Examination - Patient Management

Examination

Purpose of Examination

·        Aims to:

o  Confirm suspicion

o  Exclude other causes that mimic it

o  Measure severity

General

·        Are the conditions OK to do an exam? Is the light in the room OK, is the patient positioned and exposed, etc

·        ALWAYS OBSERVE FIRST: stand back and look.

·        Distress, comfort, central or peripheral cyanosis, pallor, jaundice, dehydration, SOB, how sick or well 

·        Cachectic = severe loss of weight and muscle wasting. Usually malignancy, but also severe cardiac disease (due to anorexia from liver congestion and impaired absorption due to intestinal venous congestion)

·        Facies: features of the face suggesting diagnoses: eg acromegaly, Cushing‟s, Down‟s, myxoedema, Parkinson‟s, hair distribution in men and women, etc

·        Weight, body habitus and posture, including deformities

·        Include vital signs in general assessment: pulse, blood pressure, temperature, respiratory rate

Fever

·        Taking a temperature:

o  Serial measurements the most useful

o  Also take pulse – if ­temp should have ­heart rate (except in typhoid)

o   Normal Values  Low    High

§  Oral          36.6   37.2

§  In hot weather  +0.5   +0.5

§  Rectal       +0.2   +0.5

§  Axillary    -0.5    -0.5

·        Children. The most common emergency presentation in paediatrics. Most common cause is viral infection, otitis media, pharyngitis, and tonsillitis. Also consider bladder infection, Rheumatic fever, Meningitis. Kids spike temperature easily. Febrile convulsions occur between 18 months and 5 years. At other ages investigate other causes

·        Types of fever:

o   Continued: does not remit e.g. typhoid, drug fever

o   Intermittent: falls to normal each day – pyogenic infections, lymphomas

o   Relapsing: returns to normal for days then rises again – Malaria, lymphoma, pyogenic

Pyrexia/Fever of Unknown Origin (PYO/FUO)

·        See also:

o   Pyrexia of unknown origin if returning from 3rd world

o   Fever in a Neutropenic Patient

·        Formal definition:  > 38 C, > 3 weeks, no known cause (ie normal admission tests already done).

·        However, often used to describe a temperature that that you haven‟t done any tests on yet

·        Usually an unusual presentation of a common disease

·        History, exam, investigations, time course, urgency and likely cause depend on setting:

o   Community acquired (Classic PUO)

o   Nosocomial PUO (ie hospital acquired)

o   Immune-deficit or HIV related PUO

·        Differential:

o   Neoplasm: lymphoma, leukaemia (check lymph nodes), other (hepatic, renal, other)

o   Infection:

§  Bacterial: Tb, abscess (subphrenic, hepatic, pelvic, renal – look for ­ neutrophils), endocarditis (any dental work?), pericarditis, osteomyelitis, cholangitis, pyelonephritis, PID, syphilis, cystitis

§  Viral: EBV, CMV, HBV, HCV, HIV, Varicella-Zoster

§  Parasitic: malaria, toxoplasmosis

§  Fungal

o   Connective Tissue: RA, SLE, Vasculitis (eg polyarteritis nordosa – check for Raynaud‟s phenomena – abnormal response in fingers to cold)

o   Miscellaneous: drug fever (especially penicillins, sulphonamides), Rheumatic fever, inflammatory bowel disease, granulomatous disease (eg Sarcoid), Fictitious/Munchausen‟s (eg injecting themselves with saliva)

·        Clues:

o   Weight loss Þ chronic

o   Check eyes: iritis in connective tissue disease, jaundice, etc

o   Check tonsils, glands, ears for infection

·        History:

o   Travel (eg malaria, did they have prophylaxis)

o   Exposure to others

o   Sexual history

o   Weight loss

o   Been to other doctors (had any antibiotics)

o   Occupational exposure (eg cows)

·        Exam:

o   Lymph nodes

o   Heart murmurs

o   Skin for rashes

o   Abdominal exam

·        Possible investigations:

o   Blood count

o   Blood cultures

o   Urine microscopy & culture

o   Liver function (eg hepatitis)

o   Viral serology

o   Malaria film

o   Chest X-ray

Tiredness

·        Differential:

