hello dear students today we are going to talk about general examination history taking and general examination are an important part of any physical examination of the patient so before you start clinical examination a proper history taking is important along with that if you do a proper meticulous general examination it gives you at least a probable diagnosis now what are the prerequisites before you start a general examination are the patient has to be put in a very comfortable position so when you do start general examination see to it that the surrounding is comfortable and it is a quiet place so you can examine the patient comfortably now most of the times the patient are very apprehensive about the examination so assure the patient what is the need and significance of doing the general examination as it is going to help you arrive at a diagnosis now when you perform general examination it has to be done in a proper light because the skin changes can be appreciated properly in a natural light so as far as possible avoid artificial light then the third point we need to know we need to remember is that general examination when we have it done it has to be done with the proper exposure of the patient of whatever part we are examining now at this point it is mandatory that i tell you that whenever you are examining a male doctor is examine a female subject a female attendant or a nurse should be present that will assure or make the female patient comfortable as well as it will prevent you from any accusations of immodesty so always remember that a female attendant should be present in whenever you examine a female patient now another important point i want to highlight is for any examination clinical examination henceforth you will be always standing on the right side of the patient standing on the right side of the patient allows you to examine the abdominal organs properly you can also observe the jugular veins and examine the apex beat properly when you are standing on the right side so it is mandatory that you stand always on the right side of the patient now with this points in mind we also have to understand that whenever you are doing examination that the you should take into consideration the severity of the patient's complaints if the patient is having very acute illness see to it that you first look at those things and if the patient is comfortable only then proceed for general examination or you can postpone till you are although his acute condition is taken care of so these are the prerequisites which you will do before you actually start the general examination now we start the general examination we have to take the consent of the patient so so once you have taken the consent of the patient now we have to start the general examination now general examination is usually started as soon as a patient arrives in your clinic so if the patient is arriving in your clinic you have to be very observant about the way he walks that is going to give or how ill is the patient whether the patient appears healthy or is ill if the patient is ill try to cause what is the severity of the patient now if the patient is lying down on the bed that the position of the patient in bed is called as decubitus so once you know that patient is lying down comfortably and how much is the severity of the illness you can proceed for your general examination if the patient is breathless you will know the position of the patient will be propped up so that is called as a decubitus or the position of the patient in bed now once you have seen that you start the examination from head to toe now first coming to the head now head examination of the head is usually more significant when you're examining a pediatric patient the size and shape of the head is important if the patient is having macro kefali or if there's a microcephaly you will know the significance of those things suppose there's hydrocephalus he will have a big head so microcephaly and macro kefali these are the things you will observe especially in pediatric patients when you are talking about the size and shape of the head then you talk about the mental condition of the patient whether how patient is oriented in time in space what is a how is the speech of the patient whether the patient is cooperative or not now most of the things you would have taken when you are taking history taking you would have asked about his uh educational qualification his occupation and all the history you have taken by now you know how cooperative the patient is and whether it is oriented in time on space and how is this speech because that gives you a lot of information about the diagnosis you are going to make later on so keep in mind about the mental state of the patient now once you have done that then you go and you observe the build of the patient so you know the what is the height and weight you have taken is age so it has to be compatible with this age and according to the gender the height and weight have to be there now two things can be the either patient is a small nourish is starved so you know it could be a chronic illness or if the patient is obese which is a very risk factor for many of our cardiovascular diseases so keep in mind the build of the patient also you have a rough idea when