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6
1 General History Taking andGeneral Examination
• Treatment history—Type and duration of
treatment to be noted.
• Menstrual/obstetric history—Females
should be enquired about their menstrual
health and obstetric status.
1.2 Examination ofPatient
1.2.1 General Examination
ofPatients
(a) General physical examination—A general
physical examination (GPE) is performed at
the beginning of the clinical examination. It
should be taught to students that they should
perform physical examinations in formal
way. The formal approach of clinical examination has many reasons. The rst is that it
ensures the examination is thorough and that
important signs are not overlooked because
of a haphazard method. The second is that
the most convenient methods of examining
patients in bed, and for particular conditions
in various other postures, have evolved with
time. By convention, patients are usually
examined from the right side of the bed, even
though this may be more convenient only for
right-handed people.
(b) General survey of patient
• Level of consciousness—Examiner
should enquire whether patient is alert,
co-operative and oriented to time and
space and person by asking name of
patient, place of living, and today’s date.
– Full consciousness—It is dened as a
state in which a patient is aware,
awake, alert, and fully responsive to
stimuli given to him or her.
– Semiconsciousness—It is dened as a
state in which patient is neither fully
conscious or fully unconscious.
– Unconsciousness—It is dened as a
state in which a patient has a decit in
awareness and responsiveness to stimuli like touch, light and sound.
– Altered consciousness—Various altered
consciousness are described below.
Confusion—It is described as disorientation due to which it is difcult for a patient to reason, give a
medical history or cooperate in the
medical examination. It can be
caused by sleep deprivation, fever,
medications, alcohol intoxication,
recreational drug use and postictal
state (recovering from a seizure).
Delirium—It is used to describe an
acute confessional state and characterized by impaired or altered functions like cognition, attention,
sleep-wake cycle, activity (hyperactivity/agitation or hypoactivity/apathy) and perception (hallucinations/
seeing things that are not there or
delusions/false beliefs). Patient can
also have instability of heart rate
and blood pressure. The causes of
delirium are alcohol withdrawal,
recreational drugs, medications, illness, organ failure and severe
infections.
Lethargy—Lethargy describes as
state of severe drowsiness, listlessness and apathy accompanied by
reduced alertness. A gentle touch or
verbal stimulation often requires by
lethargic patient to respond. Causes
of lethargy are severe illnesses or
infections, recreational drugs and
organ failure.
Somnolence—It is a state of drowsiness or feeling of deep sleep, presented as lethargy, drowsiness and
loss of appetite. It can be caused by
radiation to the brain, sleep disorders, anxiety, depression and stress.
Obtundation—Obtundation is
dened as reduced alertness with
slow responses to stimuli, requiring
repeated stimulation to maintain
attention, as well as having prolonged periods of sleep, and drowsiness between these periods. The
causes of obtundation are poisoning,
stroke, brain oedema, and sepsis.
1.2 Examination ofPatient
7
Stupor—When a patient responds
minimally to vigorous stimulation,
such as pinching the toe or shining a
light in the eyes, due to impaired
consciousness, it is known as stupor. It can be caused by stroke, drug
overdose, lack of oxygen, brain
oedema and myocardial infarction.
Coma—When a patient does not
respond or is in a state of unresponsiveness to stimuli, it is known as a
coma. There is a loss of gag reex
and pupillary response. This can be
caused by severely diminished
brain function, usually due to
extreme blood loss, organ failure or
brain damage.
• Position of patient—Sitting/lying comfortably or not, anxious or not, lying quiet
avoiding movement, holding the cheek,
not able to lie down.
• Built—The built of patient can be average/dwarf/tall stature/obese/cachetic/
malnourished.
• Nutrition—The nutrition status of patient
is noted as average/underweight/obese.
A normal general examination is presented as ‘Patient is of average built, sitting or lying comfortably, well oriented
to time, place and person no pallor,
icterus, cyanosis, clubbing, generalised
lymphadenopathy and pedal oedema’.
Vital signs are to be mentioned
accordingly.
(c) General examination
• Pallor—Pallor is to be looked in palpable
conjunctiva, oral cavity mucosa, nail bed.
