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First, describe the general condition of the patient: his alertness, consciousness,
cooperation, orientation to time, place and persons, intelligence and memory,
I- Built: According to age, height and weight (normal 10% above or lower).
Causes of stunted growth are:
a- Malnutrition (commonest type).
b- Malabsorption syndrome.
c- Chronic diarrhea.
d- Liver cirrhosis and bilharzial liver fibrosis.
e- Nephrotic syndrome (heavy albuminuria).
f- Congenital cyanotic hear diseases (chronic hypoxia).
g- Cystic fibrosis.
h- Chronic infections in childhood as tuberculosis and empyema.
i- Genetic disorders:
? Turner’s syndrome.
j- Endocrinal disorders: Cretinism and pituitary infantilism.
? Fallout’s tetralogy. b- Semisitting (orthopneic) ? left sided heart failure, pericardial effusion,
emphysema, ascites, asthma and respiratory failure.
c- Mohamed prayer position (leaning forward) ? pericardial effusion
and mediastinal tumors.
d- Lying on the affected side ? Pleurisy and lung abscess,
bronchiectasis and empyema with bronchopleural fistula (suppurative
lung syndromes to minimize expectoration).
e- Lying on healthy side (contralateral side) ? moderate amount of
pleural effusion and pneumothorax (more blood is driven to healthy
lung with better ventilation/perfusion ratio).
f- Sitting up ? Massive ascites.
g- Opithotonus ? tetanus, meningitis and strychnine poisoning.
h- Lying on back with legs drawn up ? Peritonitis.
i- Hyperextension of neck ? meningitis.
? Enlargement of tongue (macroglossia) and soft tissues of the
palate may produce obstructive sleep apnea.
? Hypertension may lead to left ventricular failure with pulmonary
edema and dyspnea.
? Increased intracranial tension due to pituitary tumors may cause
central alveolar hypoventilation.
? Retrosternal extension my cause dyspnea or mediastinal
syndrome due to compression of mediastinal structures.
? Dyspnea due to hyperkinetic circulatory state.
? Heart failure and arrhythmias produce dyspnea due to
? Obstructive sleep apnea due to macroglossia.
? Central sleep apnea due to depression of the respiratory center.
? Dyspnea due to obesity and hypoventilation.
? Dyspnea due to constipation and abdominal distension.
d- Cushing’s syndrome:
? Dyspnea due to muscle weakness and myopathy.
? Impaired diaphragmatic function (due to hypokalemia).
? Increased incidence of respiratory infections.
e- Toxic look:
? Pulmonary tuberculosis.
? Suppurative lung diseases.
f- Blue bloater: obesity, generalized edema, cyanosis, puffy eyelids, and
fish-mouth breathing ? respiratory failure due to chronic bronchitis.
g- Pink puffer: slim, cyanosis ? respiratory failure due to α
h- Cachectic: malignancy, malnutrition & chronic inflammatory diseases.
i- Infantile: pituitary infantilism.
j- Tetanus: a certain smile (risus sardonicus).
k- Myasthenia gravis: weak smile and bilateral ptosis.
b) Frontal baldness of myotonia dystrophica.
d) Alopecia areata ? chronic suppuration.
V- Loss of hair from outer 1/3 of eye brow:
? Cavernous sinus thrombosis.
? Leukemic infiltrations behind the eyeball.
? Arteriovenous aneurysm between cavernous sinus and internal
a. Horner’s syndrome.
d. Severe wasting.
? Horner’s syndrome (Pancoast’s tumor).
rd nerve palsy.
? Local eye disease.
? Myasthenia gravis.
? Congenital heart diseases.
N.B: Lid lag and retraction in thyrotoxicosis.
IX- Puffy eyelids:
a- Chronic cough (commonest cause).
b- Renal diseases.
c- Mediastinal syndrome.
d- SVC thrombosis.
f- Angioneurotic edema.
g- Nutritional edema (hypoproteinemia).
h- Advanced right-sided heart failure.
a) Bluish discoloration in hypoproteinemia, congenital osteogenesis
imperfecta and gradually occurring anemias.
a) Anemia (to be seen in lower lid because of the frequent affection of the
conjunctiva of the upper lid by trachoma).
d) Subconjunctival hemorrhage ? severe hypertension, chronic coughs
and blood diseases.
e) Bitot’s spots ? vitamin A deficiency.
a. Size: pin pointed pupils in pontine hemorrhage and opiate poisoning.
b. Equality: unilateral miosis ? Horner’s syndrome
d. Reaction to light: Argyll-Robertson pupil (the pupil responds to
accommodation and not light).
a) Redness in tip: alcoholism, mitral stenosis and cold weather.
b) Working ala nasi: pneumonia, toxemia, nervousness, bronchial asthma
and respiratory failure.
c) Nasolabial fold: vitamin B
deficiency ? sulphur granules. 2
d) Bleeding nostrils: blood diseases, local conditions and severe
e) Any discharge from the nostrils.
