Clinical medicine – General Examination 1 General Examination 1. Over view: 1. Over view: a. Built: i. Heightإذا ضمُرك ىم َسمح ىل باىقىه أوه طبُعٍ, فيدَل واحد مه اثىُه Dwarfism or Gigantism ii. Weight اىمُزان هى اىحنم وىنه مه خاله اىىظر إذا ضمُرك ىم َسمح ىل باىقىه أوه :طبُعٍ فيدَل واحد مه اثىُه Underweight or Overweight b. Decubitus: i. Dorsal recumbent position: normal ii. Semi-sitting (orthopenic) position: in 1. LSHF 2. Emphysema 3. Tense ascites 4. Mediastinal syndrome: any mass. iii. Lateral decubitus: 1. Lung abscess 2. Pleurisy 3. Extensive unilateral lung disease (pleural effusion, tension pneumothorax). iv. Kneeling (prayer) position = leaning forwards in: 1. Pericarditis 2. Pericardial effusion 3. Pancreatitis 4. Mediastinal syndrome v. Squatting position: in Fallot’s tetralogy: 1. VSD 2. Overriding of aorta 3. Infundibular pulmonary stenosis 4. Right ventricular hypertrophy c. Mental Function: i. Consciousness: causes of decreased consiousness: Intracranial. Extracranial: 1. Diabetic keto-acidosis (acetone odor, dry tongue, D.M. history). 2. Hypoglycemic coma مثو اىرٌ َرمض 3. CO2 Narcosis→ renal failure. 4. Electrolyte imbalance → arrhythmia. 5. Hepatic encephalopathy ii. Behavior iii. Orientation (to time, place and persons) iv. Mood v. Memory vi. Intelligence Clinical medicine – General Examination 2 N.B.: Normally in the examination, we say:” The patient is average in built, lies comfortably in bed in dorsal recumbent position, fully conscious, cooperative, well oriented to time, place and persons, with good mood and memory, and of average intelligence”. N.B.: In your exam.: Chest case → blue → CO2 narcosis →Renal Failure. Abdomen case → yellowish → hepatic encephalopathy → Liver Failure 2. Vital Signs: ((Puullssee+BP+RR+TTeemppeerraattuurree)) 2. Vital Signs: P +BP+RR+ m a) Pulse: Rate: using your watch. If regular→ 15 seconds then x 4. If irregular or bradycardia→ complete minute. N.B: Pulse deficit= apical pulse ( – )باىسماعتradial pulse ()باىُد If < 10 → occasional. If > 10 → marked. SAN rate = 150 impulse/min. Parasympathetic system takes the upper hand, so normal HR: 60-100 beat/min Bradycardia < 60 Tachycardia > 100 Sinus bradycardia (SAN): 50-60 Sinus tachycardia (SAN): 100-150 Escape junctional or nodal (AVN): 30-50 Paroxysmal (not SAN)> 150 أٌ وقطت تقىي فترة ثم ٍتختف Ventricular. Supraventricular. Heart block 20-30 Rapid AF. Complete heart block with escape idioventricular rhythm Rhythm: Regular Irregular: Regular irregularity Irregular irregularity Due to monofocal premature Occasional Marked beats (extrasystoles) Pulse deficit < 10 >10 In digitalis toxicity You can count 4 Can’t successive regular beats E.g.: Pulsus Bigeminus e.g.: Multifocal premature Rapid AF beats (multifocal Pulsus Trigeminus extrasystoles) Volume: Pulse pressure= systolic Pressure – Diastolic Pressure Normally 30-50 mmHg. Big Pulse volume > 50 mmHg Small Pulse Volume < 30 mmHg. Causes of Big Pulse Volume: 1. ↑↑↑ systolic /↑diastolic: Systemic hypertension. Clinical medicine – General Examination 3 2. ↑↑ systolic / normal diastolic: d. Anemia a. Thyrotoxicosis. 