– Procedure to check for pallor
On nail bed—On pressing the tip
of the nail, blanching will appear
over nail bed and on leaving the
nail, there will be relling. In normal subject, it rells immediately
while in anaemic there is delayed
relling (Fig.1.1c).
On palpebral conjunctiva—The
examiner ask the patient to look
upward, and pull down lower eyelid
to examine the lower palpebral conjunctiva (Fig.1.1a and Table1.1).
On palm—Palm skin appears pale
in pallor especially in severe pallor
(Fig.1.1d).
On tongue—Examiner has to
inspect the protruded tongue to look
colour of the tongue mucosa, in
normal it appears pink and in pallor
it looses its pink colour and appears
pale (Fig.1.1c).
– Grading of pallor
No pallor—Normal pinkish colour
of lower palpebral conjunctiva.
Mild pallor—There is lost of pink
colour of conjunctiva and/or
mucous membrane. Conjunctiva
and mucous membrane appear pale.
Moderate pallor—The conjunctiva
and/or mucous membrane + skin
will look pale.
Severe pallor—The conjunctiva
and/or mucous membrane + pallor
of skin + pallor of palmar creases
will look pale and faint.
– Type of discolouration
Sallow colour—Chronic anaemia
Lemon colour—Pernicious
anaemia
Pallor+mid scleral and cutaneous
Icterus—Haemolytic anaemia
Marked pallor + petechiae ecchymosis—Bone marrow failure
• Icterus—This is yellowish discolouration
of bulbar conjunctiva and skin. It is a
symptom of elevated serum bilirubin.
– Procedure to examine icterus—
Jaundice to be looked in bulbar conjunctiva, skin of upper limb and lower
limb as yellow discolouration
(Fig.1.2a and Table1.1).
8
1 General History Taking andGeneral Examination
Fig. 1.1 It shows how
and where to examine
for pallor; (a) palpebral
conjunctiva, (b) tongue,
(c) nail bed, (d) palm
Fig. 1.2 (a) Showing
how to examine for
icterus on bulbar
conjunctiva; (b) grades
of icterus
a
c
a
b
d
b
Table 1.1 Differential diagnosis of conjunctival
examination
Differential diagnosis conjunctival examination
Palpebral conjunctiva
Pallor—Anaemia, shock, heart failure,
hypopituitarism
Plethoric—Polycythaemia, superior vena cava
obstruction
Haemorrhage—Trauma, hypertension, bleeding
disorder, trauma
Bulbar conjunctiva
Yellow—Jaundice
Blue—Osteogenesis imperfecta
Red—Haemorrhage
– Grading of icterus (Fig. 1.2b)
Grade 1—If icterus limited to face
and neck only (serum bilirubin—10mg/dL).
Grade 2—Grade 1+Icterus extend
to upper trunk up to umbilicus
(serum bilirubin—15mg/dL).
Grade 3—Grade 2+Icterus involve
lower trunk below umbilicus to
knee (serum bilirubin—20mg/dL)
Grade 4—Grade 3+Icterus extend
to arms and lower legs below knee
(serum bilirubin—25mg/dL)
1.2 Examination ofPatient
9
Grade 5—Grade 4+Icterus extend
to palms and soles (serum bilirubin
>25mg/dL).
• Cyanosis—It refers to a bluish discolouration of skin and mucous membranes. It
is of two types.
– Peripheral cyanosis—It is dened as a
condition in which hand, feet nger
and ngertip become bluish. It can be
caused by cold temperature, Raynaud’s
disease, Hypothermia, CVS problem.
– Central cyanosis—It is dened as blu-
ish discolouration of body and mucous
membrane (lip and tongue). It is caused
by decreased level of oxygenated
haemoglobin in blood (5 g/dL with
oxygen saturation below 85%).
Fig. 1.3 (a–c) Signs of
clubbing
a
• Clubbing—It is an abnormal, painless,
rounded (bullous) shaped enlargement of
the nail bed. It is usually bilateral.
– Lovibond’s prole sign: When a nor-
mal sharp angle (<160) between the
nail bed and the cuticle is lost due to
clubbing (Fig.1.3c).
– Interphalangeal depth ratio:
Interphalangeal depth (IPD) ratio is
dened as ratio of depth of nger at
distal interphalangeal joint to depth at
the base of the nail. The normal ratio is
around 0.859 and in clubbing this is
more than 1. The depth of clubbing at
the base of nail is more (Fig.1.3b).
