Download MBBS Final Year General Survey Notes

GENERAL SURVEY & EXAMINATION

---

GENERAL SURVEY

• Level of consciousness (whether alert, oriented and co-operative)

--- Content provided by‌ FirstRanker.com ---

• Apparent age (corroborative or not)
• Decubitus (position of patient in bed)
• Build (skeletal framework: average/dwarf/tall)
• Nutrition (nourishment of body: average/obese/undernutrition)
• Facies

--- Content provided by⁠ FirstRanker.com ---

• Pallor
• Cyanosis
• Clubbing
• Jaundice
• Oedema

--- Content provided by⁠ FirstRanker.com ---

• Neck vein
• Neck artery
• Lymph nodes
• Thyroid glands
• Skin, nails and hair

--- Content provided by‌ FirstRanker.com ---

• Pulse
• Respiration
• Temperature
• Blood pressure
• Any obvious deformity (of skull, spine, limbs)

--- Content provided by‌ FirstRanker.com ---

• Any abnormal movements (eg-tremor)

• It is the expressions in the face of the patient, and very often these facial signs collectively lead to prompt aetiological diagnosis of a disease.

Moon face: e.g. cushing's syndrome
prolonged steroid therapy

--- Content provided by‌ FirstRanker.com ---

nephrotic syndrome
acute glomerulonephritis
myxoedema
superior mediastinal syndrome
angioneurotic edema

--- Content provided by⁠ FirstRanker.com ---

obesity
Alassaemic/mongoloid/chipmunk facies:

1. frontal bossing
2. depressed bridge of nose
3. hypertelorism
4. apparent mongoloid slant of the eyes

--- Content provided by⁠ FirstRanker.com ---

5. malar prominence
6. dental malocclusion
7. mild icteric tinge of conjunctiva

Hepatic facies:

• Seen in chronic liver disease (e.g. cirrhosis of liver)

--- Content provided by‌ FirstRanker.com ---

1. shrunken eyes
2. hollowed temporal fossa
3. pinched up nose with malar prominence
4. parched lips
5. muddy complexion of skin (due to pallor, jaundice and melanosis)

--- Content provided by FirstRanker.com ---

6. shallow and dry face
7. icteric tinge of conjunctiva

Masked facies:

• Seen in parkinsonism

1. infrequent blinking and staring look

--- Content provided by FirstRanker.com ---

2. loss of facial expression
3. widened palpebral fissure

Anaemia

• Definition - qualitative or quantitative diminution of RBC and/or Hb concentration in relation to standard age and sex. It is clinically manifested by pallor.
• sites:
  1. lower palpebral conjunctiva

  --- Content provided by FirstRanker.com ---

  2. tongue (specially tip and dorsum)
  3. mucous membrane of soft palate
  4. nail beds
  5. palm, sole and general skin surface

--- Content provided by‍ FirstRanker.com ---

*earliest anaemia is noticed in the soft palate

• Clinical classification: Mild Anaemia 9-12 gm/dl
  moderate anaemia 6-9 gm/dl
  severe anaemia <6 gm/dl
  Normal Hb concentration in males and females:
  

  --- Content provided by⁠ FirstRanker.com ---

  Males-14.6 to 15.5 gm/dl
  Females-13.3 to 14.6

Causes of pallor without anaemia

• Peripheral circulatory failure (e.g.-low cardiac output in acute LVF) or shock or vasoconstriction due to any cause.
• Acute myocardial infarction

--- Content provided by⁠ FirstRanker.com ---

• Severe aortic stenosis or mitral stenosis
• Myxoedema
• Nephrotic syndrome
• Sheehan's syndrome or panhypopituitarism
• Vasovagal attack

--- Content provided by⁠ FirstRanker.com ---

• Oedematous skin (anasarca)
• Thick skin (scleroderma)

Jaundice

• Definition: yellowish discolouration of the skin and mucous membrane due to excess amount of bilirubin present in blood.
• Sites to be examined:
  1. upper bulbar conjunctiva

  --- Content provided by FirstRanker.com ---

  2. undersurface of tongue
  3. Mucous membrane of soft palate
  4. palm, sole
  5. General skin surface