XIV- Pigmentation in butterfly area of face:
a- MS (malar flush)(red).
b- SLE (red).
c- Pellagra (brownish).
d- Pregnancy (brownish).
a) Pallor: anemia.
b) Cyanosis: congenital heart diseases, cor pulmonale, heart failure
and arteriovenous fistula.
c) Cheilosis: thiamine deficiency.
a) Pallor: severe anemia.
b) Cyanosis: congenital heart diseases, cor pulmonale, heart failure
and arteriovenous fistula. Cyanosis in tongue is always of the
central type except in SVC obstruction where it is peripheral.
c) Tremors: nervousness, thyrotoxicosis and parkinsonism.
d) Dry: uremia, intestinal obstruction and in mouth breathers.
e) Generalized atrophy of papillae in pernicious anemia, iron
deficiency anemia and pellagra.
f) Absence of fur in heavy smokers and fungus infection.
a) Blue line: lead poisoning.
b) Hypertrophy: monocytic leukemia and epanutin poisoning.
b) Parotid tumors.
c) Parotid stones.
d) Liver cirrhosis.
e) Endemic parotiditis especially with ankylostoma infestation.
a) Diabetic ketoacidosis ? acetone smell.
b) Uremia ? ammonia smell.
c) Hepatic failure ? fetor hepaticus (mossy smell).
d) Suppurative lung diseases ? putrid smell.
XX- Generalized pigmentation: a- Addison’s disease. b- Pellagra.
c- Hodgkin’s disease. d- Leukemia.
h- Varicose ulcers (hemosiderin pigments).
i- CHF (severe edema with hemosiderin pigments).
ry stage syphilis.
? In infective endocarditis.
? In upper part of the chest and neck, retina, conjunctiva and palate
(SVC drainage areas).
? They are round, regular, with red margins and pale centers ?.
? They appear in crops and remain for a few days and then disappear.
1- Spider navi: ? in the SVC drainage areas in patients with
liver cirrhosis, disappear by pressure on the center by a pen.
2- Flee bites: itchy, generalized, all red ? (no pale center) with
blood on clothes.
XXII- Pallor: detected in mucus membranes of lips, lower lids (not upper lids
because of trachoma) and palms:
c- Blood diseases.
d- Infective endocarditis.
e- Parasitic infestations.
g- Chronic infections.
h- Rheumatic fever.
XXIII- Jaundice: yellow discoloration of the sclera and mucus membranes,
which is apparent clinically when level of serum bilirubin exceeds 2-3
mg%, causes are:
a- Cardiac causes (due to liver congestion):
? Right sided heart failure.
? Constrictive pericarditis.
? TS and TI.
b- Chest causes:
? Pulmonary infarction (hemolysis of blood).
? Liver affection secondary to antituberculous drugs.
? Cor pulmonale.
N.B: Rifampicin changes color of body secretion to orange.
c- Liver causes.
d- Blood causes as hemolytic anemia.
XXIV- Cyanosis: It is bluish discoloration of the lips and mucus membranes due to raised level of reduced hemoglobin in capillaries more
than 5 gm% (normally 1-2 gm%), so don’t say cyanosis with pallor.
? Osaturation of arterial blood ? 95-99%. 2
? Osaturation of venous blood ? 70%. 2
? Cyanosis is apparent clinically when Osaturation is below 80%. 2
? Types of cyanosis:
a. Central cyanosis: blood leaving the heart already contains the
required amount of reduced hemoglobin or abnormal hemoglobin
(Sulph and methemoglobin), causes are:
1- Secondary polycythemia:
? Congenital cyanotic heart diseases.
? Cyanotic cor pulmonale.
? Cushing’s syndrome.
? Renal carcinoma (? erythropoietin).
2- Primary polycythemia.
3- High altitudes.
4- Acute pulmonary edema.
5- Liver cirrhosis (porto-pulmonary shunts).
6- Methemoglobin due to nitrite toxicity.
7- Sulphemoglobin due to sulphonamide toxicity.
b. Peripheral cyanosis: blood leaving the heart contains the normal
amount of reduced hemoglobin, but as it reaches the peripheral
vessels rapid extraction of O
occurs raising the amount of reduced 2hemoglobin to more than 5gm% in the periphery, causes are:
1- Right sided heart failure.
2- Peripheral circulatory failure.
(Due to low cardiac output and stagnation of blood)
3- Peripheral vascular diseases:
? Raynaud’s disease.
? Burger’s disease.
4- Cold weather.
c. Chemical cyanosis:
1- It is a type of central cyanosis.
2- It is reversible on stoppage of the drug.
3- It is due to nitrites ? metHb (bluish color) or
sulphonamides ? sulphHb (grayish color).