– Schamroth’s sign: In normal individ-
ual, a sharp angle between nail bed and
Schamorth’s sign
Schamroth’s
window
b
DPD
c
IPD
Normal Clubbed
< 160˚
Cubicle
Normal thumb Thumb with clubbing
Phalangeal depth ratio
Nail bed angle
DPD
IPD
> 180˚
Root
10
1 General History Taking andGeneral Examination
Table 1.2 Causes of clubbing
Primary/idiopathic/hereditary clubbing—It is
hereditary, passed down via genes. Several genes have
been associated with primary clubbing, including the
HPGD gene and the SLCO2A1 gene
Secondary clubbing
Lung cancer
Interstitial pulmonary brosis
Lung abscess
Pulmonary tuberculosis
Pulmonary lymphoma
Congestive heart failure
Infective endocarditis
Cyanotic congenital heart disease
Bronchiectasis
Cystic brosis
Other types of cancer including liver,
gastrointestinal or Hodgkin lymphoma,
gastrointestinal neoplasms, inammatory bowel
disease, liver cirrhosis, celiac disease, dysentery
Graves’ disease—An overactive thyroid gland
cuticle forms a tiny diamond-shaped
space when two ngers kept together
with the top of your nails facing each
other. This space is lost in clubbing, it
is known as Schamroth’s sign
(Fig.1.3a).
– Causes of clubbing (Table 1.2)
• Generalized lymphadenopathy—It is
described as enlargement of more than
two contiguous group of lymph node palpable or non-palpable.
• Palpable group of lymph nodes are
– Cervical group—It has been subdi-
vided into level 1 to level 6 (Table1.3
and Fig.1.4).
Classication of cervical group of
lymph node
Method of palpation of cervical
group of lymph node
Anterior methods—The examiner
sits in front of patient, head is stabilized with left hand and right hand
will be used for palpation. The palpation starts from submental area to
posterior triangle of neck.
Posterior methods—In this method
of palpation, examiner stands
behind the patient and use his both
Table 1.3 Cervical group of lymph node
Subdivision of cervical group of lymph node
Level 1
1a—Submental
1b—Submandibular
Level 2—Jugulodigastric group of L.N./upper cervical
2a—Anterior to SAN
2a—Posterior to SAN
Level 3—Jugulo-omohyoid group of L.N./mid cervical
Level 4—Lower cervical
4a—Behind the sternal head of SCM
4b—Behind the clavicular head SCM
Level 5—Posterior group
5a—Occipital group of L.N.
5b—Supraclavicular group of L.N.
Level 6—Central cervical group
Fig. 1.4 Level of cervical lymph node (levels 1–6)
hands for palpation of lymph node
of neck. The palpation with ngertips is to be started in the submental
area, and progress to palpate submandibular lymph node,
Jugulodigastric lymph node, omohyoid lymph node, lower cervical
and posterior group of lymph node.
Any order of examination can be
used, but a systematic approach will
ensure no areas are missed. Pad of
the second, third and fourth ngers
to be used to press and roll the
lymph nodes over the surrounding
tissue to assess the various characteristics of the lymph nodes. Using
both hands simultaneously on both
1.2 Examination ofPatient
11
sides will help examiner to evaluate
any asymmetry in size, consistency
and mobility of lymph nodes. The
caution should be taken while examining the lateral cervical chain not to
compromise cerebral blood ow
due to carotid artery compression. It
may be best to examine one side at a
time here. The piano- playing or spider’s legs technique with the ngertips over the skin is not correct
methods of palpating lymph nodes.
– Axillary group—The axillary group
of lymph node has been subdivided
into ve groups, name lateral
(humeral), anterior (pectoral), poste-
Fig. 1.5 (a) Various
axillary groups; (b–f)
methods of palpation of
axillary lymph node
rior (subscapular), central and apical
nodes. The apical nodes are the nal
common pathway for all of the axillary
lymph nodes.
Subdivision of axillary group of
lymph node (Fig. 1.5a)
Anterior group—palpated behind
the pectoralis major muscle
Posterior group—anterior to latissimus dorsi muscle
Central group—medially on chest
wall
Apical group—in apex of axilla
above the central group
Lateral group—palpated laterally
over arm
a
b
c
e
d
f
12
Inguinal lig.