4. Normal systolic /↓↓↓ diastolic: b. Aortic atherosclerosis. a. PDA 3. ↑↑↑ systolic /↓↓↓ diastolic: b. A-V fistula a. AR c. Pregnancy b. PDA d. VD therapy c. Severe bradycardia with e. Beri-Beri complete HB. f. Paget’s disease N.B.: All of the above are causes of hyper-dynamic circulation except AR and systemic hypertension. Causes of small pulse volume: 2. ↓ Pumping: 1. ↓ Filling: Cardiomyopathy Constrictive pericarditis Myocarditis Pericardial effusion Myocardial Infarction Severe tachycardia 3. Obstruction: Hypo-volemia Any valve stenosis (MS, TS, AS, PS). Irregular Pulse Volume: (In irregular rhythm) Pulsus alternans( :)وحدة قىَت واألخري ضعُفتin severe LVF, the diseased fibres have longer REFRACTORY period, so: o An impulse stimulates the normal fibres only →weak contraction. o The next impulse stimulate normal + diseased fibres → stronger contraction. Pulsus Paradoxicus( :)تختفٍ مع اىىفسcauses: o COPD o Pericardial effusion inspiration o Constrictive pericarditis. Normally, with inspiration: o Lung is congested with blood o ↑↑ VR to right sided heart o ↓↓ Blood reaching left side. o ↓ C.O. o ↓ Pulse volume. Pulsus paradoxicus is an exaggeration of the normal criteria: The above causes affect the relaxation of R.V. more than LV due to thinner wall, so with inspiration: Lung congestion More ↓ blood reaching LV. More ↓ CO. More ↓ pulse volume. Character: when you describe character, you should comment on 3 components: volume of pulse+rate of expansion (upstroke)+rate of collapse (downstroke). E.g.: Water hummer pulse (in AR): big volume+sudden expansion+sudden collapse. Plateau pulse (in AS):small volume, slow rate of expansion+slow rate of collapse. Equality ح ّ اىىبض عيً اىُدَه بعدما تخٍّ اىعَان َرفع َدَه مأوه َدعى ي س Causes of inequality: Clinical medicine – General Examination 4 Outside wall: cervical rib, Pancoast tumor (apical bronchogenic carcinoma), saccular aneurysm of aorta. Wall: dissecting aneurysm, Aortic coarctation. Lumen: thrombus, embolism. N.B.: radio-femoral lag: due to abdominal Aorta narrowing: Dissecting aneurysm Coarctation Thrombus Arterial wall condition: Normally: not felt. Cord-like: → Monckburg medial calcinosis (in media)/ midium arteries. Atherosclerosis (subintimal) / big arteries, not radial. Grape-like: polyarteritis nodosa. Peripheral pulsations (sound, murmur, thrill): Arteries: Carotid, Axillary, Brachial, Ulnar, Radial, Femoral, Popliteal, Posterior Tibial, Dorsalis Pedis. Rule: avoid thumb except in big arteries. Your comment: Absent Peripheral pulsations. Present: Sound: Pistol shot Murmur: Droisier sign Carotid shudder. Palpation of radial artery: a. By tips of middle 3 fingers. b. Against lower end of radius. c. Using moderate compression. d. Wrist should be pronated and supported by thumb or palm. b) Blood Pressure: measured: a. Directly: by catheter. b. Indirectly: Palpatory and auscultatory. KROTOKOV Sounds: I. Clear fine taps II. Murmurs III. Clear strong taps IV. Murmur (3-4 mmHg). V. Silence. Diastolic BP: I. Direct: gives pressure of phase 4. i.e. when sound starts to fade. II. Indirect: Palpatory: not used for DBP. Auscultatory: In most cases: DBP = phase 4 i.e. when sound disappears. In case of: children, AR, Hyper-dynamic circulation → DBP=beginning of phase 4, as there is prolonged phase 4. Management of Auscultatory gap: Clinical medicine – General Examination 5 I. Continue deflating cuff till zero to avoid DBP overestimation. II. Use palpatory method to avoid SBP underestimation. General Rules: In the room i.e. basal conditions: Avoid emotional stress for 5 min. Avoid exercise for 10 min. Avoid smoking for 15 min. Avoid eating for 30 min (2 hours in elderly). Evacuate the bladder. Reassure the patient to avoid WHITE COAT HYPERTENSION. In the