The General Clinical Examination - Clinical Skills Introduction

hello my name is James Gale and this is a start of what will hopefully be a series of podcasts based around clinical examination skills and this is brought to you in association with titanium health what you'll open neat that's halfway oh the whole idea if this came about because I've talking to some students about how they do revision and the like and like myself most revision and most learning is now done online or in a electronically in some form and textbooks kind of don't get quite as much input as they used to so this was an idea based upon that to try and do a series of podcasts that can be used both in a video format you know but also for pure audio if you're going running swimming revising the car something like that try to get the maximum a utility out of these things so to start off today I'm going to go over the general examination personally the general examination I don't like too much it's a bit of an artificial idea nobody walks into a doctor services doctor my generals a little bit off could you examine please but that said it is a very useful tool to start off right at the beginning with the medical students in terms of understanding how to look at a patient and how to examine them as much as it is for just starting to talk about vocabulary and understanding sort of process of the examination so to begin with in terms of doing a general examination we need to know generally how the patient is so with that what is the normal vital signs that we see looking at a patient so have a think to yourself what are the normal values for a patient's temperature their blood pressure the pulse there are spiritually rate and their oxygen saturations what do you think so let's start off at the top with temperature what is a patient's normal temperature range that should be between thirty six point five degrees Celsius and thirty seven point five degrees Celsius when a person comes in to see me and they say they're feeling a bit hot another thing that got a bug when I check their temperature and not find that they've got a temperature of 37 337 four I will say to them you've not actually got a temperature here at the minute but given the history I'm still going to say you know you definitely warm at the moment and you know that's going to feel a little bit unpleasant probably as you say there's something going on let's look a little bit closer so from there we're going on to do a patient's blood pressure but the bottom end of normal we're going to have a patient with a systolic of 90 and a diastolic blood pressure of 60 absolutely then what we go higher up our systolic at the top end of normal will be 120 and at the bottom end of certain that the top and the diastolic will be 80 okay so looking at the pulse what are we consider to be a tachycardia so a high pulse rate that's anything over 99 so 100 is the tachycardic and obviously nyah-nyah will be off normal point so at the bottom end where's Bradley card here so at some times you'll see a prat bradycardia described as 50 beats per minute but the bottom under normal is 60 beats a minute so what do you do about that middle ground I think it's reasonable to consider everything above 51 beats per minute normal they're going to receive eight this is very very useful to get an overview about how the patient is so the top end of all would expect a patient to be getting no more than save 16 beats at 16 breaths per minute at the bottom and they should be taking on quite happily with 10 breaths staying with a respiratory idea what's normal for saturations the amount of oxygen we can get into the mouth through the circulation and into the peripheries would expect thailand abnormal thing 99.1 hundred percent because it shows everything's working fine all the way down to a saturation of 92 percent now I'm actually going to start paying a lot of attention when a patient saturations hit 95 what's going on why are they down as low however we don't have to worry excessively until they get below 92 that patients in trouble and we need to sort something out so we've got a good idea of what's the vital statistics on a patient and that things that we weren't going to want to know before we go any further in terms of doing the general examination though we ideally want to start off with the patient's two pounds because there's a huge amount of information that we can see here so in a moment we're going to go through describing things that we may see in a general examination but to start any examination we must begin it properly and that involves what we might term wiping the patient so welcoming the patient introducing ourselves giving patient consider getting patient consent and then explaining the procedure technically want to explain the procedure to get the consent but you know white works as the acronym so once we've got consent for the patient to being examined well I will normally you know comment as they move over the examination couch how they walking when they get there they sitting calmly at rest was it difficult for them to get on the couch similarly have there any powerfully you know of a crushing and hailer they walking with their stick how is their gait all of these things are relevant to building that overall picture at the patient but it's it once we've got that overview we're going to start off with the house and specifically their fingers to begin with there's a lot of things that we can see in the fingers so what is one of the commonest things that medical students love to talk about clubbing absolutely saying we get these large spoon shaped up female bowlers in or with a chicken drumstick style and fingers