--- Content provided by​ FirstRanker.com ---

*jaundice is always examined in bright natural daylight.
Clinical classification

• Classified as:
  1. haemolytic
  2. hepato-cellular
  3. obstructive
     1. intrahepatic
     2. extrahepatic

     --- Content provided by⁠ FirstRanker.com ---

• Normal serum bilirubin: 0.3-1.0 mg/dl
• latent jaundice: 1.0-3.0 mg/dl
• Clinical jaundice: >3.0 mg/dl

--- Content provided by​ FirstRanker.com ---

• Mild : <6 mg/dl
• Moderate: 6-15 mg/dl
• Severe: >15 mg/dl

Common causes of different types of jaundice

--- Content provided by‌ FirstRanker.com ---

A. Haemolytic:

1. thalassemia
2. mismatched blood transfusion
3. Rh incompatibility
4. snake bite (viperidae group)
5. malaria (falciparum malaria)

--- Content provided by FirstRanker.com ---

6. primaquine induced (in G6PD deficiency)

B. hepatocellular:

1. viral hepatitis
2. drugs (rifampicin, INH, halothane, paracetamol overdose)
3. copper sulphate poisoning
4. acute fatty liver of pregnancy

--- Content provided by‌ FirstRanker.com ---

5. cirrhosis of liver
6. weil's disease
7. Wilson's disease

• C. obstructive:

--- Content provided by‍ FirstRanker.com ---

Intrahepatic cholestasis:

1. cholestatic viral hepatitis
2. chronic active hepatitis
3. cirrhosis of liver (specially primary biliary cirrhosis)
4. lymphoma or tuberculosis
5. drugs-chlorpromazine, chlorpropamide, ocp, steroid

--- Content provided by⁠ FirstRanker.com ---

6. pregnancy in last trimester
7. secondary carcinoma of liver
8. dubin Johnson syndrome

Extrahepatic cholestasis:

1. gall stone impaction in CBD
2. carcinoma of the head of the pancreas, periampullary CA

--- Content provided by‍ FirstRanker.com ---

3. CA gallbladder
4. enlarged glands at porta hepatis
5. stricture of CBD
6. sclerosing cholangitis

--- Content provided by‍ FirstRanker.com ---

CLUBBING

• Definition- bulbous swelling of the terminal part of the finger and the toes with an increase in the soft tissue mass, increased antero- posterior and transverse diameter of the nail due to proliferation of subungual connective tissue, interstitial edema and dilatation of arterioles and capillaries.
• Examination of clubbing:
  1. observe onychodermal/lovibond angle (normal-160 degree). if the angle is more than 180 degree, clubbing is present
  2. check fluctuation of nail bed. it is increased in presence of clubbing due to softening of nail bed. (earliest sign)
  3. window sign/schamroth sign-obliteration of diamond shaped area formed between two nails and proximal nail folds.

--- Content provided by FirstRanker.com ---

1st degree: increased fluctuation of the nail bed
2nd degree: above+increase in antero-posterior and transverse diameter of the nails. nails become smooth and glossy with loss of longitudinal ridges.
3rd degree: above+ increased pulp tissue
4th degree: above + wrist and ankle swelling due to hypertrophic osteoarthropathy

--- Content provided by‌ FirstRanker.com ---

Causes of clubbing
A) Cardiac causes:

1. cyanotic congenital heart disease (e.g.-fallot's tetralogy)
2. subacute bacterial endocarditis
3. atrial myxoma
4. eisenmenger syndrome

--- Content provided by⁠ FirstRanker.com ---

5. primary pulmonary hypertension

B) Lung and pleural cause:

1. bronchiectasis
2. lung abscess
3. bronchogenic CA
4. empyema thoracis

--- Content provided by‍ FirstRanker.com ---

5. fibrosing alveolitis

1. pleural mesothelioma
2. pulmonary AV fistula
3. cystic fibrosis

--- Content provided by‌ FirstRanker.com ---

C) Ulcerative colitis
D) Billiary cirrhosis
E) Intestinal causes:

1. malabsorption syndrome
2. crohn's disease
3. polyposis coli

--- Content provided by FirstRanker.com ---

4. coeliac disease

F) Normal finding (idiopathic)
G) Genetic-familial
Cyanosis

• Definition - bluish discolouration of mucous membrane due to presence of increased amount of reduced Hb (>5gm/dl) or haemoglobin derivatives (sulphaemoglobin, methaemoglobin) in the capillary blood.
• Types:

--- Content provided by⁠ FirstRanker.com ---

1. Peripheral cyanosis:
blood leaves the heart containing normal level of reduced Hb but due to its stagnation in the peripheral circulation allows more time for oxygen extraction by tissues so raising the reduced Hb.
distribution-
a) tip of the nose
b) ear lobules

--- Content provided by​ FirstRanker.com ---

c) outer aspect of lip, chin, cheek
d) tip of fingers and toes
e) nail bed of fingers and toes
*tongue is not a site for peripheral cyanosis
a) exposure to cold air or water

--- Content provided by‍ FirstRanker.com ---

b) congestive cardiac failure
c) shock
d) Raynaud's phenomenon
e) peripheral vascular disease (atherosclerosis, burger's disease)
f) venous obstruction (SVC syndrome)

--- Content provided by‍ FirstRanker.com ---

g) hyperviscosity syndrome (multiple myeloma, polycythemia)
i) cryoglobulinemia
j) mitral stenosis
k) septicaemia
distribution: a) tongue (mainly margin and tip): reduced Hb.

--- Content provided by FirstRanker.com ---

b) inner aspect of lip
c) mucous membrane of gum, soft palate, cheeks)
d) lower palpebral conjunctiva
e) all the sites of peripheral cyanosis
causes:

--- Content provided by⁠ FirstRanker.com ---

a) cyanotic congenital heart disease (fallot's tetralogy, TGA)
b) acute pulmonary edema due to left sided heart failure)
c) eisenmenger syndrome
d) acute severe asthma
e) COPD

--- Content provided by⁠ FirstRanker.com ---

f) lobar pneumonia
g) fibrosing alveolitis
h) tension pneumothorax
i) acute pulmonary thromboembolism
j) acute laryngeal edema

--- Content provided by‌ FirstRanker.com ---

k) pulmonary AV fistula
l) high altitude
Oedema

• Definition - accumulation of excessive amount of tissue fluid in the subcutaneous tissue/serous sac due to increase in interstitial component of extracellular fluid resulting in swelling of tissue.
• Examination:

1. lower limb-apply firm pressure for few seconds over the medial malleolus, above the medial malleolus, medial surface of lower end of tibia, upper part of shin bone by tip of thumb. inspect and palpate the area for any dimple or pitting.

--- Content provided by FirstRanker.com ---

ambulatory patients develop edema on dependent sites.
2. back-turn the patient into prone position and press the tip of right thumb over sacrum. It is helpful in chronic bed bound patient.
3. parietal edema-_press the chest piece of stethoscope or tip of five fingers of right hand over abdominal parietis for few seconds.
Grades of edema
Grade 1-edema below ankle

--- Content provided by‌ FirstRanker.com ---

Grade 2-edema below knees
Grade 3-edema of thighs
Grade 4-generalised edema
Classification of oedema
1. Pitting edema:

--- Content provided by‍ FirstRanker.com ---

a) congestive cardiac failure
b) cirrhosis of liver
c) nephrotic syndrome
d) hypoproteinemia with severe anaemia
e) pericardial effusion

--- Content provided by‍ FirstRanker.com ---

f) constrictive pericarditis
g) drugs-amlodipine, corticosteroids, oestrogen
h) venous obstruction
i) beri beri
2. Non pitting edema:

--- Content provided by‍ FirstRanker.com ---

a) myxoedema
b) lymphatic edema (eg-filariasis)
c) angioneurotic edema
d) scleredema (post streptococcal)
e) scleroderma

--- Content provided by FirstRanker.com ---

Lymph nodes examination

• General principles:

-inspect for any visible lymphadenopathy
-palpate one side at a time
-compare the findings with contralateral side
-examine the cervical and axillary glands with the patient sitting

--- Content provided by‌ FirstRanker.com ---

-examine the inguinal and popliteal glands with the patient in supine position.
In lymphadenopathy points to be noted:
1. site, size, number
2. Discrete or matted
3. Tenderness

--- Content provided by FirstRanker.com ---

4. consistency (e.g.-soft in cold abscess, rubbery in Hodgkin's lymphoma, firm in syphilis, hard in malignancy)
5. Surface
6. Mobility
7. Rise of local temperature
8. Skin changes (sinus, peau d'orange, inflammation)