patient: Sitting or lying, but prone position to measure L.L., and standing to diagnose postural hypertension. Remove clothes perfectly, but if tight completely take off. Elbow should be slightly flexed. Upper limb should be supported. In the sphygmomanometer: Mercury reservoir should be at the same horizontal level of heart and anti-cubital crease. Mercury column should be placed vertically. Rubber tubes should be medially. Avoid so tight and so loose. The suitable rubber bag should be used (lower limb, children and obese have special bags). Steps: 1. Palpatory: to detect SBP only and to avoid SBP underestimation in presence of auscultatory gap. 2. Auscultatory: Apply the cuff, not so tight or loose, with its lower edge above the anti-cubital crease by 3 cm with rubber tubes medially. Avoid herniation of rubber bag from the cuff. Inflate rapidly, above the level of pulse disappearance by 20-30 mmHg. Deflate slowly at 1 mmHg/sec. While placing chest piece over the brachial artery (medial to bicipital tendon) auscultate Krotokov’s sounds. SBP is the first. Diastolic BP was discussed before. Continue deflating till zero. Measuring BP in LL: Patient lies in prone position. Use larger cuff. Wrap it around mid-thigh, or around calf muscles if there is no large cuff. Place rubber tubes in midline of popliteal fossa. Auscultate popliteal artery in popliteal fossa, or posterior tibial if cuff tighted around calf muscles. Uses of sphygmomanometer: Diagnostic uses: 1. Measuring ABP: Normal ABP: 100-140/60-90 mmHg i. To diagnose hypertension (DBP): Mild 90-110 Clinical medicine – General Examination 6 Moderate 110-120 Severe 120-130 Malignant > 130 (Encephalopathy, Retinopathy, Papilledema, acute pulmonary edema). Types (causes): Essential (1ry) Secondary (renal, endocrinal, multi-factorial). ii. To diagnose hypotension: SBP < 100 mmHg. Causes: a. Over-dosage of anti-hypertensive b. Shock (SBP < 70 mmHg → cold limbs). c. Addison’s disease: never SBP > 110 mmHg. d. Postural hypotension: SBP during standing < during flat by > 20 mmHg. iii. To diagnose unequal pressure on both sides: Right > left, or left > right by 10 mmHg. Same causes of unequal pulse. iv. Compare UL and LL pressures: Normally by direct method UL > LL as closer to heart. By indirect method, LL > UL due to stronger muscle tone (20 mmHg). If LL > UL by > 20 mmHg → mild AR, > 40 mmHg → moderate AR, >60 mmHg → severe AR. If UL > LL → same cause of radio-femoral lag. v. To detect pulse pressure: Normally 30-50 mmHg. If < 30 (causes of small pulse volume). If > 50 (causes of big pulse volume). In AR pulse pressure > 60 and diastolic < 60 mmHg. 2. Hiss test: to diagnose Idiopathic thrombo-cytopenic purpura. Elevate cuff pressure between systolic and diastolic. Wait for 5 minutes. Remove the cuff: if ≥ 5 petichial hemorrhage in an area of 5 cm diameter → ↓↓ platelets. 3. Walker’s test: to diagnose Myesthenia Gravis. 4. Treasseant test: elevate > SBP → carpo-pedal spasm → latent tetany (Ca+2: 7-9 mg%, normally 9-11 mg %). 5. Lown berg test: to diagnose DVT. Apply the cuff on calf muscle and elevate pressure → the patient shout. 6. Diagnose Pulsus alternans: By auscultation: false impression of bradycardia. To diagnose, stop at SBP then deflate → sudden doubling of Krotokov’s sounds. 