and we need to be able to prove that the patient has clothing rather than just saying their fingers look a bit swollen and the way we do that is to get the patient to put the fingertips together so they're making a diamond shape between the fingers and that's called shamrock sign and indicates that there is no clubbing if we've got that diamond shape there conversely if we can't see it then it says that there is clay and a very common question at medical school is what are the causes of coming there's quite a lot of pathology or problems that can produce clubbing however there is also idiopathic that this is you know just a thing for the patient that is normal for them I've actually seen quite a few people who have familial clubbing where the families fit in well but lots of members of the family have this swollen nails type of appearance we'll talk further in the next couple of podcasts about the different specific course of clubbing when we're doing our systems reviews but for time being is worth highlighting just the range of different course of clubbing so we can have cirrhosis of the liver which would cause clubbing inflammatory bowel disease which can cause clubbing yeah empyema abscesses in the lung bronchiectasis so destruction the alveoli we can have problems with the heart one of which being cyanotic congenital heart disease where the where the where the vessels are places the wrong way around then you end up dating blue babies as you see there's a range of different systems that are affected and as I say we'll do all those we'll go over those in more specific detail later on so we've covered the swelling of the fingers what other changes can we see in the nail another classic want are splinter hemorrhages so these are little black dots or lines that people can see in the fingertips the big common course that normally comes out to medical students announce if bacterial endocarditis where you get an infection in the heart and you get bacteria for any lots of little leaflets on the valves which break off and speed through the Weisse vascular chef to lodge in the capillaries in the fingers but also the competitors in end organs such as the liver the brain and the lungs so this sign suggests there may be more to follow G going on that we can't see because these little black bits these lines that we see in the fingers or when the bacteria larger than the capillary block it and cause an area of necrosis or cell death that's what the blackness is but a more common reason and normally why I've got stool inherited most attack is because of mechanical trauma in my case usually because I've trapped my fingers with a spanner and I've been changing wheels on my bike so that's the splinters we can also get other default notice the nails so what we've been : me clear or spoon shaped nails normally we've got a nice Conqueror shape but with : ikea we get a concave shape if you could you could test it by dropping some say line on the fingertip and it would sit in this hollow this is found in patients that have chronic iron deficiency anemia another deficiency is why we see leukemia all white nails this is seen in a low-protein state so maybe something like nephrotic syndrome where you lose a lot of protein continued live for the body would cause this problem but when a lot of people see it for the first time or in pictures it does look like somebody put tip X on the fingernails you can get little white limes or white specks on the fingernails this this is not probably kanika due to low protein stays but this is normally due to simple trauma by someone bang my finger and course a little bit of whitening there okay another change that we can see we can get our splitting of the fingernail or coming away from the nail bed this is called your lysis and can be seen for example in thyroid conditions and in various other skin conditions such as psoriasis Oregon like me if you fall over and jam something into your knee I think we're seeing that I have a little bit accident-prone what we'll discuss a little bit more of that when we come to be orthopedic stuff okay what else have we got with the fingers let's stay in a straight line or simple line service move from the fingers and that's going all approximately you could get swirling at the distal and proximal interphalangeal joints if we've got osteoarthritis so the two names here would be bouchard's nodes the middle joint and Hebrides nose at the ends joint aren't distal and proximal I've always liked the things that's what we're looking at these simply is that our hybrid Ian knows our land the heavily miles in the UK they're farthest away from the mainland so that the bits that are farthest away from the body we can get swelling of the fingers and swelling of the metacarpal phalangeal joints this is what smallest seen in rheumatoid arthritis and is a significant sign that we do need to act upon quickly in order to prevent any further damage occurring to these patients fingers if we turn out the hand over and have a look at the palm we might be able to see about how quickly a patient's compared the refill is so if we press the fingers here and release the pressure the capillary refill is how many takes the blood supply to return so from a pale pattern normal pink I would normally expect that to be about one second if it's getting more sluggish this might be due to patient having hold hands or a slow volume output so somebody perhaps having hypovolemia or a low blood pressure conversely anything that is faster or an immediate brief that they refill shows we have a hypertonic or increased circulation so perhaps seen in infection successes or in hyperthyroidism for example another thing we