·        Sleep disturbance: eg anxiety, sleep apnoea, narcolepsy,

o  Depression

o  Anaemia

o  Endocrine: hypothyroidism, hypocortisol (Addison‟s), diabetes, hypercalcaemia (due to ­PTH)

o  Infection (eg EBV)

o  Cancer

o  Drugs: alcohol intoxication, sedative drugs,

o  Head injury (eg subdural haematoma)

o  Post ictal states

o  Hypoglycaemia

o  Hepatic encephalopathy, Wernicke‟s encephalopathy

o  Chronic heart failure

o  Malabsorption (eg coeliac disease)

o  Pregnancy

·        Sleepiness

Oedema    

·        Include in exam of appropriate system

·        Need to retain 3 – 4 litres before pitting begins

·        Exam:

o  Where is it? Distribution

o  Is it pitting

o  Other signs of inflammation

·        Mechanisms:

o  ↓colloid osmotic pressure

o  ↑hydrostatic pressure

o  ↓permeability of wall

·        Localised Cause:

o  Inflammatory (e.g. infection, allergy - cytokine mediated) ® pain/heat/redness/swelling

o  Trauma

o  Venous occlusion by tumour or lymph nodes

o  Thrombis (e.g. DVT)

·        Generalised Cause:

o  Is it bilateral?  Usually worse in the evenings

o  Heart Failure:

§  Mechanism: ↑preload ® ↑venous pressure, ↓renal perfusion ® ↑renin ® ↑Na/H20

§  History: check SOB, orthopnea, PND

§  Signs/Tests: CXR, ECG, Echo

o  Liver:

§  Mechanism: liver failure/malnutrition ® ↓colloid pressure ® ↓renal flow ® ↑retention

§  History: check alcohol, cholestasis, hepatitis, bleeding, bruising

§  Signs/Tests: portal hypertension, enlarged liver, jaundice, bloods (Liver Function, INR)

o  Renal:

§  Mechanism: nephrotic syndrome ® ↓colloid pressure (have to loose 3.5 g protein a day to be nephrotic. NB nephritis is inflammation)

§  History: check change in urination, nocturia (due to diuresis), diabetes

§  Signs/tests: ↑BP, urine test, 24 hr urine, dipstick, urea/creatinine

o  Drugs (eg vasodilators, like calcium channel blockers) can cause ankle oedema

o  Gastrointestinal: Malabsorption ® hypoalbuminaemia

·        Non-pitting lower limb oedema

o  Lymphoedema (eg malignant invasion of lymphatics, allergy) doesn‟t pit – push for 10 seconds

o  Hypothyroidism

Hands

·        Nails:

o  Takes ~ 6 months for fingernails to grow out

o  Clubbing:

§  Respiratory: carcinoma, fibrosis, cystic fibrosis, TB, chronic suppuration (eg bronchiectasis), idiopathic pulmonary fibrosis, NOT asthma or CORD alone

§  Cardiovascular: infective endocarditis

§  Other (uncommon): cirrhosis, IBD, coeliac disease, thyrotoxicosis

o   Blue: cyanosis, Wilson‟s disease

o   Red: Polycythaemia (red-blue), carbon monoxide poisoning (cherry red)

o   Pale nail bed: anaemia

o   Koilonychia: spoon shaped nails in Fe deficiency

o   Leuconychia: white nails in hypoalbuminaemia

o   Mee‟s lines: single white transverse line in renal failure

o   Splinter haemorrhages: usually trauma (especially manual workers) or infective endocarditis, rarely vasulitis (eg in rheumatoid arthritis), polyarteritis nodosa, sepsis, blood malignancy or profound anaemia

o   Check capillary refill: squeeze nail and see how long it takes to return to red – sign of peripheral circulation. Normal < 2 sec

