general examination : pre-classes

nie adalah aku copy paste dr lawan web ape ntah.. about general examination. klik here general examination. 


jom kita tinjau2.. aku sebebnarnya malas kalau nak baca lecture note. tp kalau PBl, MES, Makmal, dan kerja2 macam nie. aku suka laer. thats my way of studies. so, aku syorkan.. perbanyakkan MEs dan PBL. huhuhu.. baru aku ley stuidy. ngada ngada kan aku nie.. adoyai..

General Principles of Examination

The 3 Vital Steps

1. Wash Hands

2. The 3 Ps: Permission, Position, Pain

3. General Inspection
End of the bed with hands behind back.

A. Patient:

• Well/Unwell – comfortable at rest?
• Colour,
• Dyspnoea (difficulty in breathing)
• IV access,
• Tubes (drips, drains, catheters)
• Oxygen?
• Obvious cachexia, abdominal distension, scars, movement.

B. Surroundings:

• Monitors,
• Props (wheelchairs, stick, inhalers etc.)
• Infusions/fluids.

The 3 P’s!

There are a few basic things you need to get right every time you examine a
patient. We call these ‘The 3 Ps’:

• Asking permission to examine the patient (PERMISSION)
• Getting them in the correct position (and adequately exposed) (POSITION)
• Checking you are not going to cause them any pain with what you do. (PAIN)

Follow the 3 Ps and you will always impress the examiners. Forget them, and there is little point in doing anything else. So please remember to do the following in every clinical exam you ever attempt. (and don’t forget to wash your hands!) Get
this bit right and the rest will fall into place with practice. You should also do a quick general inspection from the end of the bed, before touching the patient.

General Examination

Always examine patients in a set order, this ensures a confident flow of the examination, and shows your assessors that you know what you’re doing. In this chapter, we will cover the framework of a full examination, and elaborate on the aspects of an examination that do not belong to a specific ‘system’.

There are a few things you must do before starting an examination. Get into a routine, so that you don’t have to think about them anymore when you are in a pressured situation such as an exam. The acronym HICAPP covers these preparations:

Hands – wash you hands with alcohol rub or soap.

Introduce yourself to the patient as a medical student.

Consent – ask the patient’s permission to examine them.

Adequate exposure – ask the patient to expose relevant body parts.

Position – make sure you’re on the patient’s right side, and position them appropriately (i.e. flat for abdo exam, 45° for cardiovascular, etc.).

Pain – ask the patient if they have any pain anywhere, to make sure you don’t hurt them.

All examinations proceed in the order Inspection, Palpation, Percussion, and Auscultation. Start by inspecting the patient from the end of the bed, paying attention to the state of the patient (do they look unwell, in pain, any diagnostic clues, i.e. vomit bowl full of blood) and his surroundings (i.e. drip, walking stick, insulin pen lying on bedside table). The sequence of examination starts at the hands, moves up the arm, to the face and then down the body, covering the neck, chest, heart, abdomen and legs, finishing with a neurological examination.

Look at the nails for

• Clubbing – increased curvature of nail with loss of the angle between proximal nail and nail bed. (Fig. 1) May be normal, but can be caused by lung cancer, chronic suppurative lung disease, cyanotic heart disease, infective endocarditis, fibrosing alveolitis, inflammatory bowel disease, and cirrhosis.
• Splinter haemorrhages – small dark spots or lines under the nails. Causes: trauma, infective endocarditis.
• Koilonychia – brittle, “spoon-shaped” nails of iron deficiency anaemia (Fig. 2).
• Leukonychia: white nails. Causes include low albumin, severe anaemia.
• Pitting of nails in psoriasis.
• Capillary refill time – time it takes for colour to return after squeezing the nail until it turns white; >2sec: shock, dehydration, hypothermia, vascular disease.

Look at the hands for

• Acromegaly – large, spade-like hands with recent increase in size, coarse skin.
• Arachnodactyly – long, thin fingers. May be a feature of Marfan’s syndrome.
• Nicotine staining – usually between the 2^nd and 3^rd finger.
• Scleroderma – disease causing fibrous skin tightening, limiting finger movement.
• Loss of skin turgor: skin does not recoil quickly after pinching. à Dehydration!
• Palmar erythema – bilateral reddening of palms, associated with pregnancy, liver disease, rheumatoid arthritis and thyrotoxicosis.
• Dupuytren’s contracture (Fig.3) – associated with cirrhosis, alcoholism, epilepsy.
• Metabolic flap (asterixis) – forward flapping of the hand when the arm is extended and the hand is flexed backward. Associated with liver disease.

Palpate the radial pulse, assessing rate and rhythm. Check for the collapsing pulse of aortic regurgitation. Move up the arm and take the blood pressure.

Look in the eyes for yellowing of the sclera (the white of the eye) indicative of jaundice, and pull down the lower eyelid to look for paleness signifying anaemia.

Look in the mouth for cracked, sore corners of the mouth (angular stomatitis, seen in iron deficiency), a bluish discoloration of the tongue (central cyanosis), dry mucus membranes (dehydration!) and bad dentition.

Scan the face for the characteristic facial features of Parkinson’s disease (fixed, mask-like expression with unblinking eyes and mouth slightly open), hyperthyroidism (dry, puffy skin with hair loss of eyebrows), acromegaly (protrusion of jaw and coarsening of facial features), and Down’s syndrome (slanted eyes, accentuation of epicanthic fold, flattening of nose bridge, protruding tongue).

Examine the neck for cervical and supraclavicular lymphadenopathy (swollen lymph nodes). Check for an enlarged thyroid gland (goitre). Look for the Jugular Venous Pressure (see Cardiovascular Exam). Assess the carotid pulse for character and volume. Auscultate over the carotid arteries for bruits.

Now proceed to examine the cardiovascular and respiratory system, the abdomen, cranial nerves and peripheral nervous system, and / or other relevant examination. When you feel reasonably confident in examining the separate system, you should try to integrate the examinations to make it easier on the patient. For example, consider examining the neck for lymphadenopathy (usually done from behind the patient) at the same time as inspecting, percussing and auscultating the back of the chest, and checking for sacral oedema, so that you only have to ask the patient to sit forward once.

i have found the clinical examination online book. lets look out and share between us.. shaing is caring 

klik here clinical exam. untuk kita kita yg agak miskin nie, just klik website tue, then klik "browse clinical exam online" . ok?? then, pilih laer..