general physical examination

GENERAL PHYSICAL EXAMINATION

ASSESSMENT OF NUTRITION

Macronutrient assessment1) Body Mass Index (Quetelet Index)It is calculated by the formula weight/ height2 (Kg/m2) However the disadvantage is it doesn’t describe thedistribution of body fat.

BMI non Asian

BMI Asian

Underweight <18.5 <18.5Normal 18.5-24.9 18.5-22.9Overweight 25-29.9 23-24.9Obese 30-39.9 25-29.9Morbidly obese >40 >30

2) Waist Circumference: Normal <94 cm in men and <80 cm in women3) Waist:Hip ratio:

<0.8 in females <0.9 in males inceased waist hip ratio has increased risk of

coronary artery disease

Micronutrient assessmentClinical findings in Vitamin deficienciesThiamine: Beri beri, neuropathy,muscle weakness

and wasting, cardiomyopathyRiboflavin: Angular stomatitis, Magenta tongueNiacin: Pellagra- dermatitis diarrhea dementiaVitamin B6: Glossitis, confusion, microcytic anemiaFolate: Megaloblastic anemiaVitamin B12: Megaloblastic anemia, neuropathy Vitamin C: Scurvy, imflamed and bleeding gums

Vitamin A: Xerophthalmia, night blindness, Bitot spots, follicular hyperkeratosis

Vitamin D: Rickets, osteomalaciaVitamin E:Peripheral neuropathy, spino cerebellar

ataxiaVitamin K: Bleeding DisorderIron: Koilonychia, pica, anemiaCalcium: Reduced bone massFluoride: Increased dental caries

Atrophic glossitis (bald tongue)

Angular cheilitis

Fissured tongue in Vitamin Bdeficiency

Bitot spots seen in Vitamin A deficiency

Koilonychia seen in iron deficiency anemia

PALLOR

Sites of examinationExamined in the areas where blood vessels are near to

the surface.Lower palpebral conjunctiva, Tongue, Nails, Palmar

creaseSeen in Anemia. On hyperextension of the palm, if palmar creases are

light in colour than the surrounding skin then the concentration of hemoglobin is usually less than 8g/dl.

Non anemic causes of pale skin: Fair skinned individuals, hypopituitarism, hypogonadism

Pale lower palpebral conjuctivaPale palms compared with normal

ICTERUS

Yellowish discolouration of skin,mucous membrane and sclera.

Due to increased bilirubin.Yellowish discolouration of sclera is due to the high

elastin content in the scleraSites to examine icterusUpper bulbar conjunctiva, lower surface of tongueIt denotes the concentration of serum bilirubin of

atleast 3mg/dL

Differential diagnosis of yellowish discolouration of skin

Carotenoderma ( increased intake of carrots, oranges and leafy vegetables): here there is no yellowish discolouration of sclera

QuinacrineChronic exposure to phenolsLong standing anemia

CYANOSIS

Cyanosis is the bluish discolouration of skin and mucous membrane.

It results from the increased amount of reduced hemoglobin the the blood.

Manifests when the reduced hemoglobin is >4g/dLCyanosis may be masked in severe anemiaTypes:1) Central cyanosis: Due to the decreased SaO2

Respiratory cause: High altitude, Alveolar hypoventillation, pulmonary A-V shunts & fistula, Cardiac causes: Congenital heart diseases

Sites: Skin, lips, tongue

Other causes: Methemoglobinemia, sulfhemoglobinemia

2) Peripheral cyanosisExposure to cold, arterial obstruction, reduced

cardiac output, venous obstruction. Sites to be examined: tip of the nose, ear lobule,

nails

CLUBBING

Bulbous enlargement of the distal part of the fingers and toes due to proliferation of connective tissue

Theories: 1) Platelet derived growth factor theory: This is

the most accepted theory. There is release of PDGF from the platelets in response to imflammation or hypoxia leading to vasodilation and proliferation of soft tissues

2) Neurogenic theory: Vagal mediated stimulation causing vasodilation

3) Humoural theory: GH, PTH, estrogen,PG, bradykinin causes vasodilation and clubbing

4) Ferritin theory5) Hypoxic theoryNormal angle between the nail bed and and nail is known

as Lovibond angle and is about 160.Causes: HereditaryIdiopathicRespiratory: Bronchogenic carcinoma,

bronchiectasis, cystic fibrosisCardiac: Cyanotic heart disease, infective endocarditis

GIT causes: Liver cirrhosis,Imflammatory bowel disease

Hypertrophic osteoarthropathy: Clubbing along with subperiosteal distal diaphyseal new bone formation with symmetric arthritis like changes in shoulders, elbow, knee, ankle seen in lung cancers, mesothelioma, bronchiectasis, hepatic cirrhosis.

Cyanosis in the nails with Clubbing

LYMPHADENOPATHY

Check for the number, size, site consistency and tenderness.Some important lymph node involvement in certain diseases.Jugulodigastric nodes: URTI, tonsillitisVirchow’s node (Troisier sign): enlargement of left

supraclavicular node due to GIT or testicular malignancies.Right supraclavicular nodes: malignancy of right lung and

left lower lobeAxillary lymph nodes: Carcinoma breast, LymphomaEpitrochlear nodes: Secondary syphilis. Non hodgkin’s

lymphomaPeriumbilical nodes ( Sister Mary Joseph’s nodule)

abdominal malignancy

EDEMA

Accumulation of fluid in interstitial space.Types: Pitting type: Apply firm pressure on the shin of

tibia or 2cm above the medial malleolus for 20-30 s and see for pitting.Causes: Congestive cardiac failure, nephrotic syndrome, liver cirrhosis, hypoproteinemia

Non pitting type: Graves disease (non pitting due to deposition of hyaluronic acid), filariasis (lymphatic obstruction)

Pitting seen in the left limb