could see with hyperthyroidism on par will be palmar erythema so we'll read palms but that's not the only thing that can cause it we can also get this red power appearance in to other conditions one being cirrhosis of the liver said liver damage and the other pregnancy and these two conditions connect because they're both high eastern states when you live against damage you end up with high levels of estrogen because of it I can't break it down and similarly when you're pregnant there are higher levels of estrogens supporting their pregnancy and thus we get the pulmonary edema but note it's not the East region that causes pulmonary edema in hyperthyroidism that is merely a hyper dynamic circulation so we've got increased blood supply stand with the palm we can get whitening of the palmar creases which like our Colavecchia might indicate a patient being anemic now who's the protocol is actually having the UK yes you're right it's Bill knives if you look at all of his films and in his pictures he's always pulling very cool poses with his fingers the reason being that is you can't actually move his little gambling finger he has something called super trance contracture which is a thickening of the path pressure now normally this will just be present is like a feeling of a cord of thickening under the skin but as it worsens this cord will contract down and we'll pull the outer two fingers down into position hopefully we'll get a patient seen by the orthopedic team before they get to any significant deformity so we can release it and allow their fingers to go back to normal this can be like loving can be familial due to bad luck and there are some studies that suggest there is a connection with alcohol abuse as well carrying on form the palms the other thing that we may see here is a single partner crease such as an impatient with Down syndrome although to be fair there are large number of other visual features that we're going to see those are going to indicate Down syndrome rather than just that single crease having looked at the hand we need to move again close throughout the body so we're going to start off doing the radial pulse these is going to find your radial pulse it's find your radial styloid so they're normally bit at the base of your thumb put two fingers here and just let it slip down into the hollow beneath it from here you should be able to feel the beat of your pulse what we're talking about a peripheral pulse like the radial pulse we can get two bits of information what is the patient's pulse rate so is it 60 beats a minute and what is the rhythm so is it normal sinus rhythm so regular one two one two or is that an arrhythmia an abnormal an abnormal rhythm for example you could have a regularly irregular arrhythmia so one two three one two three one two three we could also get an irregular arrhythmia so one two three one two one two one two one two people want to bouncing all over the place which is seen in atrial fibrillation which like clubbing has a large number of causative factors which can bring on this abnormal pulse moving further up to the arm the brachial pulse here is worthwhile checking or the carotid as well because we get an additional piece of information from the pulse that character is that's how forceful or strong the pulses is it weak and thready if we've got a patient who has shut down they've got a low blood pressure maybe they're septic or is it a hyperdynamic circulation is it pounding a very forceful pulse as this patient got high blood pressure are they affected by hyperthermic hyperthyroidism it's the pulse cranked up to 10 at this point in our examination we also want to do the blood pressure looking taking it from the brachial pulse here carrying on up have a look over the face so we can start off looking at the patient's eyes do they look nice and white sclera fears or is it in yellow is it jaundiced which might indicate a hematological or a blood problem or more likely a problem of the liver both of which resulting in higher levels of bilirubin in the system from there we can actually have a look at the iris so the colored part around the pupil is there a white up around this called corneal parker's this is normally due to high levels of cholesterol in the blood Dipendra seen in people as they get older a little bit as well if there's a higher level of cholesterol we might see around the eyes yellow deposits of cholesterol called sample asthma we may have noticed those further that earlier on in the body or we can get white absolutely yellow patches on the tendons again cholesterol deposits called tendons and thermo we would then want to get the patient to pull their eye eyelids down we can have a look in the conjunctiva underneath the eyelid to see if it's a hail suggesting they might be anemic which will go along with our tale par creases and potentially Konya or we may have signed an infection meso very red and possibly sticky discharge at that point carrying on down the face we want to have a look at the mouth so having a look at the lips are we getting any evidence of central cyanosis so we can have two times two silences peripheral sign ups is where we make it blue fingertips which could be due to cold and the blood vessels are simply shutting down and not letting new blood get the fingers or is it something connected with the heart or the lungs in which case we'll get our central cyanosis we get a blue tinge to the lips this is a very worrying sign of suggesting as mentioned that there is quite a significant problem in the cardiovascular system we can also confirm this by having a look under the time which might show us again blue blood vessels under there whilst we're