--- Content provided by⁠ FirstRanker.com ---

9. Lymphangitis
10. Draining area (e.g.-in epitrochlear lymphadenopathy examine the hand)
Causes of lymphadenopathy:
1. Generalised:
viral- EBV, CMV, HIV

--- Content provided by FirstRanker.com ---

Bacterial-brucellosis, syphilis
protozoal-toxoplasmosis
neoplastic-lymphoma, leukemia
others-RA, SLE, sarcoidosis
2. localised:

--- Content provided by​ FirstRanker.com ---

infective-most common
neoplastic-secondary metastasis, Hodgkin's lymphoma, non Hodgkin's lymphoma
a) from behind: examine the submental, submandibular, pre auricular, post auricular, tonsillar, supraclavicular, deep cervical, scalene nodes.
b) from the front: post auricular, occipital
Axillary glands: sit in front of the patient, supporting the arm of the patient on the side of examination. palpate the right axilla with the left hand and vice versa.

--- Content provided by‍ FirstRanker.com ---

Apical, central, anterior group: examine from front, using opposite hand
Lateral group: examine from front, using same hand as the patient's
Posterior group: examine from back, using same hand
Epitrochlear glands: while supporting the patient's right wrist with the left hand, grasp the patially flexed elbow with the right hand and use the thumb to feel for the epitrochlear gland.e
Examine the left epitrochlear gland with the left thumb.

--- Content provided by⁠ FirstRanker.com ---

Inguinal glands: palpate horizontal chain just below the inguinal ligament and vertical chain along the saphenous veins.
Popliteal glands: use both hands to examine the popliteal fossa with the knee flexed to less than 45°
Pulse

• It is expansion and elongation of the arterial wall imparted by the column of blood and is passively produced by the pressure changes during ventricular systole and diastole.
• Points to note:

1. Rate

--- Content provided by FirstRanker.com ---

2. rhythm
3. volume
4. condition of the arterial wall
5. radio-radial delay
6. radio-femoral delay

--- Content provided by​ FirstRanker.com ---

7. any special character
8. palpation of other peripheral pulses

• Examination:

* The radial pulse at the right wrist of the patient, present lateral to the flexor carpi radialis tendon, generally examined with the pulp of three fingers (index, middle, ring finger).
*Patient's forearm will be semipronated and the wrist slightly flexed.

--- Content provided by⁠ FirstRanker.com ---

*rate and rhythm are better palpated in the radial artery.
*volume and character better understand in carotid artery
1. Rate: normal 60-100/min
1. bradycardia HR <60
causes: physiological: elderly (due to SA node degeneration)

--- Content provided by⁠ FirstRanker.com ---

sleep (due to decreased adrenergic drive)
athletes (increased vagal discharge)
pathological: bradyarrhythmia
inferior wall AMI
hypothyroidism

--- Content provided by‌ FirstRanker.com ---

hypothermia
drugs (beta blockers, non DHP CCB, digoxin)
raised ICT (cushing reflex)
obstructive jaundice
Relative bradycardia: heart rate does not increase in proportion to temperature. it is also called faget's sign.

--- Content provided by‍ FirstRanker.com ---

normally for every 1°C rise in temperature from baseline, HR increased by 15-20/min.
for every 1°F rise, HR increased by 10/min
Causes:
infectious: typhoid
brucella

--- Content provided by‌ FirstRanker.com ---

viral fever
legionella
non infectious: drug induced fever
factitious fever
fraudulent fever

--- Content provided by​ FirstRanker.com ---

• Tachycardia: HR >100/min

causes: physiological: infants
anxiety
exercise
pathological: tachyarrhythmia

--- Content provided by FirstRanker.com ---

anterior wall AMI
hyperthyroidism
fever, heperthermia, hyperpyrexia
drugs (beta agonist, DHP CCB, thyroxin overdose, theophylline)
2. Rhythm: normally there is fixed interval between consecutive beats-regular rhytm.

• Sinus arrhythmia:

--- Content provided by⁠ FirstRanker.com ---

-pulse interval changes with respiration.
-It is predictable variation
-HR increases with inspiration, HR decreases with expiration
Irregular rhythm-commonly seen in AF
3. volume: it reflects the width of pulse pressure.

