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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3230_Библиотеки_им_академика_М_И_Перельмана
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CHAPTER 5 General examination physical signs
72
General principles
The findings discussed here are presented in a sequence of the general
examination. While taking the patient’s history you will be looking at the
patient’s face. If you are asked to look at the hands, look at the patient’s
face and note any recognizable features of significance as you introduce
yourself and greet the patient. Then begin with the fingernails and joints,
backs and fronts of the hands, arms, and elbows, moving up to the neck
and scalp, then down to the face, mouth, throat, breasts, axillae, trunk,
and groin. Note any skin abnormalities.
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CHAPTER 5 General examination physical signs
74
Fingernail abnormality
Classify fingernail changes by naming them first. Some have very few
causes.
Classification
Clubbing
due to many
causes
(see pp. 76–77)
Suggested by: angle lost between nail and finger (no
gap when nails of same finger on both hand apposed,
bogginess of nail bed, increased nail curvature both
longitudinally and transversely, and drumstick finger
appearance).
Confirmed by: see p. 76
Terry’s lines
due to many
causes
(see p. 78)
Suggested by: nail tips having dark pink or brown
bands
Confirmed by: see next page (p. 78)
Nail fold
infarcts
due to vasculitis
due to many
causes (see next
page, 79)
Suggested by: dark blue-black areas in nail fold
Confirmed by: see next page (p. 79)
Koilonychia
due to iron
deficiency anemia
(occasionally
ischemic heart
disease [IHD] or
syphilis)
Suggested by: spoon-shaped nails
Confirmed by: dHb, dferritin from iron deficiency
(basal or exercise ECG for IHD; serology for syphilis)
Onycholysis
due to
psoriasis,
hyperthyroidism
Suggested by: nail thickened, dystrophic, and
separated from the nail bed
Confirmed by: clinical appearance and evidence of
cause, e.g., skin changes of psoriasis or iFT4 (free
T4), ± iFT3 (free T4) and dTSH (thyroid-stimulating
hormone)
Beau’s lines
due to any
period of severe
illness
Suggested by: transverse furrows
Confirmed by: history of associated condition
Longitudinal lines
due to
lichen planus,
alopecia areata,
Darier’s disease
Suggested by: transverse furrows (ending in triangular
nicks and nail dystrophy in Darier’s disease)
FINGERNAIL ABNORMALITY1
75
Onychomedesis
due to any
period of severe
illness
Suggested by: shedding of nail
Confirmed by: history of associated condition
Muehrcke’s lines
due to hypo-
albuminemia
Suggested by: paired white, parallel, transverse bands
Confirmed by: serum albumin <2.0 g/dL
Nail pitting
due to psoriasis
and alopecia
areata
Suggested by: small holes in nail
Confirmed by: rash on extensor surfaces with silvery
scales (psoriasis) or circumscribed areas of hair loss
(alopecia areata)
Splinter
hemorrhages
due to infective
endocarditis
(sometimes due
to manual labor)
Suggested by: fine, longitudinal hemorrhagic streaks
under the nail
Confirmed by: history of manual labor (or fever,
changing heart murmurs, and bacterial growth on
several blood cultures)
Chronic
paronychia
due to chronic
infection of
nail bed
Suggested by: red, swollen, and thickened skin in
nail fold
Confirmed by: response to antibiotics (erythromycin
for bacterial infection or nystatin for fungal infection)
Mees’ lines
due to arsenic
poisoning or
renal failure,
Hodgkin’s disease,
heart failure
Suggested by: single, white, transverse bands
Confirmed by: presence of associated conditions
Yellow nails
due to
lymphedema,
bronchiectasis,
hypoalbuminemia
Suggested by: color
Confirmed by: presence of associated condition
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CHAPTER 5 General examination physical signs
76
Clubbing
Clubbing is present when the angle is lost between the nail and finger;
alternatively, there is no gap when the nails of the same finger on both
hands are apposed.
Some differential diagnoses and typical outline evidence
Subacute
bacterial
endocarditis
Suggested by: general malaise, weight loss, fever, PMH
of heart valve disease or congenital heart disease,
heart murmurs
Confirmed by: growth on blood cultures of organism,
e.g., Streptococcus viridans, etc. Endocardial vegetations
(but not always) on echocardiography
Cyanotic
congenital
heart disease
Suggested by: long past history, central cyanosis
Confirmed by: echocardiography
Lung
carcinoma
Suggested by: malaise, increased cough, weight loss,
hemoptysis. Smoking history. Opacity (suggestive of
mass, ± pneumonia ± effusion) on chest X-ray (CXR)
and computerized tomography (CT) scan
Confirmed by: Bronchoscopy appearances and histology
Bronchiectasis Suggested by: chronic cough, productive of copious
purulent, often rusty-colored sputum
Confirmed by: CXR and CT scan appearances
(thickened tram line [dilated] bronchi). Bronchoscopy
appearances
Lung abscess Suggested by: cough, very ill, spiking fever, PMH of lung
disease
Confirmed by: CXR: mass containing fluid level (air
above pus)
Empyema Suggested by: cough, very ill, fever, stony dull over one
lung
Confirmed by: high neutrophil WBC. CXR: long
opacity on one view. Aspiration of pus, culture and
sensitivity
CLUBBING1
77
Pulmonary
fibrosis
Suggested by: cough, fine crackles, especially bases
Confirmed by: CXR: bilateral diffuse nodular shadows or
honeycombing (late finding)
Cirrhosis Suggested by: long history of alcohol intake, ascites,
prominent abdominal veins. In males: spider nevi,
Gynecomastia
Confirmed by: dserum albumin, abnormal liver
function tests (LFTs) and i bilirubin (sometimes).