·        Hands:

o   Palmar erythema: pink spots on pale background – should be bilateral - Chronic liver disease, pregnancy, rheumatoid arthritis, polycythaemia, thyrotoxicosis, SLE

o   Skin: subcutaneous bleeding: petechiae small, purpura bigger, ecymosis – biggest. Petechiae caused by a platelet problem, not due to coagulopathy

o   Dupuytren‟s Contracture: extend fingers back – shortening of palmar aponneurosis – in alcoholic liver disease, epilepsy, manual workers and idiopathic

o   Asterixis: metabolic flap – coarse, non-symmetrical – neural inhibition ® encephalopathy in renal failure (­urea), respiratory failure (­CO2), liver failure (­nitrogenous material), hypoglycaemia, barbiturate poisoning

o   Raynaud‟s Syndrome: intermittent attacks of ischaemia of fingers or toes due to intense arterial vasospasm, often precipitated by cold or emotional stimuli

o   Tendon Xanthomata: lipid deposits in tendons of hands or arms in hyperlipidaemia

Head

·       Headache

·        Recent onset of severe headache: the most common cause is idiopathic

·        Ask about associations/antecedents

·         Red flags: fever, change in mental status/personality, fits, focal neurological signs, sudden and severe, affected by postural change, normally headache free, waking at night or in the morning with a headache

·        Types of headache:

o  Tension headaches, eg chronic daily headache, gradual onset (chronic), sleep not disturbed, treat by ¯stress (massage, relaxation). ? Depression. Types: post-coital, ergotamine misuse

o  Cluster headache: clusters of extreme, recurrent non-throbbing deep pain in and around an eye, spreading onto the face. Eye typically becomes swollen and watery

o  Migraine: visual symptoms, unilateral, throbbing, nausea, aura

o  Facial structure: eg TMJ dysfunction, sinusitis, NOT teeth

o  Neuralgic: eg idiopathic, trigeminal neuralgia

o  „True vascular headache‟: associated with TIA/stroke, artery dissection, giant cell arteritis

o  Associated with ­ICP: focal lesions, venous thrombosis, meningitis, severe hypertension

o   Acute: ?meningitis, sinusitis, head injury

o   Associated with post Lumbar puncture

·        Treatment: Ongoing unchanged tension or migraine headache: TCAs

·        Differential of morning headache:

o   ­ICP

o   ­CO₂ (eg sleep apnoea)

o   Diabetic going hypoglycaemic overnight

Eyes

·        Jaundice: primary liver disease, liver congestion secondary to heart failure

·        Anaemia: pale conjunctiva – especially anterior border just inside eye lid

·        Sclera not affected by hypercarotenaemia

·        Puffiness below eye: early nephritis (before feet oedema), myxoedema of hypothyroidism

Mouth

·        Mouth: Foetor hepaticus, ulceration, pigmentation, telangiectasia, gingivitis/hypertrophy, glossitis

·        Ulcers: aphthous, drugs (e.g. gold), trauma, Crohn‟s, infection (HVZ, HS)

·        Pigmentation: heavy metals (lead, iron), drugs (anti-malarials), Addison's, Melanoma, Kaposi‟s sarcoma

·        Snotty nose = coryza

Throat

Bacterial : Viral

High fever          : Runny nose

Pus/exudate      : Red raw throat

Productive cough (if any) :    Persistent dry cough

·        Whitish-yellow membrane over tonsils - ?EBV

·        Patches of exudate on mucosa - candida

·        Differential: Bacterial sore throat, viral URTI, glandular fever, rheumatic fever, quinsy (peri-tonsillar abscess, can lead to airway obstruction)

 ·        Acute Pharyngitis : Clinical signs: fever, respiratory distress, cervical lymphadenopathy, pharyngeal erythema, pharyngeal exudates

Lymph Nodes

·        Occipital Nodes: scalp infections, bad nits, infected cradle cap, rubella

·        Mastoid and posterior auricular

·        Parotid: mumps

·        Posterior sternomastoid

·        Anterior sternomastoid: sore throat

·        Jugulodigastric

·        Submandibular and Submental: tooth infection, glandular fever

·        Superior, deep and lateral cervical (internal jugular) nodes

·        Supra & sub-clavicular: lung and lung surface infections, Tb, lung metastasis

·        Enlarged lymph nodes and oral thrush ® ?AIDS