Clinical Examination Dr Osama Mahmoud

General sheet

I

A CASE OF HYPERTENSION

CJfr

Personal hj,stoty:

* Age.

* Sex: female (pills)

* Smoking

CJfr

C/O:

* Asymptomatic, or presented with complications e.g:

- Heart Failure. (Dyspnea)

- Strokes (weakness

of one side of the body)

* Ask

about

the causes (renal - endocrinal.

).

* Ask

about

complication (as above)

* Ask

about

drug use; e.g. steroids, pills, NSAIDs

(Na & H20 retention)

*

Left ventricular enlargement

* Sustained apex

* Loud, 2nd heart sound aortic component.

* 4th H.S. (Apex).

* Loud S 1 with Lt. v. ++.

* Ejection

systolic

click over A 1

*

Ejection

systolic

murmur over A 1.

Q. Uses of sphygmomanometer!?

o Measuring

the B.P.

8 Diagnosis

of pulses alternans .

., Diagnosis

of latent tetany.

e Hess test in vascular purpura.

" Diagnosis

of coarctation of aorta and Takayasu's disease.

o Diagnosis

of deep vein thrombosis.

& Tourniquet

in venesection.

«3 Haemostasis.

o Hill's sign

in A. I.

Normal heart rate at mental

and physical rest = 60 - 90/minute. (90-

100 high normal)

Tachycardia

Bradycardia

(Rate>

1OO/m)

(Rate < 60/m)

* Sinus tachycardia.

Sinus bradycardia

* Paroxysmal

atrial or ventricular tachycardia.

Complete heart block

* Atrial flutter.

Second degree heart block

* Atrial fibrillation with

high ventricular response.

~ Causes of sinus tachycardia:

~

Physiological

e.g. stress

~

Heart failure,

= stroke V. X H.R}

{Sympathetic

drive (to maintain C.O.P) as C.O.P

~

Thyrotoxicosis.

~

Drugs: sympathomimetics

(Salbutamol)

~ Diagnosis of extrasystole:

C/O: irregular

palpitation at rest e.g. occational

strong beat or extra

beat.

OlE:

* You can count 4 successive, regular

beats.

< 101 m.

* Exercise

decrease irregularity.

* Pulse deficit

* Neck V.

A wave is present,

to be differentiated from AF.

General

sheet

* Atrial fibrillation

(AF): It is a form

of marked

irregularity or irregular

irregularity.

* Multiple, frequent

extrasystoles and variable

degree of heart block may give irregular

irregularity? .

~ Diagnosis

of A.F.: It gives

irregular pulse in both timing and volume.

* You can not count 4 successive

regular

beats.

* Pulse defecit

>1 O/m.

* Neck V.

~

Absent A wave.

* Exercise

increase

irregularity

why?

As this enhance

A-V conduction

~ Increase

passage

of impulses from atrium to

ventricle

(increased

ventricular

response)

~

Causes

of A.F.:

* MVD (Rh. Heart)

*ASD (CHD)

* Ischemic heart disease.

* Thyrotoxicosis

or thyrocardia.

(Thyrotoxicosis with cardiac

manifestations

only)

* Constrictive pericarditis.

* Lone A.F. (without apparent

cause).

* Systemic

Hypertension.

* Infective

endocarditis

* Pulmonary embolism.

(3) Volume (amplitude):

"* Big pulse volume (Bounding pulse):

I.e.: Big

difference

between

systolic and diastolic pressure (wide pulse

pressure)

leads to increase pulse amplitude. The pulse

pressure

is wide when it is > 50% of

the systolic

pressure.

~

Causes:

* A.1.

* Heart block

* Fevers.

* Atherosclerosis.

* Thyrotoxicosis.

* L.C.F. (Vasodilatation)

* Hypoxia.

~

peripheral vasodilatation.

The

normal peripheral pulse Is made up of

four

phases:

Mech.:

The artery

collapses

completely between each

beat,

but

distends abruptly due

to

large pulse

pressure

to give sudden shock. This

occurs

with

pulse pressure about

80

or more with diastolic

pressure < 50 mmHg.

Causes:

* severe A.I.

* P.D.A.

Causes:

Lt. ventricular failure which leads to difference in

refractory

period of

the

muscle fibers, the diseased fibers have long ARP.

(E) Pulsus paradoxus:

It is an inspiratory decline in systolic BI. pressure>

15 - 20 mmHg. Normally

there is slight decline in systolic pressure during inspiration,

so pulsus

paradoxus

is

considered to be an exaggeration of a normal phenomenon.

because

during

inspiration

the lung expands and accommodates

a big volume of blood,

this will leads to decrease

of blood

flow to the

left side of heart

~

low cop, but this is

compensated

by the increase in the venous return during

inspiration,

so there is a slight

decline in the systolic blood pressure.