4- It is due to change of iron from the ferrous form to the
ferric form that cannot utilize oxygen.
d. Differential cyanosis: (cyanosis in LL and not in UL)
1- Eisenmenger PDA or reversal of shunt from pulmonary
artery to aorta due to elevation of the pulmonary artery
pressure secondary to increased flow or pulmonary
2- PDA + infantile coarctation of aorta (preductal type) due
to drop of blood pressure after the site of constriction so
blood passes from pulmonary artery to aorta.
Central cyanosis Peripheral cyanosis
1- Site: Under surface of tongue Extremities: hands, nose
and nail bed
2- Temperature: Hot (peripheral Cold (peripheral
3- Clubbing: Present Absent
4- Femoral O: Below 80% Normal 2
5- O therapy: Improves cyanosis due No improvement of 2
to lung disease only cyanosis
XXV- Neck Examination:
? Shifted to site of lesion: Lung or pleural fibrosis or lung collapse.
? Shifted to opposite side: pleural effusion, pneumothorax, lung
tumors or thyroid swelling.
? Describe the enlargement if present.
? Percuss upper border of sternum for retrosternal extension.
? Palpate lower border while swallowing for retrosternal extension.
? Palpate for systolic thrill (thyrotoxicosis).
? Auscultate for systolic bruit (thyrotoxicosis).
c. Lymph nodes:
? Site, consistency, borders, tenderness, matted or discrete and the
presence or absence of sinuses.
? Other lymph node enlargement e.g. axillary, inguinal or mediastinal
? If present, Check for:
? Liver and spleen enlargement.
? Purpuric rash.
? Sternal tenderness.
? Bleeding tendency.
? Important causes of lymphadenopathy are:
? Hodgkin’s disease.
? Local causes as tonsillitis.
d. Neck pulsations:
Arterial Pulsations Venous Pulsations 1- Not obliterated on pressure Obliterated on pressure 2- Single wave Wavy (A and V waves) 3- Synchronous with heart beat V wave synchronous and A wave
asynchronous with heart beat 4- In anterior triangle of neck In posterior triangle of neck
(medial to sternomastoid) (lateral to sternomastoid) 5- Easily felt than seen Easily seen than felt 6- No effect with respiration Change with respiration 7- Don’t change with position Change with position
1- Causes of arterial pulsations in neck (pulse pressure > 60 mmHg):
1st- Systolic ? and diastolic ?:
2nd- Systolic ? and diastolic normal:
? Atherosclerosis of ascending aorta.
? Complete heart block.
3rd- Systolic ? and diastolic ?:
? Systemic hypertension.
4th- Systolic normal and diastolic ?(hyperkinetic circulation):
? Severe anemia.
? A-V fistula.
? Liver cell failure.
? Paget’s disease of bone.
2- Examination of neck veins:
? Congested neck veins only:
i. SVC thrombosis.
ii. Aortic aneurysm causing mediastinal syndrome.
iii. Mediastinal tumor.
(These causes are usually associated with dilated veins on chest wall)
iv. Constrictive pericarditis.
v. Cardiac tamponade.
? Pulsating neck veins:
i. Prominent V wave in tricuspid incompetence.
ii. Absent A wave in atrial fibrillation.
iii. Prominent A wave in:
? Severe PS.
? Severe pulmonary hypertension.
? Complete heart block (giant A wave due to
simultaneous contraction of atrium and ventricle
against a closed tricuspid valve.
? Nodal rhythm.
? Atrial flutter.
? Congested pulsating neck veins:
i. Right sided heart failure.
ii. Increased intrathoracic pressure e.g. emphysema.
iii. Increased intra-abdominal pressure e.g. massive ascites.
iv. Constrictive pericarditis.
v. Pericardial effusion.
? Technique of neck veins examination:
i. Normal venous pressure is from 3-13 cmH
ii. Site patient 90? and if the column of blood is seen above
the clavicle (sometimes upper level cannot be determined)
? severe congested neck veins and usually associated with
dilated veins on chest wall ? SVC obstruction
iii. If not seen, lie patient 45? to see whether it is normal or
there is increase in venous pressure.
iv. If more than 2 cm above clavicle ? congested neck veins
? look to the upper level of vein to see pulsations:
? Inspiratory emptying ? Rt. Sided heart failure.
? Inspiratory filling and steep Y descend ?
v. We can measure the venous pressure clinically by a line
drawn horizontally from the upper level of the vein (while
the patient is sitting 45?) then measure the distance from
that line to the sternal angle and add 5 (distance between
the sternal angle and midatrial point).
XXVI- Blood pressure:
a. Normal B.P. varies with age and the maximum normal for middle-aged
subject is 150/90. Normally, 5% of the population has hypotension
(systolic B.P. below 100 mmHg).
b. Methods of recording B.P.: ? Oscillatory: Mercury oscillates with beginning of the systolic pressure.
1- To attain a rough idea about the systolic B.P.
2- To avoid the auscultatory gap (in hypertensive patients).
1- To determine the systolic and diastolic B.P.