Horizontal
group
Vertical
group
Fig. 1.6 Inguinal group of lymph node
Method of palpation of axillary
group—The patient to be seated in
front examiner, ask to bend the
hand and keep it over examiner
hand to relax the muscles. The left
hand is used to palpated the right
side except the lateral group, which
is palpated by same side. The opposite hand is used to stabilize the
shoulder while palpating the anterior, central, posterior and apical
group (Fig.1.5b).
– Inguinal group of lymph node—This
group has been subdivided into two
subgroup (Fig.1.6).
Division of inguinal group of lymph
node
Horizontal group—They are
located horizontally along the
inguinal ligament.
Vertical group—This group is
located along the saphenous vein.
Method of palpation—The palpation is done in supine position.
Horizontal group—To palpate this
group, examiner places his or her
ngers lateral to pubic tubercle to
1 General History Taking andGeneral Examination
palpate horizontally along and
below the inguinal ligament.
Vertical group—To palpate this
group, examiner places his ngers
approximately 3 cm lateral to the
pubic tubercle. The palpation of
lymph node is done vertically
downwards over the saphenous
opening and the proximal portion of
the great saphenous vein to assess
the vertical group of supercial
inguinal lymph nodes.
Causes of generalised lymphadenopathy—Infection, autoimmune disease,
malignancy, histiocytosis, benign hyperplasia, drug reaction, AIDS
• Pedal/pitting oedema—It is dened as
swelling of soft tissue caused by accumulation of excess uid under the skin in the
extracellular spaces within the tissues. It
often affects the lower body, such as the
legs, feet and ankles. If a pit (indentation)
appears on oedematous subcutaneous tissue after pressure is applied over, it is
called pitting oedema.
– Methods to evaluate the oedema—This
is evaluated by pressing on oedematous
tissue over bony prominence like medial
malleolus, tibia or dorsum of foot for
30s and leave. If a pit appeared, recovery
time is recorded in seconds (Fig.1.7a).
Fig. 1.7 The pitting oedema
1.2 Examination ofPatient
13
– Scoring system of pitting oedema
No clinical oedema=0
≤2mm indentation=1+ oedema
O/E—There is slight pitting, no
visual distortion and disappears
rapidly.
2–4mm indentation=2+ oedema
O/E—Somewhat deeper pitting, no
readably detectable distortion and
indentation disappears in 10–15s.
4–6mm indentation=3+ oedema
O/E—Pit is noticeably deep, may
last >1min and dependent extremity looks fuller and swollen
6–8mm indentation=4+ oedema
O/E—Pit is very deep, last as long
as 2–5min
Causes of pitting oedema (Table
1.4).
(d) Vital signs
• Pulse—A peripheral pulse is a valuable
clinical tool and also a most commonly
performed physical examination in medicine. It can be used to identify many different types of pathology. It is a palpation of
the high-pressure wave of blood moving
away from the heart through vessels in the
extremities following systolic ejection.
• Evaluation of pulse—A peripheral pulse
to be evaluated and documented in terms
of rate, rhythm, volume, intensity, symmetry, condition of arterial wall, comparison b/w 2 radial pulses, Radio-femoral
delay, any special character.
Table 1.4 Causes of pitting oedema
• Severe lung disease
• Liver diseases
• Congestive heart failure
• Low protein levels
• Deep venous thrombosis (DVT)—blood clots,
usually in the legs
• Congestive heart failure
• Venous insufciency
• Kidney failure
• Obesity
• Pregnancy
• Administration of intravenous uids
• Medications
– Pulse rate—The normal pulse rate at
rest averages about 72/min in adult,
90–110/min in children and 55–65 in
old age.
– Rhythm
Regular—It shows pattern of pulse
is regular and interval between all
pulse in normal and regular.
Regularly irregular—It means
irregular at regular interval.
Irregularly irregular—Irregularity
is repeated at irregular interval.
– Amplitude—Measured by lift of mid-
dle nger
Normal pulse—Lift is moderate.
Bounding pulse—Lift is more.
Feeble pulse—Lift is poor.
– Force—Degree of force required to
stop pulse to be felt at middle nger is
known as force, it is light, moderate
and heavy.