you start general examination you look at the build of the patient so now we will start the general examination proper now there are six things which are most important when you are doing the general examination so we have this acronym pickle what does p stand for p stands for pallor pallar is the painless of the skin so we have to examine the subject for parallel we'll talk about it in detail when we see the patient so right now i'm just going to tell you what are the the stands for so p stands for palla i stands for actress actress is the yellowish discoloration of the skin which we have to examine c stands for cyanosis cyanosis is bluish discoloration of the skin which is seen when the reduced hemoglobin is more than 5 grams per deciliter then another c stands for clumping clubbing is a spelling of the soft tissues of the fingernails then l stands for lymphadenopathy that is enlargement and palpable lymph nodes and lastly e stands for edema that is collection of fluid in the interstitial spaces so these are the six important most important parameters which you should do when you're doing general examination the acronym is pickle p stands for pallor i stands for actress c stands for cyanosis another c stands for clubbing alpha lymphadenopathy and e for edema now we will go and examine all these things on a subject now we are going to examine the subject for pallor what do you mean by pala paler is the paleness of the skin it is usually due to reduce hemoglobin content in the blood or there is various amount of blood for example when the patient is in shock then the palate will be visible or the patient is having anemia because of reduced hemoglobin content so what are the areas which you are going to examine for palla balance usually seen in the lower palpable conjunctiva so to examine the lower palpable conjunctiva instruct the subject to look up and just retract the lower eyelids to look for upper dick okay so then look for palla at the tip of the tongue and the soft palate akarna okay then examine the palms of both the hands for palla and the nails so these are the areas which you will assess to look for pallow now palla can be graded from 0 to 3 when there is the sign 0 is no anemia so if there is grade 1 there is mild anemia if the parallel is grade 2 it is moderate and grade 3 is severe anemia so those are the things which you will do when you want to look for palette so the next point is now we have to look for ictress ictress is the yellow is the discoloration of the skin which is usually seen in jaundice so you examine the sclera the skin and the mucous membrane to look for actress now when you want to look for actress it instruct the subject to niche now and retract the upper eyelid instruct the subject to look down and detract apple id to look for actress you can also look on the nail bed and this if the skin appears yellow or not so you check for actress okay so these are the areas now ictress is because as i told you it is because of the yellows discoloration of the skin now why does the skin appear yellow the actresses as i told you jaundice is a major cause for uterus and whenever the bilirubin level in the blood increases that causes yellows escalation normal serum bilirubin levels are 0.2 to 0.8 milligram per deciliter when bilirubin level increase more than 2 milligram per deciliter that appears as ah clinically it will appear as yellow is discoloration of the skin apart from jaundice keratinemia is the other condition where you will get the uh john yellow is describation of the skin now jaundice can be because of there could be different causes of jaundice one could be hemolytic jaundice which occurs because of excessive destruction of the red cells or it could be a hepatic jaundice where the liver cells are damaged increasing the bilirubin concentration on a post hepatic jaundice where it is an obstructive jaundice where is obstruction to the flow of bile and that also increases the bilirubin count and that appears as a yellowish discoloration of the skin the next point is now we are look going to look for cyanosis now what is cyanosis cyanosis is a bluish discoloration of the skin which is and the mucous membrane which is seen as seen because of increase in the reduced hemoglobin contain more than 5 grams per deciliter now cyanosis can be of two types peripheral cyanosis and central sinuses peripheral sinuses you see usually in the dependent parts of the body for example in the nail beds or on the ear lobule central cyanosis is usually seen on the central part of the tip of the nose or g bhayanikala so on the lips and on the tongue now what are the causes of cyanosis now peripheral cyanosis is usually caused when there is slowing of the blood to the tissue that allows more amount of oxygen to be removed from the tissue and that causes cyanosis usually so person is having a cardiac is in cardiac failure where the cardiac output decreases the cyanosis will be visible or if there is a local vasoconstriction because of extreme cold you will the cyanosis appears now sinuses can also occur when the viscosity of the blood is more for example in polycythemia so these are the causes of peripheral cyanosis now what are the causes of central cyanosis in central cyanosis the as a there is increase in the