In constrictive

pericarditis or tamponade

the compressed

right side

of the

heart

prevents

the

proper

venous return and filling of the

right

side of the

heart,

meanwhile

the expanding

lung

accommodates

a greater

amount

of blood

so, the

amount, of

blood reaching

the

left side of the heart decreased

~

i COP

~

i systolic

blood

pressure

~ weak pulse volume. Also severe asthmatic

attack ~

i intrathoracic

pr ~

.J... venous

return ~

i COP.

* Thoracic

outlet $.

*

Embolus

or thrombus in brachial or radial arteries.

*

Dissecting aortic aneurysm.

*

Atheroma

in Subclavian artery.

(9) Force is the minimal

degree of

compression to obliterate the radial

pulsation, this reflects

the systolic

pressure.

(10) Condition of the arterial wall:

Genercl sheet

Compress

the radial

artery by

the index then

roll the artery under the middle

finger after emptying

by the

index,

in young

persons

the arterial wall is so

compliant

that you can not feel

it, but

in old age it is felt

as a cord like structure

(arteriosclerosis).

Radial artery

Brachial artery

Femoral artery

Popliteal artery

Posterior tibial artery

Dorsalis pedis artery

Also, we

can examine

the pulse volume, tension and force by using the fingers

of left

hand to palpate the radial artery of the patient's

right

arm and use the right thumb to

compress

the brachial artery until the radial

pulse

is completely

obliterated,

then

release the pressure

gently over the brachial

artery

until you feel

the radial

pulse

again.

¢ Ptosis:

¢ Retraction

of eye lid in hyperthyrodism

@> Congenital

¢ Ectropion,

entropion.

@> Hysterical.

¢ Blepharospasm in painful eye conditions

@> Mechanical.

¢ Stye and blepharitis

@> Oculomtor nerve paralysis

@> Horner's syndrome.

@> Myasthenia

gravis.

¢ Oedema and puffy eye lids:

@> Renal, nephrotic or nephritic.

@> Myxoedema.

@> Mediastinal

syndrome with SV.C.

obstruction.

@> Lack of sleep or excessive sleep

!?

@> Chronic cough.

@> Angioneurotic

oedema.

@> Rarely as a part of generalized oedema,

as liver cirrhosis and C.H.F.

I~Sclera:1

¢ Blue sclera:

@> Congenital

glucoma.

@> Osteogenesis

imperfecta.

¢ Jaundice: See complexion.

<iI>

Vitamin deficiency

as Xerosis (Vit. A 1), vascularization (Vit. B2 1).

<II>

Pingueculae

are

triangular yellow deposits beneath the conjunctiva

between the canthus and the edge of cornea, they develop with

advancing years,

and

are of no clinical

value. Pterygium is a patch

of

progressive

fibrosis

in the same area

which may encroach upon

the

cornea.

:iY

Redness

of the tip of the nose: alcoholism.

~

Sunken bridge (saddle nose) in congenital $,

Toph;~1Ht&-

Trauma,

congenital or Wegner's granuloma.

~ Working

ala nasi (pneumonia or nervousness.)

~

Rhinophyma

(thickening of the nasal skin with induration

and redness),

the nose may appear bulbous. It may be associated with alcoholism.

~, Ochronosis

(blue black pigmentation

of the ear, nose and cheeks from bindi g of

homogentisic

acid to connective tissue

and cartilage) this occur in Alkaptonuria.

~, Lupus

pernio

(bluish red swelling of the nose and ear in cases of sarcoidosis).

~, Nasal polyps

with chronic atopic rhinitis and aspirin sensitive

asthma.

~

Large nQse: congenital - 'acromegaly - myxoedema.

~, Ears:

Gouty

tophi on the helix, discharge, F.B in the external

meatus.

~y

Low set ear may be associated with congenital anomalies

e.g. congenital H.D.

'(4)

Cheeks:

.'

Pale in anemia - Malar flush

in M.S. and myxedema - Butterfly erythema in S.L.E. -

Bloated in cushing disease -

ochronosis as above.

<=>

Cheilosis is a reddening and cracking of one or both angles of the mouth

(angular

cheilosis or angular stomatitis),

it occurs

due to riboflavine or iron deficiency, it is

also caused by candida.

<=>

Cheilitis: painful vertical fissures mainly

of lower lip caused by malnutrition

or with

Crohn's disease, it may occur with exposure to sunlight and wind.

<=> Pallor, syanosis (See complexion.)

<=>

Angioedema, herpes labialis.

"

The surface

of the tongue

normally

varies

as regard colour and appearance.

Shades

of pink and

red or even

yellow,

brown

or

almost black may be of no

medical

significance

though they are a potential cause

of anxiety to the subject.

Dry mouth

. .

...