7. Diagnose pulsus paradoxicus: While measuring BP, Krotokov’s sounds will disappear at a given cuff pressure during inspiration. Deflate in steps until Krotokov’s sound is heard all through the respiratory cycle. This = SBP at weak beats. If this < expiratory SBP by > 10 mmHg → Pulsus paradoxicus. Clinical medicine – General Examination 7 Therapeutic Uses: As a tourniquet. Rotatory method (closed vene-section) for treatment of acute pulmonary edema in anemic patient. c) Respiratory Rate: see chest. d) Temperature: Sublingual Axillary Rectal More accurate as no V.C. due to no Add 0.5 ° C. More reliable. sympathetic supply. Subtract 0.5° C. o Indication for Rectal: 1. Children 5. Cough 2. Comatosed 6. Vomiting 3. Convulsions 7. Hysterical 4. Mouth-breather o Technique: 1. Shake thermometer very well. <35 ° C Hypothermia 2. Apply it 35-36.5° C Subnormal 36.5-37.2° C Normal 3. Keep it for 3 minutes. >37.2° C Fever >41.1° C Hyper-pyrexia o Causes of Fever: 1. Infection 6. Hemolysis 2. Trauma (crush syndrome) 7. Malignancy 3. Hypersensitivity 8. Hyperthyroidism 4. Collagen disease 9. Fever of unknown cause. 5. Sun stroke o Causes of Hyperpyrexia: 1. Hyperthyroid crisis 4. Pontine hemorrhage 2. Salicylate poisoning 5. Heat stroke 3. Hemolytic hemorrhage o Causes of hypothermia: 1. Shock 4. Cold weather 2. Starvation 5. Hypothalamic surgery 3. Myxedema 6. Old age 3. Regional Examination: 3. Regional Examination: 1.. Head:: 1 Head o Cranium o Face: Facies: Complexion: Clinical medicine – General Examination 8 Jaundice: It’s yellowish discoloration of skin and mucous membranes due to elevation of total bilirubin > 2.5 mg%. Normal total bilirubin = 0.8-1.2 mg%. How to detect? 1. Ask patient to look upwards. 2. Pull lower eyelid downwards. 3. Inspect sclera in the daylight. N.B.: Sclera is rich in elastin to which bilirubin is attached. Bilirubin reaches sclera by diffusion, as it’s avascular. Eye still yellow 2 months after treatment of hyperbilirubinemia. 4. Color: o Lemon-yellow → hemolytic jaundice. o Olive-green → obstructive jaundice. o Orange-yellow → hepato-cellular jaundice. D.D: 1. Dark races: brownish sclera. 2. Xanthomatosis 3. Uremia 4. Hypercarrotenemia:↑ intake: D.M. + vegetarians. ↓ metabolism: myxedema. Causes of jaundice: Hemolytic Obstructive Hepatocellular ↑ hemolysis Biliary obstruction Liver cell failure ↑ indirect bilirubin ↑ direct ↑ both (direct+indirect) Lemon-yellow sclera Olive green sclera Orange-yellow sclera Dark stool Clay-colored stool Pale-clay colored stool Normal urine Dark urine Dark urine Other manifestations: Itching. Manifestations of LCF (see hemolytic anemia Sinus bradycardia. abdomen) Cyanosis: Definition: bluish discoloration of skin and mucous membranes due to elevation of reduced Hb > 5 gm% in arterial blood of underlying capillaries. N.B.: Blood normally dark red, but the depth → blue. Better seen in m.m. or areas of thin skin as no keratin. Reduced Hb: carboxyHb –metHb –SulfHb Normal reduced Hb =2.5 gm% Central cyanosis Peripheral cyanosis Causes 1. ↓ O2 inhalation: high altitude, strangling, 1. V.C.: cold weather, peripheral drowning, URT obstruction as FB, laryngospasm. vascular disease as Raynod’s. 2. Right to left shunt: Eisenminger’s syndrome, F4. 2. Low CO: HF. 3. Any extensive lung disease. 3. 1ry polycythemia: ↑ viscosity Clinical medicine – General Examination 9 4. 1ry polycythemia: as ↑ RBCs→↑Hb. 4. SVC obstruction. 