– Tension—It is the index of diastolic
pressure. It is degree of pressure
required to collapse the artery.
– Condition arterial wall—Artery is
pressed by middle nger to emptied it
now roll the artery under middle nger.
Methods of palpation of pulse—
The peripheral pulse may be palpated
on wrist, neck, and groin, behind the
knee, near the ankle joint, and on foot
because artery can be compressed
against bony surface. In clinical practice, radial artery is most commonly
and routinely palpated. Other arteries
can be palpated are brachial, femoral,
popliteal, posterior tibial, and dorsalis
pedis arteries. The choice of where to
palpate a peripheral pulse is dependent on various factors like patient’s
age, body habitus, and the clinical
situation (e.g., resuscitation, routine
vitals at an ofce visit, evaluation for
peripheral arterial disease, etc.).
Clinician should palpate pulse on
both sides to compare bilateral pulse
for any asymmetry and also in upper
and lower limb.
14
1 General History Taking andGeneral Examination
Palpation of pulse in the upper
extremities—There are two peripheral
pulses radial and brachial but examiners commonly and routinely palpate
the radial artery during a routine examination of adults. This is due to the
unobtrusive position required to palpate it and its easy accessibility in various types of clothing.
Radial Pulse—The palpation of
radial pulse is done on exor surface of anterior wrist just proximal
to the base of the thumb. First, ask
patient to slightly ex wrist that
helps to bring his/her radial artery
closer to the surface. Now examiner
places his three ngers on the radius
bone close to the exor aspect of
the wrist and the middle nger use
to feel the pulse while the distal nger prevents reexion of pulsation
from palmer arch of arteries and the
proximal nger uses to stabilize the
artery (Fig.1.8).
Brachial pulse—The brachial is
palpated proximal to the elbow
between the medial epicondyle of
the humerus and the distal biceps
tendon. It is often the site of palpation of pulse during cardiopulmonary resuscitation of infants
(Fig.1.9).
– Palpation of pulse in neck
Carotid pulse—Carotid artery pulsations are symmetrical and have
similar characteristics as the radial
artery and preferred pulse used dur-
ing resuscitation of adults.
Procedure of palpation of carotid
artery—First tilt the head gently to
relax the sternocleidomastoid mus-
cle and now place the ngers over
the carotid over upper neck roughly
between the SCM muscle and thy-
roid cartilage to palpate the carotid
pulse. Only one side to be palpated
at a time to avoid compression of
both carotid at same time (Fig.1.10).
Auscultation of carotid artery—It is done
to hear carotid bruit to ruled out carotid stenosis. Diaphragm of stethoscope to be
placed over carotid artery between the larynx and the anterior border of the sternocleidomastoid muscle; now ask the patient
to take a deep breath and then hold it while
you listen. Be aware that at this point in the
examination, the presence of a ‘carotid
bruit’ may, in fact, be a radiating cardiac
murmur due to aortic stenosis.
– Palpation of pulse in the lower
extremities—The artery can be palpated in lower extremity are femoral,
posterior tibial, dorsalis pedis, and
sometimes the popliteal.
Femoral pulse—The femoral
artery is present in femoral triangle
lateral to femoral vain. The femoral
pulse is palpated distally to the
Fig. 1.8 Palpation of radial artery pulse
Fig. 1.9 Method of palpation of brachial pulse
1.2 Examination ofPatient
15
Fig. 1.10 Carotid pulse
examination. (a)
Posterior method and
(b) anterior method
Fig. 1.11 Method of
palpation of lower limb
pulse. (a) Femoral pulse,
(b) Popliteal pulse, (c)
Posterior tibial pulse, (d)
Dorsalis pedis pulse
a
a b
b
posterior
tibial artery Dorsalis pedis artery
inguinal ligament at a point less
than halfway from the pubis to the
anterior superior iliac spine
(Fig.1.11a). Femoral artery pulse is
most sensitive in assessing for
septic shock. It is also routinely
checked during resuscitation.
Popliteal artery
dc
Popliteal artery pulse—The popli-
teal artery is located in the popliteal
fossa slightly lateral of the midline.
It is felt deep in the centre of the
popliteal fossa with the patient
lying on his back with exion of
knee joint (Fig.1.11b).