--- Content provided by​ FirstRanker.com ---

normal level= (SBP-DBP)= (30-60)mm of Hg
a) low volume: called as thready pulse (<30 mm of Hg)
seen in shock (hypovolemic, cardiogenic)
b) high volume: called as bounding pulse (>60 mm of Hg)
seen in AR, MR, PDA, Pregnancy, hyperthyroidism, anaemia, AV fistula, paget's disease, beri beri

--- Content provided by‍ FirstRanker.com ---

Percussion wave- due to isovolumetric contraction
Anacrotic notch- due to opening of semilunar valves
Tidal wave- ejection phase, amplitude depends on cardiac output
Dicrotic notch- due to closure of semilunar valve
4. character

--- Content provided by‍ FirstRanker.com ---

a) Anacrotic pulse: low volume pulse with an upstroke felt in the ascending limb of pulse wave.
e.g.-severe valvular aortic stenosis. it is known as pulsus parvus et tardus (slow rising low volume pulse)
b) Dicrotic pulse: upstroke felt in the descending limb of the pulse wave.
e.g.-hypovolemic shock
c) Pulsus bisferiens: two peaks in systole.

--- Content provided by⁠ FirstRanker.com ---

e.g.-combined AR and AS
severe AR
d) Pulsus alternans: regular alteration of pulse amplitude at same interval.
e.g.- LVF
e) Pulsus bigeminus: two beats and a pause occur repeatedly in regular fashion.

--- Content provided by‍ FirstRanker.com ---

e.g.-digitalis toxicity
f) Pulsus paradoxus: normally (SBPexp -SBPinsp ) =0 to 10 mm of Hg
if this difference is >10 mm of Hg it is pulsus paradoxus.
mechanism: due to decrease in SVR more than physiological limit. it occurs due to LV filling decreases during inspiratory phase more than physiological limit.
Causes of pulsus paradoxus: cardiac tamponade

--- Content provided by FirstRanker.com ---

constrictive pericarditis
restrictive cardiomyopathy
acute severe asthma/COPD
pulmonary thromboembolism
SVC syndrome

--- Content provided by​ FirstRanker.com ---

g) Water hammer pulse: it is characterised by-high volume
sharp rise
ill sustained
sharp fall
cause: AR (most common)

--- Content provided by​ FirstRanker.com ---

PDA
systolic HTN
fever
pregnancy
anaemia

--- Content provided by FirstRanker.com ---

beri beri
thyrotoxicosis
AV fistula
paget's disease
Demonstration of water hammer pulse

--- Content provided by FirstRanker.com ---

palpate the wrist in such a way that webs of palm fell on the radial artery and rest of the palm lies over the ulner artery.
Examine the volume of the pulse for few seconds.
Now elevate the whole upper limb suddenly above the level of the heart.
Try to recognise any changes in the volume of the pulse.
-radial delay: normal anatomical variation

--- Content provided by‌ FirstRanker.com ---

thoracic inlet syndrome
aneurysm of the arch of aorta
pre-subclavian coarctation
supravalvular aortic stenosis
takayasu disease

--- Content provided by​ FirstRanker.com ---

6. Radio-femoral delay: coarctation of aorta
atherosclerosis of aorta
thrombosis or embolism of aorta
aortoarteritis
7. Other peripheral pulses: carotid artery

--- Content provided by​ FirstRanker.com ---

brachial artery
femoral artery
popliteal artery
posterior tibial artery
arteria dorsalis paedis

--- Content provided by​ FirstRanker.com ---

8. Condition of arterial wall: normally the arterial wall is impalpable and may be palpable in old age due to arteriosclerosis.
Temperature

• Normal: 98°F-99°F( with diurnal variation of 1°F)
• Subnormal: below 98°F
• Hypothermia: below 95°F
• Pyrexia/febrile: oral AM temperature >98.9°F, oral PM temperature >99.9°F

--- Content provided by FirstRanker.com ---

• Hyperpyrexia: above 106.7 °F
• Types of fever

1. intermittent: fever is always present only for several hours and always touches the baseline sometime during the day. it has three sub division.
a) quotidian: daily rise and daily fall
-UTI

--- Content provided by‌ FirstRanker.com ---

-TB
-septicaemia
-amoebic liver abscess
b) tertian: the paroxysm occurs on alternate days.
1. benign tertian malaria (P.vivax, P.ovale)

