By Evelyn Coleman,2014-06-26 20:14
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     ميحرلا نمحرلا لا مسب


     First, describe the general condition of the patient: his alertness, consciousness,

    cooperation, orientation to time, place and persons, intelligence and memory,

    then describe:

    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.

    ? Dwarfism.

    ? Mongolism.

    ? Achondroplasia.

    j- Endocrinal disorders: Cretinism and pituitary infantilism.

    II- Decubitus:

    a- Squatting

    ? 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.


    III- Appearance:

    a- Acromegaly:

    ? 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.

    b- Thyrotoxicosis:

    ? 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

    pulmonary congestion.

    c- Myxedema:

    ? 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

     antitrypsin 1


    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.

IV- Skull:

    a) Acromegalic.

    b) Frontal baldness of myotonia dystrophica.

    c) Microcephaly.

    d) Alopecia areata ? chronic suppuration.


    V- Loss of hair from outer 1/3 of eye brow:

    a- Myxedema.

    b- Artificial.

    VI- Exophthalmos:

    a) Bilateral:

    ? Thyrotoxicosis.

    ? Congenital.

    b) Unilateral:

    ? Cavernous sinus thrombosis.

    ? Leukemic infiltrations behind the eyeball.

    ? Arteriovenous aneurysm between cavernous sinus and internal

    carotid artery.

    VII- Enophthalmos:

    a. Horner’s syndrome.

    b. Dehydration.

    c. Shock.

    d. Severe wasting.

VIII- Ptosis:

    a- Unilateral:

    ? Horner’s syndrome (Pancoast’s tumor).

    ? 3

    rd nerve palsy.

    ? Local eye disease.

    ? Congenital.

    b- Bilateral:

    ? 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.

    e- Myxedema.

    f- Angioneurotic edema.

    g- Nutritional edema (hypoproteinemia).

    h- Advanced right-sided heart failure.


    X- Sclera:

    a) Bluish discoloration in hypoproteinemia, congenital osteogenesis

    imperfecta and gradually occurring anemias.

    b) Jaundice.

    XI- Conjunctiva:

    a) Anemia (to be seen in lower lid because of the frequent affection of the

    conjunctiva of the upper lid by trachoma).

    b) Jaundice.

    c) Inflammation.

    d) Subconjunctival hemorrhage ? severe hypertension, chronic coughs

    and blood diseases.

    e) Bitot’s spots ? vitamin A deficiency.

XII- Pupils:

    a. Size: pin pointed pupils in pontine hemorrhage and opiate poisoning.

    b. Equality: unilateral miosis ? Horner’s syndrome

    c. Regularity.

    d. Reaction to light: Argyll-Robertson pupil (the pupil responds to

    accommodation and not light).

XIII- Nose:

    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).

XV- Lips:

    a) Pallor: anemia.

    b) Cyanosis: congenital heart diseases, cor pulmonale, heart failure

    and arteriovenous fistula.

    c) Cheilosis: thiamine deficiency.


    XVI- Tongue:

    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.

    XVII- Gums:

    a) Blue line: lead poisoning.

    b) Hypertrophy: monocytic leukemia and epanutin poisoning.

    XVIII- Parotids:

    a) Mumps.

    b) Parotid tumors.

    c) Parotid stones.

    d) Liver cirrhosis.

    e) Endemic parotiditis especially with ankylostoma infestation.

    XIX- Breath:

    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.

    e- Thyrotoxicosis.

    f- Neurofibromatosis.

    g- Scabies.

    h- Varicose ulcers (hemosiderin pigments).

    i- CHF (severe edema with hemosiderin pigments).

    j- Jaundice.

    k- Purpura.

    l- 2

    ry stage syphilis.


    XXI- Petichae:

    ? 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.

    ? D.D:

    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:

    a- Anemia.

    b- Malignancy.

    c- Blood diseases.

    d- Infective endocarditis.

    e- Parasitic infestations.

    f- Malnutrition.

    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.

    ? Acrocyanosis.

    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

    vasodilatation) vasoconstriction)

    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:

    a. Trachea:

    ? Shifted to site of lesion: Lung or pleural fibrosis or lung collapse.

    ? Shifted to opposite side: pleural effusion, pneumothorax, lung

    tumors or thyroid swelling.

    b. Thyroid:

    ? 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

    (D’Espine sign).

    ? If present, Check for:

    ? Liver and spleen enlargement.

    ? Purpuric rash.

    ? Sternal tenderness.

    ? Bleeding tendency.

    ? Fever.

    ? Important causes of lymphadenopathy are:

    ? Lymphoma.

    ? Leukemia.

    ? Infections.

    ? Tuberculosis.

    ? Secondaries.

    ? 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 ?:

    ? AI.

    ? PDA.

    2nd- Systolic ? and diastolic normal:

    ? Atherosclerosis of ascending aorta.

    ? Thyrotoxicosis.

    ? Complete heart block.

    3rd- Systolic ? and diastolic ?:

    ? Systemic hypertension.

    4th- Systolic normal and diastolic ?(hyperkinetic circulation):

    ? Severe anemia.

    ? Fevers.

    ? Pregnancy.

    ? 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:

    ? TS.

    ? 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

    O. 2

    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 ?

    constrictive pericarditis.

    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.

    ? Palpatory:

    1- To attain a rough idea about the systolic B.P.

    2- To avoid the auscultatory gap (in hypertensive patients).

    ? Auscultatory:

    1- To determine the systolic and diastolic B.P.

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