5. Met+sulf Hb. 6. Liver cirrhosis: V.D. material → opening of intrapulmonary A.V. shunts Mechanism Hypoxic hypoxia Stagnant hypoxia Hands Warm (VD due to hypoxia) Cold Warming Worsens condition Improve Arterial PO2 ↓↓ Normal Oxygenation Improve No effect Polycythemia 1ry + 2ry 1ry Clubbing Present Absent Sites Under surface of tongue Nails Inner surface of lips N.B.: Never in tongue as no Conjunctiva + nails stagnation as it’s: Near heart Movable No sympathetic supply No V.C. V.D. N.B.: to differentiate between central and peripheral or to detect presence of peripheral cyanosis in patient having central cyanosis: Tongue → central Cold→ peripheral. Does anemia associate cyanosis? Never, neither anemia nor severe anemia. Pallor: Our complexion color is complex of 3 colors: Yellow due to keratin. Brown due to melanin Red due to Hb. Pallor= absence of red component= absence of Hb. Sites of Pallor: 1. Inner surface of lip. 2. Nail 3. Palmer creases 4. Conjunctiva: but not seen in Egyptians due to TRACHOMA. Causes: 1. Anemia بأسبابها 2. Low CO: shock, HF, syncope. 3. Renal failure. Butterfly rash: Brown: pregnancy, Pellagra. Red: Bright red → Systemic Lupus Erythromatosis. Dusky red → Malar flush (MS+ pulmonary hypertension) = hypertension stage of MS (unknown mechanism). Clinical medicine – General Examination 10 Individual organs: Eye: Causes of eyelids puffiness: 1. Renal failure: due to salt and water retention. 2. Myxedema 3. Angioneurotic edema 4. Chronic cough 5. SVC obstruction 6. Excessive sleeping 7. Excessive crying Mouth: Lip: cyanosis + pallor. Tongue: Cyanosis Red glazed tongue=Beefy tongue: Vitamin B deficiency Folic acid deficiency Iron deficiency Liver failure Diabetes Anti-cancerous drugs White dry coated tongue: Starvation and dehydration Fever as Typhoid Uremia Diabetes Halitosis: Bad Odor of Mouth. DKA: acetone odor RF: ammoniacal urineferous LCF: fetor hepaticus Alcoholic Suppurative lung syndrome Gastro-colic fistula → fecal odor Pyloric obstruction Bad oral hygiene 2.. Neck:: 2 Neck o Skin: Thyroidectomy scar, spider nevi. o Muscles: Neck retraction: meningitis, subdural hemorrhage. Over-action of accessory respiratory muscles (Sternomastoid, Scalini). Abnormal movement: Attaxia, Parkinsonism, AR (nodding head=De Musset sign). o Trachea: Trail’s sign: marked tracheal shift pushing sternomastoid. o Thyroid مه اىجراحت Clinical medicine – General Examination 11 o Carotid Artery: Visible carotid pulsation=Corrigan’s sign=AR. Systolic thrill: AR =carotid shudder AS + thrill at base of heart Carotid artery aneurysm or stenosis or throbus. o Neck Veins: Introduction: Any vein is: Capacitant: its capacity > its blood content (1/10), so blood accumulates in its dependent lower parts more than upper parts, so distension of the lower part > the upper. Collapsible: collapsed upper part due to decreased V.R. Distensible: in lower part due to effect of gravity. Right IJV EJV Deep to sternomastoid Superficial to sternomastoid Does not pierce deep fascia Pierces the deep fascia Has no valves Has valves In direct continuity with SVC Makes an angle with SVC Examination of Neck Veins: Pressure: N.B.: Distance from angle of Lewis to center of right atrium = 5 cm. JVP: it’s the vertical distance in cms between angle of Lewis (zero level) and upper level of distension or pulsation of IJV. Normally: 0-3 cm water or blood. CVP=JVP+5. Normally = 5-8 cm blood. How to measure the pressure? 1. Ask the patient to lie in 45° (starting position). 2. Ask him to lie in an angle between 30°-90° (according to the case) that makes the upper level of distension or pulsation obvious. 