deoxygenated hemoglobin more than 5 gram percentage usually you see when there is a shunt here so in av shunt uh av a shunt is there when the venous blood bypasses the pulmonary circulation and mixes with the arterial blood that increases the amount of deoxygenated hemoglobin and that appears as cyanosis other causes of cyanosis could be at high altitude where there is decrease in the oxygen content of the blood that causes cyanosis or if there is any lung abnormality for example there is a lung collapse that can lead to cyanosis or there is defective gas exchange across the respiratory membrane that can also lead to increase in the deoxygenated hemoglobin in the blood so the next point we are going to look for clubbing what do you mean by clubbing clubbing is the bulbous enlargement of the soft part of the nail bed or there is increase in the curvature of the nail but excessive curvature of the nail bed that leads to clubbing now clubbing has to be observed on the nails now what how do you what are tests you will absorb do for the accessing the clubbing so first you check for the fluctuation in the nail bed now for testing the fluctuation first hold the nail bed and with the finger you just have to palpate the nail bed normally there is no fluctuation but if there is excessive fluctuation it can be made out and that will be tested as clubbing then secondly you also look for the angle between the nail bed and the adjacent skin normally it is an obtuse angle when there is obliteration of this angle you it denotes clubbing then the third sign which is important which can be done is the shabrod sign in this you tell the subject to approximate his nail beds and you look for the space between the nail beds normally there is some space when there is approximation of the nail bits obliteration of the space indicates clubbing okay now what are the physiological causes of clubbing now there is no no specific reason given given behind why clubbing occurs but there are some theories which have been there reason given is that the increase in number of av channels in the fingers which it causes hyper pressure of the skin around the nail bed and that causes clubbing other causes could be there is capillary stresses and black flow of blood which causes edema of the finger and that appears as clubbing or it could be because of any uh increasing number of growth factors which is a reason behind clubbing or a vitamin or endocrine abnormality which could cause clubbing as clubbing is seen acromegaly and thyrotoxicosis too so those could be those factors which are implicated in clubbing what are the causes of clubbing clubbing can be seen in bronchitis in lung abscess and carcinoma of the lung or in cardiac abnormalities like uh it can cyanotic heart disease or subendocardial pericarditis it is also seen it could be a healthier tree caused by the tree or as i told in endocrine disorders like in thyrotoxicosis or acromegaly or whether liver is involved whether cirrhosis of liver or ulcerative colitis so now we have to examine the lymph nodes so lymph nodes have to be examined in the neck and in the axillary region so it has to be done in a systematic manner you stand behind when you want to examine the nymph stand behind the subject and tell the subject to slightly flex her neck and you have to examine the lymph nodes starting from the submental region then the submandibular region then in the in the preoricular area the posterior area cervical lymph nodes and the occipital lymph nodes then once you are examining the lymph nodes in the neck we are also examining the lymph nodes in the axilla so tell the subject to abduct her arms now in the axilla you have to examine remember the acronym apical apical stands for anterior posterior inferior central alpical and the lateral lymph nodes so you have to examine the lymph nodes in all these areas anterior posterior inferior central apical and lateral so these are the areas in the neck and the axilla where you will examine for the lymph nodes number lymph nodes what you are supposed to look for you look for the size and shape of the lymph nodes now normally you have to measure the size of the lymph nodes along the longest diameter of the lymph node so if it is more than one centimeter that indicates malignancy so in the lymph nodes the size is more than one centimeter and they appear irregular it is usually a malignant lymph node then you examine for the consistency of the lymph nodes normally the lymph nodes are rubbery and they are elastic in nature if the lymph node is hard again it indicates malignant condition or if it is fixed or and it is very firm usually in tuberculosis you get a very firm lymph node so you have to differentiate and with practice it comes whether the lymph nodes is hard or it is firm then you look for the mobility of the lymph nodes now it could they could be mobile or they could be fixed again in malignancy the lymph nodes are fixed to the adjacent area okay then you have to look for the tenderness when we are examining the lymph nodes if the patient complains of pain that indicates there is some inflammation around the area where the lymph nodes have been drained and in malignancy usually the lymph nodes are non-tether so now what are the causes of lymphedeopathy the causes of