CSL MED - General

CSL MED - General
Mon 19 Aug 2002

Dr Adrian Wu

Suppl. With Talley (Chap 2)

Hx before P/E ® helps narrow down P/E

P/E before Hx ® doesn't allow Hx to bias examiner

Examine Pt from R-side of bed

General appearance

Face, hands, body

Elements of P/E: Inspection, Palpation, Percussion, Auscultation (Function, Measuring)

FIRST IMPRESSIONS

How sick does the Pt appear?

VITAL SIGNS

CV + RS ® pulse, BP, Temp, Resp rate

FACIES

Erythema, Jaundice, Pallor
Tanned

Diagnostic facies

Acromegalic ® large supraorbital ridge (+ frontal bossing), thickened lips, enlarge tongue, lower jaw firm + square (protruding jaw = prognathism)

Cushingoid ® plethora, moon-shape, telangiectasia, supraclavicular fat pads

Down syndrome ® oblique orbital fissures, conjunctivitis, Brushfield spots on iris, small simple ears, flat nasal bridge, mouth hanging open, protruding tongue, narrow high-arched palate

Hippocratic (advanced peritonitis) ® sunken eyes, collapsed temples, pinched nose, lips crusted, clammy forehead

Marfanoid ® high-arched palate

Mitral ® rosy cheeks with a bluish tinge (dilatation of malar capillaries) - assoc. with pulmonary HT and lower CO

Myopathic

Myotonic ® partial ptosis, cataracts, subcapsular fine deposits, temporalis atrophy, baldness, triangular facies, SCM atrophy (weak neck flexion)

Myxoedematous ® skin generally thickened, alopecia, periorbital oedema, xanthelasma, coolness and dryness of skin and hair, thinning of scalp hair, tongue swelling

Pagetic ® enlarged frontal + parietal areas, prominent skull veins, bony warmth, systolic bruits, angioid streaks, optic atrophy, short neck, low hairline, head held in extension

Parkinsonian ® mask-like, titubation (tremor) of head, absence of blinking, dribbling of saliva, weakness of upward gaze, seborrhoea + sweatiness (ANS dysfunction)

Ricketic ® frontal bossing, parietal flattening

Thyrotoxic ® frightened facies (thyroid stare), lid retraction (sclera visible above iris), lid lag, exophthalmos (protrusion of eyeball from orbit), complications of ptosis (chemosis - oedema of conjunctiva + injection of sclera; conjunctivitis; corneal ulceration; optic atrophy - rare; opthlmoplegia - weakened IR muscle),

Turner's syndrome ® micrognathia (small chin), epicanthic folds, ptosis, fish-like mouth, deformed or low-set ears, hearing loss, neck webbing, low hairline, redundant skinfolds on back of neck

Virile facies ® frontal hair recession, deepening of voice, hair over beard area

Jaundice

BR esp. deposited in elastin-rich tissues (eg. Sclerae)

Jaundice is the only condition causing yellow sclerae

Causes of jaundice: haemolytic anaemia (pale lemon yellow), obstructed bile flow from liver (dark yellow / orange), hepatocellular failure
Maybe with scratch marks due to assoc. pruritis

Cyanosis

Blue discoloration of skin + mucous membranes (deoxy Hb in superficial BV)

Central cyanosis: abn amt de-oxy Hb in arteries (blue discoloration in part with good circulation - eg. Tongue)

¯ Arterial oxygen saturation: ¯ concentration of inspired oxygen (eg. Altitude), lung disease (eg. COPD), R® L cardiac shunt (eg. Cyanotic congenital heart disease)

Polycythaemia

Hb abn (rare): metHbaemia, sulpHbaemia

Peripheral cyanosis: blood supply diverted from one part to another (eg. Cold weather - lips blue, tongue spared)

All causes of central cyanosis cause peripheral cyanosis

Exposure to cold

¯ CO (eg. LV failure, shock)

A or V obstruction

Pallor

Anaemia: deficiency of Hb (pallor = sign; anaemia = based on lab)

Shock

Hypovolaemic: ext. fluid loss, sequestration of fluid to ab (ascites), chest (haemothorax), limbs (#)

