SCHEME OF CLINICAL EXAMINATION.pptx

SCHEME OF CLINICAL EXAMINATION Dr. weam Aribi Pediatric specialist Faculty of Medicine Clinical skills instructor. International Maaref University  Preparation for examination Privacy  Attendant  Room temperature and your hands temperature  light  Bed or examination couch  Position for examina...

SCHEME OF CLINICAL EXAMINATION Dr. weam Aribi Pediatric specialist Faculty of Medicine Clinical skills instructor. International Maaref University  Preparation for examination Privacy  Attendant  Room temperature and your hands temperature  light  Bed or examination couch  Position for examination  Tools for examination  Hygiene of your hands and hand wash ( infection control)  Exposure  ( Unless you uncover you will not discover )  General principles of examination.  Use the standard text books routine for clinical examination  You have to practice clinical examination on as many cases as you can. “ repetition is the secret of learning “  After history taking you should have formed an idea about the differential diagnosis or possible diagnosis, so your examination is not done as a routine examination only but try to:  Confirm or refuse the suspected diagnosis  If the diagnosis is confirmed try to find : - Any cause for the diagnosis - Any complication from the diagnosis  General principles of examination ( cont.)  Examination starts from the moment the patient walks in the room or the moment, you have seen the patient  During history taking you can make a lot of observations vital to the clinical examination like:  Memory Intelligence Behavior and attitude and mood  Speech  General appearance  Any special features or deformities   Methodology of examination Greeting of the patient. Introduce yourself. Explain to the patient what you want to do ,take verbal consent. Follow the principles of examination  Inspection  Palpation  Percussion  Auscultation  Any special tests  Do general examination  Examine the affected system or systems or regions of the body CVS, RS, nervous system, abdomen, skin, musclo skeletal systems  Examine the other body systems : Treat the patient as a whole, not treating the part of the body according to your specialty)  The general examination A- General inspection of the patient Level of consciousness  Mental and emotional states  General fascial appearance or fascial look and expression  Abnormal movements , odors and sounds  Attitude position and skeletal deformities  Skin color  Built, distribution of body fat and state of nutrition  Assessment of hydration  B- Vital signs C- Examination of head and neck in detail D- Examination of the hands E- Examination of legs F- Examination of lymph nodes  General inspection of the patient ( cont.) Consciousness level - If altered consciousness - Glasgow coma scale  Mental and emotional status - Attention and concentration - Orientation - Memory - Intelligence If any abnormality carry out the mini or abbreviated mental state examination - Any mood changes Mood means how the patient see and his perception of the world - Cooperation and understanding  General inspection of the patient ( cont. )  Facial appearance look and expression - Certain facial appearances are typical of certain diseases - Moon face in Cushing's syndrome, Acromegally, scleroderma, Down’s syndrome, cretinism, parkinsonism, and hypothyrodism - Facial expression - Anxious patient - Patient in pain - Poverty of expression and apathic in depression Abnormal movements, Odors and sounds All these signs can be observed during history taking  Involuntary movements with extra pyramidal system - Twitching and jerks of the muscles - Tremor of the hands  Odours - Odor of skin sweating may indicate self neglect and poor body hygiene - Smell of urine and faeces many indicate incontinence - Fetor hepaticus in liver failure - Smell of acetone in diabetic keto acidosis - Smell of gangrene and dead and necrotic tissue - Smell of alcohol and tobacco - Smell of other drugs - Halitosis or bad breath  Sounds - Wheezing - Stridor - Hoarsness of voice - Speech abnormalities  Attitude, position gait and deformities  Attitude - Patients may take special position depending on their medical condition - May be restless and rolling with severe colicky pain - Lying still as in peritonitis - Leaning forward as in pancreatitis - May prefer to sit on one or lie on one side  Some deformities may be typical and obvious - Tall or short stature - Paget’s disease of bone - Acromegally - Marfan’s syndrome - Achondroplasia  General inspection of the patient ( cont.)  