lymphede as we have seen it could be neoplastic acute or chronic leukemias carcinoma of the breast carcinoma of the lungs or it could be inflammatory causes like tuberculosis syphilis those are the causes where lymph nodes can be enlarged certain drugs could also cause a lymphadenous and severe infections can also lead to lymphadenopathy and our last point in the pickle is edema edema is the swelling of the skin under subcutaneous tissue which is caused because of excess of fluid accumulation in the interstitial spaces now edema can be localized or generalized or it could be a pitting or a non-fitting edema now where do you look for edema now edema is usually examined on the dependent parts so above the median malleables just apply pressure on the skin for at least 20 seconds and just look for any pit which will be formed once you release the skin so there is no edema here so edema pitting type of edema there could be four causes of pitting type of vedima either it could be a cardiac cause a congestive cardiac failure it could be a renal cause nephrotic syndrome or acute nephritis it could be a liver pathology like in hepatitis or cirrhosis of liver or it could be because of anemia so these all uh in this all these conditions you will get the pitting type of edema a non-pitting edema is usually seen in mixed edema or hypothyroidism now what is the special features or how you differentiate between these four different types of pitting edema now in cardiac if the cause is a cardiac edema pitting type of edema usually along the edema in the dependent past the patient will also complain of dyspnea that is the feature you should remember when you when you want to differentiate between a cardiac and other other types of edema in renal area if there is a cause is renal then there will be along with the edema there will be puffiness of the face which will be seen especially around the orbital region that could then that indicates that the renal involvement is there if the patient is anemic and the patient is having anemia anemia along with edema there will also be the edema is usually generalized if liver is the cause or if all hepatic involvement is there then along with edema the patient will also have ascitis so this is how we will differentiate between adrenal cardiac hepatic and anemic edema fitting type of edema now what is the pathological basis behind this edema now in congestive cardiac failure where the cardiac output is decreased the blood pressure is decreased now because of decrease in the cardiac output there is accumulation of blood that right ventricular failure occurs and there is increase in the back pressure in the venous circulation and that causes edema accumulation of fluid in the interstitial spaces we demo because of decreased blood pressure activates the renin system that any angiotensin in turn increases the aldosterone secretion the aldosterone in turn increases the water and sodium reabsorption and that causes edema then the renal causes of edema while edema occurs in nephrotic syndrome or in acute nephritis now here the capillary permeability to the proteins increases so there is a lot amount of loss of protein in the urine causing hyper proteinaemia now because of hypoprotein amino there is decrease in the colloidal osmotic pressure in the capillaries and that causes fluid to filter into the industrial spaces and that leads to eating similarly in anemia also there is hypoproteinaemia is the major cause in anemia which causes edema lastly in liver disease or wherever there is hepatitis or cirrhosis of liver the liver cells are damaged leading to decreasing the protein synthesis again leading to hyperproteinaemia and hence decrease in the colored osmotic pressure and that leads to eating so now we have finished the six important uh parameters that is the pickle palette now we will go to the four vital signs which should be examining all your patients that is a tpr vp temperature pulse respiration and blood pressure now temperature has to be examined using a thermometer usually the thermometer is placed under the in the mouth or under the axilla and taken for one minute recording of the temperature gives you a lot of information usually a temperature chart is maintained in the water normal temperature is around 98 to 99 degree fahrenheit increasing temperature above 99 degree fahrenheit will be labeled as fever now there are three different types of fevers we can have intermittent continuous or remittance fever continuous fever which is present throughout the day usually the cause of continuous fever is urine track infection if the patient is having fear which is high throughout the day and never touches the baseline and is called as limited fever remittance fever is usually seen in infective endocarditis then you have intermittent fever where the fever remains high throughout the day when you look for the pulse the ladle artery is used to examine the pulse normal pulse rate is around 70 to 80 beats per minute along with the pulse you also look for the respiration calculate the respiratory rate which is around 12 to 16 per minute and examine the bp normal blood pressure is 120 to 80 millimeters of mercury now these three practicals will be taken separately a link of which will be provided to you thank you