Cardiac: pump failure, cardiac tamponade, dissecting aortic aneurysm, arrhythmia

Massive pul embolus

Sepsis (endotoxin)

Anaphylaxis

Endocrine failure: adrenal failure, hypothyroidism

Neuropathic: drugs (anti-HT, anaesthesia), SC inj of autonomic neuropathy

Normal variant ® deep lying veins + opaque skin

Hair

Bearded / bald women
Hairless men

Eyes

Ptosis: Horner's syndrome (most common cause ca lung)

Xanthoma: cholesterol deposit on eyelid

Eyebrow: not present in hypothyroidism

Colour of sclera: jaundice (BR elevated significantly before detectable clinically)

Retina: eg. In HT

AV nipping (crossing of artery with vein, there is narrowing; due to press effect of HT

Hard exudates (remnant of fluid exudation from BV)

Soft exudates: cotton wool spots = infarcts (ischaemia of part of retina due to obliteration of blood supply due to high BP)

Haemorrhage (rupture of BV; flame-shaped haemorrhages)

Papilloedema (indistinct optic disc).

Can also see DM changes in the eye

Fundoscopy: indicated in ® raised ICP (emergency);

WEIGHT, BODY HABITUS, POSTURE

Obesity: BMI > 30 = frank obesity
Cachexia: BMI < 20

Body habitus syndromes

Endocrine

Acromegaly ® molluscum fibrosum (skin tags at axillae), acanthosis nigricans, coarse body hair, gynaecomastia, kyphosis, OA in hip and knees

Cushing's syndrome ® central obesity, proximal myopathy, buffalo hump

Hypopituitarism ® skin pallor, ¯ nipple pigmentation, decreased body hair (men), secondary breast atrophy (women), loss of pubic hair

Psuedohypoparathyroidism ® short stature, round face, short neck, thin stocky build

Rickets ® bowing of radius/ulna and femur/tibia, 'rickety rosary' - thickening of costochondral junctions, Harrison's groove - indentation of lower ribs at diaphragmatic attachment

Paget's disease ® short stature (bending of long bones), kyphosis (vertebral involvement causing collapse of vertebral bodies), anterior bowing of tibia, lateral bowing of femurs

Musculoskeletal

Marfan's syndrome ® tall stature, thoracic kyphosis, pectus ecavatum, arachnydactyly (spider fingers), long limbs

Turner's syndrome ® increased carrying angle, lymphoedema of hands and feet, shield-like chest (widely spaced nipples)

Klinefelter's syndrome ® tall and thin, small firm testes, sexual ambiguity

Achondroplasia ® AD disease of cartilage ® short stature, short limbs, normal trunk, large head, XS lumbar lordosis, SC compression

Wasting of muscles

Neurological
Debilitating disease (eg. Malignancy)

XS short / tall stature

Limbs deformed or missing

Physique consistent with chronological age

Gait

HYDRATION

Dehydration (based on 70kg man)

Mild (<5%) = 2.5L lost ® mild thirst, dry mucous membrane, concentrated urine

Moderate (5-8%) = 4L lost ® also moderate thirst, ¯ skin turgor (arms, forehead, chest, ab), tachycardia

Severe (9-12%) = 6L ® also great thirst, ¯ eyeball pressure, collapsed veins, sunken eyes, gaunt face, postural hT, oliguria (< 400mL urine / 24hr)

Very severe (>12%) = >6L lost ® also comatose, moribund, signs of shock

Intravascular volume overload ® jugular venous pressure

HANDS

Dystrophia myotonica (rare): Pt unable to let go after shaking hands

Nail changes ® CVS + RS disease

Acromegaly ® size of hand

Arthritis ® gross distortion of hands' architecture

Neuro disease ® tremor, muscle wasting

Anaemia ® pallor of palmar creases

Muscles of hand: hypothenar + thenar eminence wasting?

Condition of skin

Sweaty palm: hyperthyroid? Nervous?