Liver biopsy findings
Crohn’s disease Suggested by: history of chronic diarrhea and
abdominal pain, low weight
Confirmed by: colonoscopy and biopsy, barium
enema and barium meal and follow-through
Ulcerative
colitis
Suggested by: history of intermittent diarrhea with
blood and mucus, low weight
Confirmed by: colonoscopy and biopsy
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CHAPTER 5 General examination physical signs
78
Terry’s lines: dark pink or brown bands
on nails
Some differential diagnoses and typical outline evidence
Cirrhosis Suggested by: long history of alcohol intake, ascites,
prominent abdominal veins. In males: spider nevi,
gynecomastia
Confirmed by: dserum albumin, abnormal
liver function tests and i bilirubin (sometimes).
Liver biopsy findings
Congestive
cardiac failure
Suggested by: dyspnea, orthopnea, paroxysmal nocturnal
dyspnea (PND), iJVP, gallop rhythm, basal inspiratory
crackles, ankle edema
Confirmed by: CXR and echocardiography
Diabetes
mellitus
Suggested by: thirst, polydipsia, polyuria, fatigue, FH
Confirmed by: fasting blood glucose ≥120 mg/dL on two
occasions OR fasting, random or glucose tolerance test
(GTT) glucose ≥200 mg/dL once only with symptoms
Cancer
somewhere
Suggested by: weight loss and anorexia with symptoms
developing over months, bone pain
Confirmed by: careful history, examination, CXR,
complete blood count (CBC), erythrocyte
sedimentation rate (ESR), and follow-up
Old age Suggested by: age >75 years
Confirmed by: normal follow-up
VASCULITIC NODULES ON FINGERS1
79
Vasculitic nodules on fingers
These nodules and dark lines in nail folds are focal areas of infarction,
which suggest local vasculitis.
Some differential diagnoses and typical outline evidence
Systemic lupus
erythematosus
Suggested by: swelling of distal interphalangeal (DIP)
joints, any other large joints, malar rash, pleural
effusion, especially in Afro-Caribbean females.
Multisystem dysfunction
Confirmed by: CBC: dHb (hemoglobin), dWBC.
ESR: i or iCRP (C-reactive protein)
Anti-nuclear antibody positive, especially if directed
at double-stranded DNA
Subacute
bacterial
endocarditis
(Osler nodes)
Suggested by: general malaise, pallor, low-grade fever,
changing heart murmurs
Confirmed by: CBC: dHb, iWBC. ESR: ii, iiCRP
.
Growth of streptococci, e.g., S. viridans after serial
blood cultures
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CHAPTER 5 General examination physical signs
80
Hand arthropathy
Look at the finger joints (the interphalangeal [IP] joints), the knuckles
(metacarpophalangeal [MCP] joints), and compare them. Finally, look at
the wrist.
Some differential diagnoses and typical outline evidence
Primary (post-
menopausal)
osteoarthritis
Suggested by: Heberden’s nodes (paired bony nodes
on terminal IP joints)
Confirmed by: X-ray appearances of affected joints
Rheumatoid
arthritis
Suggested by: swelling and deformity of phalangeal
joints (with ulnar deviation) and wrist, rheumatoid
nodules
Confirmed by: positive rheumatoid factor. X-ray
appearances of affected joints
Psoriatic
arthropathy
Suggested by: swelling and deformity of distal (or all)
IP joints
Confirmed by: dry rash with silvery scales (especially
near elbow extensor surface). X-ray appearances of
affected joints
Systemic lupus
erythematosus
Suggested by: swelling and deformity of all (or distal)
IP joints, butterfly facial rash, signs of pleural or
pericardial effusion, renal impairment
Confirmed by: positive anti-nuclear factor,
double-stranded DNA antibodies
LUMPS AROUND THE ELBOW1
81
Hand and upper limb rashes
Look at the back of the hands and forearm, the palms and forearm elbow
flexures, the extensor surface of the elbows, and then the upper arm.
Some differential diagnoses and typical outline evidence
Atopic eczema Suggested by: vesicles, erythema, scaling, lichenification,
fissures on flexor surfaces, wrists, palms. FH
Confirmed by: no evidence of contact precipitant
Contact
dermatitis and
irritant
Suggested by: vesicles, erythema, scaling, lichenification,
fissures related to contact with chemical or object,
e.g., oil, nickel alloy
Confirmed by: response by improvement on removal of
precipitant (and recurrence with re-exposure)
Psoriasis Suggested by: dry rash with silvery scales (especially
near elbow extensor surface)
Confirmed by: clinical appearance if obvious, otherwise,
histology
Lumps around the elbow
Inspect and, with care not to hurt, palpate around the elbow.
Some differential diagnoses and typical outline evidence
Osteoarthritis Suggested by: joint deformity, intermittent pain and
swelling, paired Heberden’s nodes over distal IP joints
in primary osteoarthritis
Confirmed by: clinical appearance usually. If there are
doubts, negative rheumatoid factor, X-ray shows loss
of joint space (due to atrophy of cartilage)
Rheumatoid
nodules
Suggested by: mobile subcutaneous nodule
Confirmed by: history or joint changes of rheumatoid
arthritis and positive rheumatoid factor
Xanthomatosis Suggested by: pale subcutaneous plaques attached to
underlying tendon
Confirmed by: hyperlipidemia on blood testing
Gouty tophi Suggested by: irregular hard nodules, risk factors or
PMH of gout
Confirmed by: iplasma urate. Biopsy: urate crystals
present
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