3. Keep patient’s head supported and looking forwards. 4. Place the ruler vertically with its zero at angle of Lewis level or at clavicle if he’s in 45°. 5. Determine the JVP. 6. Determine the CVP=JVP+5 NB: IJV is better to be seen than EJV due to (see table above). Causes of low JVP: (upper level doesn’t appear at 30°) Clinical medicine – General Examination 12 Hypovolemia (hemorrhage, polyuria, diarrhea, vomiting, dehydraton). Causes of high JVP: 1. Causes of hyper-dynamic circulation 2. Cardiac: a. SVC obstruction b. Tricuspid Stenosis c. Right ventricular failure d. Constrictive pericarditis and pericardial effusion e. Pulmonary Stenosis f. Pulmonary hypertension 3. Chest: increased intrathoracic pressure leading to pressure on right ventricle (emphysema, pleural effusion, pneumothorax) 4. Abdominal: tense ascites. Relation to respiration Forced expiration increases +ve intrathoracic pressure, so pressing on right ventricle expiratory filling of neck veins. Constrictive pericarditis and pericardial effusion Kaussmall’s sign = Inspiratory filling of neck veins. Normally: Inspiratory filling (slightly). Jugular Waves Late Diastole Systole Early Diastole Early Late Maximum filling Reduced filling Event Right Atrial Atrial Relaxation Atrial filling Atrial emptying Contraction Pressure ++ -- -- -- -- ++ Blood column in neck vein a x y v y´ y´: y ascent reduced filling in flow from atrium to ventricle < flow from neck veins to atrium. Systolic collapse: Normally X-wave occurs with pulse. Clinical medicine – General Examination 13 Systolic collapse with giant a-wave: when right atrium contracts against pressure as TS, PS, PH. Deep x: in constrictive pericarditis (Freidniche sign). Deep y: in constrictive pericarditis (Freidniche sign). Systolic expansion: (Giant V) TR (tricuspid regurge). AF (atrial fibrillation). Escape junctional rhythm, simultaneous atrial and ventricular contraction Systolic Giant v- wave Cannon wave. N.B.: In complete heart block occasional Cannon wave. Absent a-wave in AF (no contraction of atrium). Congested non-pulsating neck veins: o SVO o Marked distension of neck veins. How to comment on waves? 1. Palpate pulse at radial artery and look to jugular vein pulse. 2. Systolic: a. Collapse: b. Expansion: i. Normal i. TR ii. Deep x, y. ii. AF iii. Giant-a wave: TS, PS, PH. iii. Cannon sign. N.B.: Visible Carotid Pulsations Jugular Venous Waves Along upper ½ of anterior border of sternomastoid. Along lower ½ of posterior border of sternomastoid. Felt better than seen. Seen better than felt. Pulsitile which means: Wavy or undulating which means: 1 wave per cardiac cycle 2-waves/cardiac cycle. Main movement: outwards Main movement: inwards Unchangeable Changeable: with: position, compression, respiration, Valsalva maneuver, hepato-jugular reflux). Hepato-Jugular Reflux=Abdomino-Jugular Reflux= 1 minute test: 1. Press on patient’s abdomen at umbilicus for 1 minute, and inspect neck veins elevation: a. Transient = normal b. Sustained: i. Constrictive pericarditis ii. Pericardial effusion iii. Right sided heart failure 2. Mechanism: increased intra-abdominal pressure squeeze of blood back flow into jugular veins. 