Thick calluses: manual labourer? Mechanics hands (eg. CT disease): look like labourers hands (rough) but Pt is not a labourer

Nails

Blue nails ® cyanosis, Wilson's disease, ochronosis

Red nails ® polycythaemia (red-blue), CO poisoning (cherry red)

Yellow nails ® yellow nail syndrome

Clubbing ® ca lung, chronic pulmonary suppuration, IE, cyanotic heart disease, congenital

Splinter haemorrhages ® IE, vaculities, systemic sclerosis (thin skin at nail bed, dilated BV visible)

Koilonychia (spoon-shaped) ® Fe deficiency, fungal infection, Raynaud's

Pale nail bed ® anaemia

Onycholysis ® thyrotoxicosis, psoriasis

Non-pigmented transverse bands (Beau's lines) ® fever, cachexia, malnutrition

Leuconychia (white nails) ® hypoalbuminaemia

Transverse opaque white bands (Muehrcke's lines) ® hypoalbuminaemia, chemo, severe illness

Single transverse white band (Mees' lines) ® arsenic poisoning, renal failure, chemo, severe illness

Nailfold erythema + telangiectasia ® SLE

Half and half nails (Terry's nails) (proximal portion white/pink, distal portion red/brown) ® CRF, cirrhosis

Finger clubbing

4 categories
Look at angle of nailbed (should be convex)
Angle may be flat or concave in Pt's with finger clubbing
Can be congenital
Categories of causes

Suppurative or infection within thorax: bronchiecstasis, abscess, IE. Chronic bronchitis does NOT lead to finger clubbing (CB is in aw not lung parenchyma)
Malignancy within chest: bronchogenic carcinoma, malignant mesothelioma (pleura)
GIT: UC, IBD (uncommon in Chinese), liver disease
Thyroid acropatchy (hyperthyroidism): looks like finger clubbing

Jts of hand

RA: ulnar deviation. Affects MCPJ + PIPJ, esp. thumb
OA: classically affects DIPJ first
Gouty arthritis: difficult to distinguish between this and RA (both inflammatory). Gouty tophi: over jts - white deposits of uric acid in ST. Skin ulcerates and uric acid comes out, looks like bird droppings
SLE

TEMPERATURE

Normal: mouth 36.8; axilla 36.4; rectum 37.3 (Celsius)

Fever: mouth > 37.3; rectum > 37.7 (Celsius)

Diurnal variation: ¯ in morning, between 6-10pm

Pattern of pyrexia (fever)

Continued, does not remit ® typhoid fever, typhus, drug fever, malignant hyperthermia

Intermittent, falls to norm each day ® pyogenic infection, lymphoma, miliary TB

Remittent, daily fluctuation > 2 deg, does not return to norm ® not char of any disease

Relapsing, ret to norm for days before rising again

Malaria: (1) Plasmodium vivax/ovale: 3d pattern peaking every other day (2) P malariae: 4d pattern fever, fever peaks every 3^rd day
Lymphoma: Pel-Obstein fever of Hodgkin's disease (v rare)
Pyogenic infection

Hyperpyrexia (> 41.6 deg C)

Exposure

Exertion (excessive)

Malignant hyperthermia ® genetically-determined; response to anaesthetic (halothane), m relaxant (suxamethonium)

Neuroleptic malignant syndrome

Hypothalamic disease

Hypothermia (< 35 deg C): need special thermometer

Hypothyroidism

Exposure to cold (prolonged)

SMELL

Liver failure ® sweet breath

Smokers ® stale smell (clothes, referral letter)

NECK

Goitre

2 hands from back of Pt ® thyroid between thyroid cartilage and cricoid cartilage

Size, smooth/nodularity, symmetry, firmness, moves with swallowing (if it doesn't, it is not a goitre)

Graves disease: Ab stimulate thyroid gland: symmetrical enlargement of thyroid which is smooth

Thyroid ca: asymmetrical, different consistency (firmer)

Chronic thyroiditis leading to fibrosis (or metastasis to thyroid): thyroid is hard

Cysts

Thyroglossal cyst: in midline, moves with tongue (remnant of thyroglossal duct)

Scar

Supraclavicular
Ant triangle
Border of SCM
Submandibular
Submental
Auricular
Occipital
Post triangle