Skin color and pigmentation, change in skin color may be obvious and typical of certain medical conditions - Pallor - Cyanosis - Yellow discoloration Jaundice and hyper carotenaemia - Purple color In polycythemia - White discoloration Albinism, vitiligo - Brown pigmentation Addison's disease Haemo chromatosis Gaucher’s disease  General inspection ( cont. )  Built, state if nutrition and distribution of body fat: general impression about the built Wasting or cachectic Underweight  Average weight  Over weight  Obese  But this estimations are not very accurate better to calculate the body mass index ( BMI) BMI = Weight in Kg ( Height in cm )2 Under weight < 18.5 Normal 18.5 – 24.9 Overweight 25 – 29.9 Obese 30 – 39.9 Morbid obesity > 40  Measurement of waist / hip ratio   General assessment ( cont )  Assessment of hydration  Asses degree of dehydration      skin turgor(elasticity). Tongue and mucous membranes Pulses and blood pressure Level of consciousness Fontanelle in babies Vital signs  Pulse Blood pressure Temperature Respiratory rate Examination of the pulse - Place the three middle fingers of the right hand over the radial pulse of the patient’s right hand - Assess - The rate - normal rate in adults 60 -90 beats per minutes - Rhythm - Volume - Character - Synchronicity   Vital signs ( cont. )  Blood pressure  Use of sphygmomanometer or electronic devices  Cuff size in adults at least 12 cm wide and 30-35 cm long  Explain to the patient what you want to do  Make the patient as comfortable as possible  Normal blood pressure - 120/70 mm Hg in adults  Temperature Sites of measuring temperature  Mouth  Axilla add 0.5 C0  Rectum - minus 0.5 C0  External auditory meatus Use either - Mercury thermometers - Electronic thermometers Normal temperature 35. 8 C0 to 37.2 C0 Hypothermia - < 35 C0 Hyperthermia - > 40.1 C0 Fever if temperature > 37. 2 C0 Respiratory rate - Note rate and pattern of breathing - Count the rate by observing the chest movements tachypnea if rate > 15 cycles / minute  Examination of the head and neck  Examination of scalp and skull  Size and shape hydrocephalus , microcephally etc…  Hair  Any swelling - Sebaceous cysts, osteomas, etc.. - Feel Fontanelle and sutures in babies  Examine ears - Shape, size, extra ears, discharge sinuses  Eyes - Shape Pallor Jaundice Xantholasmas and arcus senalis Eye movements  Nose - Shape , discharge  Examination of the head and neck ( cont.)  Mouth  Lips - Cyanosis, ulcers, angular stomatitis pigmentation  Tongue -  cyanosis pallor Dryness Size of tongue Ulcers Movements and any deviation swelling Teeth - loss of teeth, artificial teeth and dentures - Any septic foci , dental hygiene  Examination of the head and neck ( cont.) Oral mucosa - any swellings - Orifices of parotid and submandibular glands - Dryness  Soft and hard palate - Clift palate and perforation - Any swelling  Tonsils and oropharynx  Face - Any deformity - Color – pallor, malar flush , plethora and pigmentation - Any ulcers or sinuses - Any swelling    Examination of the head and neck ( cont.) Neck - Swelling - Thyroid - Nodes  Engorged neck veins  Pulsations  Ulcers, sinuses and fistulae  -  Examination of the hands  Quick examination of the hands is done and if abnormity is detected a more detailed examination is carried out. - Inspect both hand surfaces - palpation - Examination of nails - Examination of the circulation - Examination of the nerves  Inspection of the hands Shape, size, color of hands and if any deformities - Number of fingers, shape , deformities and swellings Color of the hand - Pallor - Cyanosis - palmer erythema - Staining  Muscle wasting  Sinuses , scares, ulcers  Examination of the hands ( cont. )  Palpation of the hand - Temperature - Tenderness - Sweating or dryness - Any thickening or nodules  Examination of nails - Color - Shape - koilonychia “ spoon shaped’ - Leukonychia “ white nails “ - Bean’s lines Transverse white lines associated with severe systemic disease  Examination of the hands ( cont. ) - Clubbing of nails - Cardiac cause congenital cyanotic heart disease infective endocarditis - Respiratory - Gastro intestinal - liver inflammatory bowel - Examination of circulation - Examination of nerves - Tremor - muscle movements - Sensations  Examination of the legs Inspection - Swelling – if unilateral or bilateral if localized or generalized - Color of the limbs - Deformities - Scars and sinuses - Nails - Ulcers - Count the toes , inspect the area between the toes - Any varicosities  Palpation - Temperature - Look for oedema - Assess the circulation - Capillary refill test - Pedal pulses Examination of the lymph nodes Cervical nodes  Axillary nodes  Inguinal nodes  Cervical nodes  Circular group - sub mental - Sub mandibular - Pre auricular - Past auricular - Occipital  Vertical group - upper deep cervical - Middle deep cervical - Lower deep cervical  Supra clavicular, Virchow’s node if enlarged the sign is called Troisier’s sign  Superficial cervical in posterior triangle   The sloan catering memorial hospital classification Level Level Level Level Level Level I - Sub mental and submandibular II – Upper deep cervical III - Middle deep cervical IV – Lower deep cervical V - Posterior triangle node VI – Central nodes, paratracheal and laryngeal