3.. Chest:: 3 Chest o Spider Nevi: مهم Definition: dilatation of central arterioles and their branching capillaries. Size: few mm to 2 cms. Site: distribution of SVC: head, neck, upper limbs, upper chest (never below nipples). Clinical medicine – General Examination 14 Color: red and blanches by pressure on its center. Mechanism: unknown, but there are theories as increased estrogen, increased VD. Causes: LCF Pregnancy Vitamin B deficiency Some normal individuals D.D.: Insect bite: exposed areas, does not blanch with pressure. Cample de Morgan spots: cherry red (capillary hemangioma). Venus star: small varicose vein. Purpuric eruptions. o Gynecomastia: Definition: fibro-adenosis in male breast. Causes: Liver cell disease: decreased estrogen destruction. Digitalis: anti-androgen. Spironolactone: anti-ADH (small dose decreased action of androgen, large dose decreased synthesis of androgen). D.D.: Unilateral (rare) lipoma. Bilateral: o Symmetrical (uncommon) simple obesity. o Asymmetrical (common). Picture: firm disc beneath nipple: Tender: if formed rapidly. Not tender: if formed slowly. 4.. Upper lliimb:: 4 Upper mb o Tremors: Fine: Thyrotoxicosis Parkinsonism Anxiety Alcoholism Cigarette smoking Familial Senility Coarse: Static: Parkinsonism Kinetic: cerebellar ataxia Flapping: end organ failure o Skin and adenexa: Spider nevi (see before) Clinical medicine – General Examination 15 Palm: Pallor in the creases Hyperkarrotinemia Palmer erythema: Definition: well-demarcated shinny redness in thenar, hypothenar and root of fingers with central pallor that balches by compression. Causes: 1. Same causes of spider nevi. 2. T.B. 3. Thyrotoxicosis 4. Reticulosis: abnormal RBCs. 5. Rheumatic arthritis. 6. ACTH therapy. Mechanism: (as spider nevi). Nail: Color: o Splinter hemorrhage: in infective endocarditis. o Leuconychia: in hypoalbuminemia + normally o Cyanosis (see before). o Pallor (C B 4 ) o Brownish: in renal failure. Shape: o Spooning: in iron-deficiency anemia. o Clubbing: in chronic toxemia or hypoxia leading to V.D., edema and proliferation of nail bed tissue. Grade of Picture Diagnosis Clubbing 1 Obliteration of angle Window test: absent x-space 2 Parrot’s beak Inspection 3 Drum stick clubbing Inspection 4 As grade 3 but tender, come in Inspection+palpation Bronchogenic Carcinoma 0 Fluctuation test N.B.: Grade 3 = pulmonary osteo-arthropathy. Types of Clubbing: 1. Pale (pallor): in toxemia 2. Blue (cyanosis): in hypoxia Causes: System Pale Blue CVS Subacute infective endocarditis Congenital cyanotic heart disease Chest 1. Suppurative syndrome Chronic respiratory failure. 2. Bronchogenic carcinoma 3. Mesothelioma Abdomen 1. LCF 2. Steatorrhea 3. Ulcerative colitis 4. Crohn’s disease 5. Intestinal polyposis Clinical medicine – General Examination 16 Traumatic Normal color Heredo-family 5. Lower limb: L.L. Edema Unilateral Bilateral Causes Local: cellulites, DVT, traumatic, lyphedema ↑ hydrostatic pressure: General cause with lateral decubitus as in hemiplegia 1. RSHF: systemic congestion, liver congestionNa+H2O retention. 2. Renal failure na+H2O. 3. Pregnancy 4. Orthostatic: prolonged standing. ↓ osmotic pressure: a. Liver failure b. Malnutrition c. Protein loss (see chest) ↑ permeability: a. V.D. b. Allergy Deposition: a. Lymphedema b. Mexedema Tenderness Tender in local causes. Not tender Extent: Site of obstruction: DVT. Severity of general cause. Pitting at: 1. Dorsum of foot 2. Medial maleolus 3. Shin of tibia 4. Ischium 5. Sacrum 6. Pinching method in abdomen and thigh. Not pitting Soft pitting Hard pitting 1. Renal failure 1. Early 2. Heart failure lymphedema 3. Increased H2O 2. Increased protein.