthic fold, Ear folded, Mongolian slant, Myoclonus
• Marfan syndrome -Aortic aneurysm, aortic and/or mitral regurgitation-
Arachnodactyly with hyperextensibility, subluxation of lens and other joint
deformities

79. • William’s syndrome- Supravalvular AS, PA stenosis - elfin facies (consisting
of some of the following: upturned nose, flat nasal bridge, long philtrum,
flat malar area, wide mouth, full lips, widely spaced teeth, periorbital
fullness)
• DiGeorge syndrome- Interrupted aortic arch, truncus arteriosus, VSD, PDA,
TOF- Hypertelorism, short philtrum, down slanting eyes, hypoplasia or
absence of thymus and parathyroid, hypocalcemia, deficient cell-mediated
immunity
• CHARGE syndrome- TOF, truncus arteriosus, aortic arch anomalies (e.g.
vascular ring, interrupted aortic arch)- Coloboma, choanal atresia, growth
or mental retardation, genitourinary anomalies, ear anomalies, genital
hypoplasia

80. GENERAL PHYSICAL
EXAMINATION OF CENTRAL
NERVOUS SYSTEM

81. Attitude
In a patient with hemiplegia
Upper limb- Adduction at shoulder, Flexion at elbow, Semipronated,
Thumb tucked into the palm
Lower limb- Extended at hip and knee, Externally rotated at hip, Foot
inverted, Plantar flexed

82. Pulse
• Decreased pulse rate—increased intracranial pressure (ICP)—Cushing
reflex
• Resting tachycardia autonomic dysfunction
• Irregularly irregular—atrial fibrillation (AF)
• Feeble pulse –atherosclerosis
• Palpable blood vessel – HTN, ATHEROSCLEROSIS
• Carotid bruit(SCM), vertebral bruit(Line joining medial 1/3rd of clavicle
to the mastoid) – Atherosclerosis ( not heard in initial phase or full
occlusion)

83. Respiratory Rate
• Cushing’s reflex – irregular resp
• Brainstem lesion – apneustic breathing

84. Blood pressure
• Increased BP—intracranial (IC) bleed : reactionary hypertension
• Decreased BP- Cushing’s reflex, Orthostatic hypotension

85. Fever
• Meningitis
• Encephalitis
• malignancy
• CVA – can lead to bad prognosis as it increases infarct size; can be a stroke complication due
to infection
• CVT
• Brain abscess
• Epidural abscess
• Vasculitis
• Complex partial seizures
• Normal pressure hydrocephalus
• Myotonic dystrophy
• Hypothalamic dysfunction
• Paraplegia case can be Pott’s spine I.e. TB

86. Pallor
• Vitamin B12 deficiency
• Pica, restless leg syndrome—iron deficiency
• Chronic liver disease (CLD), chronic kidney disease (CKD)—
encephalopathy
• Microangiopathic haemolytic anemia by prosthetic heart valves can
cause emboli

87. Icterus
• Hepatic encephalopathy
• Kernicterus.

88. Clubbing
• Syringomyelia
• Chronic hemiplegia Median nerve injury.

89. Cyanosis
• Aspiration pneumonia in stroke pt
• Pulmonary embolism by dvt in a stroke pt
• TOF AND POV – paradoxical emboli

90. Lymphadenopathy
• Lymphoma—neuropathy, cerebellar ataxia, intracranial metastasis
• Paraneoplastic syndrome: Lung carcinoma—Lambert–Eaton
Myasthenic syndrome
• Drug induced—phenytoin.

91. Edema
• Autonomic dyfunction

92. NERVE THICKENING
Infective
• Leprosy
Hereditary
• Hereditary motor and sensory neuropathy types 1 and 3 (Charcot–Marie–Tooth neuropathy, Dejerine–Sottas syndrome)
• Refsum’s disease
• Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP)
• Chronic inflammatory sensory polyradiculopathy (CISP)
• Multifocal acquired demyelinating sensory and motor polyneuropathy (MADSAM)
• Relapsing Guillian-Barre syndrome (GBS).
Tumors of nerves or nerve sheath
• Schwannoma
• Neurofibromatosis 1 and 2
Nerve infiltrations
• Acromegaly
• Amyloidosis
• Sarcoidosis.

94. NEUROCUTANEOUS
SYNDROMES/PHAKOMATOSES
• Neurofibromatosis I and II
• Tuberous sclerosis
• Von Hippel–Lindau disease
• Sturge–Weber syndrome
• Klippel–Trenaunay–Weber syndrome
• Osler–Weber–Rendu syndrome
• Ataxia-telangiectasia

95. Neurofibromatosis 1, 2

96. Tuberous sclerosis

98. Ataxia Telangiectasias

99. Anthropometry
• Head:Neck ratio >13:1 = Cripple fail syndrome – cervical vertebra
fusion predisposes to paraplegia

100. Markers of RHD
• Fever
• Arthritis
• Erythema marginatum
• Subcutaneous nodules
• Tachycardia.

101. MARKERS OF IE

102. MARKERS OF TB
• Matted lymph nodes
• Erythema nodosum
• Phlyctenular conjunctivitis
• Choroid tubercle
• Discharging sinuses
• Scrofuloderma
• Lupus vulgaris
• Beaded vas deferens
• Positive Mantoux test
• Generalized tinea versicolor
• Uveitis.

103. MARKERS OF MALIGNANCY
• Cachexia
• Grade IV clubbing (HPOA)
• Hard lymph nodes
• Acanthosis nigricans

104. MARKERS OF CAD
• Xanthoma
• xanthelasma
• Skin tags
• Arcus senilis
• Nicotine staining
• Frank’s sign
• Locomotor brachialis

105. THANK YOU