--- Content provided by‍ FirstRanker.com ---

2. malignant tertian malaria (P.falciparum)
C) quartan paroxysm of attack occurs at two days interval
e.g.-P. malariae
2. continued: fever does not fluctuate more than 1 °C (1.5° F) during the 24 hours period. it never touches base line.
a) lobar pneumonia

--- Content provided by‍ FirstRanker.com ---

b) second week of enteric fever
c) milliary TB
d) meningococcal meningitis
e) ARF
f) Collagen vascular disease

--- Content provided by​ FirstRanker.com ---

3. remittent: daily fluctuation of fever is more than 2 °C (3° F) during the 24 hours period. it never touches baseline.
a) third week of enteric fever
b) acute broncho pneumonia
c) acute tonsillitis
d) amoebic liver abscess

--- Content provided by‌ FirstRanker.com ---

e) bacteraemia, septicaemia, pyemia
Neck vein

• Examination:

• Always examine internal jugular vein. it is in direct continuity with the right atrium and reflects the pressure changes in the right atrium as well as CVP.
• The patient should be reclining supine at 45°
• Neck muscle should be relaxed properly

--- Content provided by FirstRanker.com ---

• Tangential light application is better to visualise the wave.
• It is better to examine right sided vein.
• Stand on the right side of the patient and turn patient's face slightly to the left.
• Look in between two heads of sternocleidomastoid muscle, and if it seems full, observe uppermost point of distension.

--- Content provided by​ FirstRanker.com ---

• Characteristics of venous pulsation:

1. wavy
2. better seen than felt
3. becomes prominent on expiration, on lying down, on application of abdominal pressure (hepato jugular reflux)
4. can be abolished by gentle digital pressure applied above the clavicle.

--- Content provided by‍ FirstRanker.com ---

5. it has definite upper level.
6. pulsatile displacement of ear lobes in high CVP
7. Becomes prominent on valsalva manoeuvre
a wave- produced due to effective and synchronised contraction of right atrium
c wave- isovolumetric contraction of right ventricle.

--- Content provided by⁠ FirstRanker.com ---

tricuspid valve bulge into the right atrium due to increased pressure.
x wave- ejection phase
v wave -due to venous return in right atrium.
isovolumetric relaxation also occurs here.
y wave- due to early filling phase of diastole.

--- Content provided by‌ FirstRanker.com ---

Causes of increased JVP:
Engorged and pulsatile:
1. congestive cardiac failure
2. chronic constrictive pericarditis
3. cardiac tamponade

--- Content provided by‌ FirstRanker.com ---

4 TI and TS
5. restrictive cardiomyopathy
Engorged and non pulsatile: superior mediastinal syndrome
hepato jugular reflux: patient reclining at 45° firm pressure is applied over right hypochondrium for 10 sec sustained rise of >3cm in JVP for at least 15 sec
importance: -to diagnose incipient right heart failure

--- Content provided by‍ FirstRanker.com ---

-to differentiate between arterial and venous pulsation
-to differentiate between obstructive and non-obstructive causes of engorged neck vein.

• Waves of JVP:

• Absent 'a' wave: in atrial fibrillation
• Large 'a' wave: TS, RVH, RVF

--- Content provided by‍ FirstRanker.com ---

• Canon 'a' wave: SA node arrest, complete AV block
• Absent 'x'descent: TR, AF
• Deep' x' descent: cardiac tamponade
  constrictive pericarditis
  restrictive cardiomyopathy

--- Content provided by‌ FirstRanker.com ---

Absent/low 'v' wave: SVC obstruction
Large' v' wave: constrictive pericarditis
restrictive cardiomyopathy
TR
AF

--- Content provided by​ FirstRanker.com ---

Rapid 'y' descent: constrictive pericarditis
Slow 'y' descent: TS, RVH, RVF
Absent 'y' descent: collapsed RV due to cardiac tamponade

• Kussmaul sign:

Normally JVP decreases during inspiration. but if JVP rises during inspiration due to failed relaxation of right atrium it is called kussmaul sign.

--- Content provided by⁠ FirstRanker.com ---

causes: constrictive pericarditis
restrictive cardiomyopathy
severe TS
RVF