looking inside the mouth you may find evidence of poor dentition which can be associated with patients that have poor cardiovascular outcomes however it's important to highlight that this doesn't seem to be positive I hate bad teeth cause of problems with your heart but it's more Association that people who have poor dentition may have life staff which is resulted in large numbers cardiovascular risk factors staying with the tongue we can see other things which might suggest an anemia we might get a pale tongue so then we've got our pale power creases are cool Aniki or pale conjunctiva and our pale tongue or suggesting and anemic patient but we might get a big red beefy top and it's becomes smooth and lost the papillae on it that we're going to get a vitamin b12 deficiency and if we get some changes like that we might actually see a different type of anemia a mattress a tick anemia where we get large blood cells as opposed to the iron deficiency anemia where we get small blood cells staying with if we've got this 2012 deficiency we may also see angle stomatitis so crap schools are the edges of the mouth but note this is different from the comic also work because that's a viral infection we also get a vesicle so little tiny fluid-filled blisters associated with a viral infection but we don't get with the angular stomatitis from literally 12 carrying on down we want to huddle that the patient's neck and it can be useful to do that from the side to see if there's any closer or swollen back which might be associated with a thyroid problem we would also want to check over the neck around the head to see what is present with regard to lymph nodes the lymph nodes are essentially the barracks the immune system if you for example get a sore throat but white blood cells are going to have to move to this area in order to fight what has causing infection and thus will get these glands occurring in the neck most patients would kind say that their glands are swollen not anything is that they have lymphadenopathy we want to check on the superficial and deep cervical chains position yeah the large muscles of the neck the sternocleidomastoid muscles going up from there I like to check along a fossil of those and then along to along its mandibular lymph nodes you can actually press quite far inside your jaw without causing any discomfort it's a fine piece of fat and these lovers are normally lost if we have problems with in dead tissue such as abscess of affecting the teeth not the very front of the jaw we house for mental if there's restrain from the tongue and they're long indicate significant pathology there such as a tea houses or again damaged infections very purpose we have to look at pre and post irregular than first so them front and behind of the year before we fire the fish off at the back of the skull with our occipital lymph nodes so that completes our head neck learn that there is another set of lymph nodes which is very important this is the super curricular lymph nodes we've got our patients our shrug our shoulders up and forwards so you can push your fingers deep into the supercommittee la fossa there and to see if there is any swelling there this is very important because on the left side there is a lymph node that over house node which becomes infinite and large if we have problems with the lungs or the pancreas or the stomach and this is a very significant sign of how poor pathology potentially lung cancer for example having completed this when we do the general examination it's not only worthwhile to have your patient expose of the chest and we may see if there's any signs on the chest related to something like spider Niva which are wonderful well I said they're wonderful I like them because they're little /a blood vessels that when you press the center of them they will disappear and when you remove your finger they refill from the center outwards now they're not unusual in normal people so we do need to look at the front and the back of the chest and we can have up to 10 being considered to be normal that's quite important because they're also seen in pregnancy connected to that high levels of estrogen and that indicates what can be our perfo logical cause of that if we've got liver failure or anything else causing high levels of estrogen then we'll probably get more than our 10 spider neva present the last bit that we need to do with our general examination is check for peripheral edema that's done down at the ankle normally and you want to press in the medial or inside part of the ankle on the tibia with 10 millimeters of mercury that will be enough to turn the fingertips of your are what fingers white and will be enough to displace any fluid from inside the tissues outside leaving an indent which should then be able to feel with your fingers we complete our examination by reviewing any Bluffs any Bloods that the patient might have checking again any drugs that there might have brought with them and thanking our patient for their time today so that will complete our overall general examination as you can see it's about looking at the patient as an overall as an overall rather than examining one specific symptom it's one specific system which we'll do over the next few podcasts instead so I'll be very interested to know your feedback on this as it's the first try do you think this is being worthwhile you know is it something that you would want to listen to again or crucially other things that you want to change ultimately this is about creating a potential revision resource if there are things that will be better then please drop them in the comments below and I'll see if I can incorporate those into further podcasts