1. Principles of Clinical History and Examination
    2. 1. Managing clinical encounters with patients
    2. General aspects of history taking
    3. General aspects of examination
  2. System-based Examination
    3. 4. The cardiovascular system
    5. The respiratory system
    6. The gastrointestinal system
    7. The nervous system
    8. The visual system
    9. The ear, nose and throat
    10. The endocarine system
    11. The reproductive system
    12. The renal system
    13. The musculoskeletal system
    14. The skin, hair and nails
  3. Applying History and Examination skills in Specific Situations
    4. 15. Babies and children
    16. The patient with mental disorder
    17. The frail elederly patient
    18. The deteriorating patient
    19. The dying patient
  4. Putting History and Examination Skills to use
    5. 20. Preparing for assessment
    21. Preparing for practice
Principles of Clinical History and Examination
3. General aspects of examination
GENERAL PRINCIPLES OF PHYSICAL EXAMINATION
PREPARING FOR PHYSICAL EXAMINATION
SEQUENCING FOR PERFORMING A PHYSICAL EXAMINATION
INITIAL OBSERVATION
▢ Gait and Posture:
▢ Facial expression and speech:
HANDS
▢ Deformity:
▢ Colour:
▢ Temperature:
▢ Skin:
▢ Nails:
❖ Clubbing:
◉ Causes:
◈ Congenital or Familial (5-10%):
◈ Acquired:
  1. Respiratory (70%)
    1. Lung cancer
    2. Chronic suppurative conditions
      1. Pulmonary tuberculosis
      2. Bronchiectasis
      3. Lung abscess
      4. Empyema
      5. Cystic fibrosis
    3. Mesothelioma
    4. Fibroma
    5. Pulmonary fibrosis
  2. Cardiovascular
    1. Cyanotic congenital heart disease
      1. Transposition of great vessels
      2. Tetralogy of Fallot
      3. Truncus arteriosis
      4. Total anomalous pulmonary venous connection (TAPVC)
      5. Tricuspid valve abnormalities
    2. Infective endocarditis
    3. Arteriovenous shunts
    4. Aneurysms
  3. Gastrointestinal
    1. Cirrhosis
    2. Inflammatory bowel disease
    3. Coeliac disease
  4. Others
    1. Thyrotoxicosis (Thyroid acropachy)
    2. Primary hypertrophic osteoarthropathy
◉ Theories:
◈ PDGF theory:
graph TD 1["Megakaryocytes lodge in the tips of the digits"] 2["Releases PDGF (Platelet Derived Growth Factor) and VEGF (Vascular Endothelial Growth Factory)"] 3["Increases endothelial permeability"] 4["Activate and cause proliferation of connective tissue cells (E.g., Fibroblasts)"] 1 --> 2 2 --> 3 3 --> 4
◈ Neurogenic theory: Persistent vagal stimulation causes vasodilation and clubbing (E.g., Lung carcinoma)
◈ Hypoxic theory: Causes opening of deep arterio-venous fistula in fingers (E.g., Tetralogy of Fallot)
◉ Grading:
Grade
Observation
1
Increased fluctuation of nail bed
2
  1. Loss of Lovibond angle/ Onychonychial angle (Normal is <180°)
  2. Profile sign
  3. Schamroth sign
3
  1. Parrot beaking
  2. Drumstick fingers
    1. Severe cyanotic heart disease
    2. Bronchiectasis
    3. Empyema
4
  1. Pain along the distal ends of long bone due to subperiosteal new bone formation
  2. Condition seen generally seen with bronchogenic carcinoma
5
Glossy changes in nails and adjacent skin with longitudinal striations
SKIN
▢ Haemochromatosis:
▢ Haemosiderin:
▢ Easy bruising:
▢ Hypercarotenaemia:
▢ Discoloration:
❖ Jaundice:
❖ Pallor:
◉ Causes:
  1. Anaemia
    1. Iron deficiency anaemia
      2. ● Associated symptoms:
      1. Angular stomatitis
      2. Glossitis
      3. Koilonychia
      4. Blue sclerae
  2. Vasoconstriction
    1. Cold exposure
    2. Sympathetic activation
◉ Sites:
  1. Conjuctiva (Anterior rim of Palpebral conjunctiva)
  2. Palmar skin creases
  3. Face
  4. Nail bed
❖ Facial flushing:
◉ Causes:
  1. Physiological
    1. Fever
    2. Exercise
    3. Heat exposure
    4. Emotional
  2. Drugs
    1. GLyceryl trinitrate
    2. Calcium channel blockers
    3. Nicotinic acid
  3. Anaphylaxis
  4. Endocine
    1. Menopause
    2. Androgen deficiency (in men)
    3. Carcinoid syndrome
    4. Medullary thyroid cancer
  5. Others
    1. Serotonin syndrome
    2. Food/ alcohol ingestion
    3. Neurological (E.g. Frey's syndrome)
    4. Rosacea
    5. Mastocytoses
❖ Facial plethora:
◉ Causes:
  1. Polychthemia
  2. Superior venacaval obstruction
❖ Cyanosis:
◉ Central cyanosis:
◈ Site:
  1. Lips
  2. Tongue
  3. Buccal or Sublingual mucosa
◈ Causes:
  1. Cardiac disease
  2. Respiratory disease
◉ Peripheral cyanosis:
◈ Site: Distal extremities
◈ Causes:
  1. Low cardiac output states
  2. Arterial disease
  3. Venous stasis
  4. Venous obstruction
▢ Characteristic skin changes:
❖ Scurvy:
❖ Neurofibromatosis:
❖ Acanthosis nigricans: