Physical diagnosis
THE COMPREHENSIVE
PHYSICAL
EXAMINATION
Dr. Samir Lamichhane, MD Clinical Pharmacology
GENERAL EXAMINATION
PILCCOD
or
JALCyClOD
PILCCOD
Pallor
Icterus
Lymphadenopathy
Clubbing
Cyanosis
Oedema
Dehydration
JALCyClOD
Jaundice
Anemia
Lymphadenopathy
Cyanosis
Clubbing
Oedema
Dehydration
Pallor
Pallor
Pale appearance of skin and mucous membrane
A sign in a patient with anemia
Pallor
Anemia is defined as the qualitative or quantitative
diminution of RBC and/or hemoglobin concentration
➢ in relation to standard age, sex and altitude of
residence
Normal Hb concentration
Male:13.8 -17.2 gm/dL
Female: 12.1-15.1 gm/dL
Sites to be examined for pallor
Lower palpebral conjunctiva
Dorsum of tongue
Soft palate
Nail beds
Palms, soles and general skin surfaces
Pallor
Pallor
A. Technique of
examining for
pallor in lower
palpebral
conjunctiva
B. Normal
conjunctiva
C. Pale conjunctiva
Pallor
Pallor
Pallor
Anemia
Grading of severity
Mild
60-80% of Hb (9-12 g/dl)
Moderate
40-60% of Hb (6-9 g/dl)
Severe
< 40% of Hb (< 6 g/dl)
Anemia
Classification
According to the size of RBC
Microcytic
◼ MCV: < 80 fl
Normocytic
◼ MCV: 80 - 100 fl
Macrocytic
◼ MCV: > 100 fl
Anemia
Causes: According to MCV
Microcytic (MCV: < 80 fl)
Iron deficiency anemia
Thalassemia
Anemia of chronic disease
Sideroblastic anemia
Lead poisoning
Anemia
Causes: According to MCV
Normocytic (MCV: 80-100 fl)
Acute blood loss
Hemolysis, sickle cell anemia
Aplastic anemia
Anemia of chronic renal failure
Hematological malignancies, myelodysplasia
Hypersplenism
Anemia
Causes: According to MCV
Macrocytic/Megaloblastic anemia (MCV: >100 fl)
Vitamin B12 deficiency
Folate deficiency
Hypothyroidism
Liver disease
Chronic alcohol
Congenital metabolic diseases
Cytotoxic drugs e.g. methotrexate
Anemia
Symptoms
Decreased oxygen transport
Fatigue,weakness, syncope, dyspnea, angina, lack of
concentration
Increased cardiac output
Palpitation, tinnitus
Congestive cardiac failure
Orthopnea, paroxysmal nocturnal dyspnea
History to remember
Age/sex
Puberty, pregnancy
Residence
Tropical areas
Occupational history
Personal history
Past medical history
History to remember
Family history
Blood disorders
Nutritional history
Dietary deficiency of folate, vitamin B12, iron
Drug history
NSAIDs
Steroids
Menstrual history
Clinical examination
General: jaundice, lymphadenopathy, edema
Cardiovascular system
Tachycardia
Water hammer pulse
Hyperdynamic apex beat
Systolic murmur
Abdominal examination: hepatosplenomegaly
Clinical examination
Iron deficiency anemia
Angular stomatitis
Bald tongue: in severe IDA
Koilonychia
Platynychia (platonychia)
Clinical examination
Clinical examination
Vitamin B12 def
Glossitis: atrophic glossitis
Painful ‘beefy’ red tongue
Nervous system: peripheral neuropathy
➢ Glove and stocking paresthesia
Clinical examination
Hemolytic anemia
Chipmunk facies (thalassemia)
◼ Frontal bossing
◼ Maxillary hypertrophy
◼ Depressed nasal bridge
◼ Malocclusion of teeth
Chipmunk facies (thalassemia)
Chipmunk facies (thalassemia)
Chipmunk facies (thalassemia)
Clinical examination
Fanconi anemia
Microcephaly
Micropthalmia
Clinical examination
Fanconi anemia
Microcephaly
Micropthalmia
Dangling thumb
Short stature
Rocker bottom foot
Clinical examination
Fanconi anemia
Microcephaly
Micropthalmia
Dangling thumb
Short stature
Rocker bottom foot
Clinical examination
Plummer-Vinson syndrome
Atrophic glossitis
Post-cricoid esophageal web
◼ Difficulty swallowing
Iron deficiency
Motor palsy: lead toxicity
THANK YOU
Physical diagnosis
THE COMPREHENSIVE
PHYSICAL
EXAMINATION
Dr. Samir Lamichhane, MD Clinical Pharmacology
GENERAL EXAMINATION
PILCCOD
or
JALCyClOD
PILCCOD
Pallor
Icterus
Lymphadenopathy
Clubbing
Cyanosis
Oedema
Dehydration
JALCyClOD
Jaundice
Anemia
Lymphadenopathy
Cyanosis
Clubbing
Oedema
Dehydration
Icterus
Icterus
Sign manifesting jaundice
Jaundice is defined as yellowish discoloration of
skin and mucus membrane due to excess amount of
bilirubin present in blood
Icterus
Normal bilirubin level
0.3 -1 mg/dl
Conjugated bilirubin < 20%
Hyperbilirubinemia
Bilirubin level > 1 mg/dl
Icterus
Clinical manifestation of jaundice
Bilirubin level > 3 mg/dl
Latent jaundice
Clinically not evident jaundice
Only detected by serum analysis
Bilirubin level: 1-3 mg/dl
Icterus
Sites to be examined for icterus
➢ Always seen in daylight
Upper bulbar conjunctiva
Scleraexamined by retracting upper eyelids upwards
and asking the patient to look downwards
Both eyes at a time
Undersurface of tongue
Soft palate
Palms and soles, general skin surface
Fig. Sites to be examined for icterus
Macrophage
Heme
Heme
oxygenase
Biliverdin
Biliverdin
reductase
Bilirubin
Fig. Bilirubin synthesis
Blood
Fig. Bilirubin metabolism
Causes of jaundice
Hemolytic
Hepatocellular
Obstructive
Intrahepatic
Extrahepatic
Causes of jaundice
Hemolytic
Thalassemia
Sickle cell anemia
Blood transfusion
Malaria
Causes of jaundice
Hepatocellular
Viral hepatitis
Alcoholic hepatitis
Cirrhosis
Drugs: paracetamol, rifampicin, isoniazid
Hemochromatosis
Wilson's disease
Acute fatty liver, e.g. of pregnancy
Causes of jaundice
Obstructive
Intrahepatic
◼ Cholestatic viral hepatitis
◼ Pregnancy
◼ Drugs: OCPs, erythromycin, steroids
Causes of jaundice
Obstructive
Extrahepatic
◼ Gallstone impaction in common bile duct
◼ Carcinoma of head of pancreas
◼ Periampullary carcinoma
◼ Enlarged gland of porta hepatitis
◼ Sclerosing cholangitis
Comparison among types
Features Hemolytic Hepatocellular Obstructive
Bilirubin Unconjugated Both Conjugated
Color Lemon-yellow Orange-yellow Greenish-yellow
Urine CB -ve CB -ve CB +ve
Normal color Yellowish Deep yellow
Stool High colored High colored Clay colored
Features of + - -
hemolysis Anemia,
splenomegaly
Pruritus Absent Variable Present
History to remember
Age/ Sex
Residence
History of travel
History of blood transfusion
History of gallstone
History of alcohol intake
Drug history: OCP, Isoniazid, Rifampicin, PCM
“Medicine is learned at the bedside and
not in the classroom”.
➢ (Sir William Osler 1849 – 1919)
THANK YOU
Physical diagnosis
THE COMPREHENSIVE
PHYSICAL
EXAMINATION
Dr. Samir Lamichhane, MD Clinical Pharmacology
GENERAL EXAMINATION
PILCCOD
or
JALCyClOD
PILCCOD
Pallor
Icterus
Lymphadenopathy
Clubbing
Cyanosis
Oedema
Dehydration
JALCyClOD
Jaundice
Anemia
Lymphadenopathy
Cyanosis
Clubbing
Oedema
Dehydration
Lymphadenopathy
Lymphadenopathy
Enlargement of lymph nodes
Inflammatory or non-inflammatory
Groups of lymph nodes
Lymphadenopathy
Groups of lymph nodes
Cervical
Axillary
Inguinal
Mediastinal
Abdominal
Popliteal
Epitrochlear
Fig. groups
of lymph
nodes in the
body
Cervical group
Submental
Submandibular
Anterior cervical chain
Posterior cervical chain
Preauricular
Postauricular
Occipital
Fig. cervical
lymph nodes
Cervical group
Examination
Patient on sitting position
Always palpated from behind
Patient’shead bending forward to relax the muscles in
the anterior part of the neck
One side of the neck is palpated at a time
If one side of the neck is palpated, the neck should be
flexed to that side
Cervical group
Axillary group
Sub-groups
Central
Apical
Anterior or
pectoral
Posterior
Lateral
Inguinal group
Horizontal chain: lies below the inguinal ligament
Vertical chain: lies along the saphenous vein
➢ Both sides are palpated one after another in supine
position extending the thighs.
Inguinal group
Description of lymph node
Position, situation or extent
Number
Size
Discrete or matted
Tenderness
Consistency: soft, rubbery, firm, hard
Description of lymph node
Surface
Mobility: fixity to overlying skin or surrounding
structures
Rise of local temperature
Skin changes: sinus, orange skin appearance
Lymphangitis
Draining area
Significant lymphadenopathy
Cervical or axillary >1cm
Inguinal >1.5cm
Supraclavicular and epitrochlear lymph nodes are
significant if they are palpable
Causes of lymphadenopathy
Cervical lymphadenopathy
Infection
◼ Tonsillitis, pharyngitis, oral ulcers
◼ Miliary tuberculosis
◼ Infectious mononucleosis
◼ HIV infection
Causes of lymphadenopathy
Cervical lymphadenopathy
Malignancy of oral cavity and throat
Lymphoma
Leukemia
Metastasis in lymph nodes from head, neck, breast,
throat, stomach and lung malignancy
Causes of lymphadenopathy
Axillary lymphadenopathy
Breast carcinoma
Infection of upper extremity
Lymphoma
Leukemia
Tuberculosis
Causes of lymphadenopathy
Inguinal lymphadenopathy
Infection or cellulitis of lower limb
Filariasis
Metastasis from genital malignancy, pelvic carcinoma
Syphilis
Chancroid
Lymphogranuloma venereum
Lymphoma, leukemia
Virchow’s node
Palpable left supraclavicular lymph node
In carcinoma of
Stomach
GI tract
Lungs
Virchow’s node
Virchow’s node
Generalized lymphadenopathy
Characterized by the involvement of three or more
noncontiguous lymph node areas
Generalized lymphadenopathy
Causes
Lymphoma
Acute lymphoblastic leukemia (ALL)
Chronic lymphoblastic leukemia (CLL)
Miliary tuberculosis
AIDS
Secondary metastases to lymph nodes
Sarcoidosis
CMV, EBV
THANK YOU
Physical diagnosis
THE COMPREHENSIVE
PHYSICAL
EXAMINATION
Dr. Samir Lamichhane, MD Clinical Pharmacology
GENERAL EXAMINATION
PILCCOD
or
JALCyClOD
PILCCOD
Pallor
Icterus
Lymphadenopathy
Clubbing
Cyanosis
Oedema
Dehydration
JALCyClOD
Jaundice
Anemia
Lymphadenopathy
Cyanosis
Clubbing
Oedema
Dehydration
Clubbing
Clubbing
Bulbous swelling of the terminal part of the fingers
and the toes with
An increase in the soft tissue mass, and
Increased anteroposterior as well as transverse
diameter of the nails
◼ Due to proliferation of the subungual connective
tissue
Clubbing
Clubbing
Clubbing
Clubbing
Clubbing
Causes
Pulmonary
Bronchogenic carcinoma
Lung abscess
Bronchiectasis
Empyema thoracis
Clubbing
Causes
Cardiac
Infective endocarditis
Cyanotic congenital heart disease
Alimentary
Ulcerative colitis
Hepatoma
Idiopathic
Clubbing
Causes: remember as ‘CLUBBING’
Congenital heart disease
Lung abscess
Ulcerative colitis
Bronchogenic carcinoma
Bronchiectasis
Infective endocarditis
Normal
Genetic
Clubbing
Examination
Lovibond’s angle
Fluctuation test
Schamroth’s window
Clubbing
Examination
Lovibond’s angle
Angle between nail bed and proximal nail fold
➢ Also onychodermal angle or hyponychial angle
➢ ~ 160◦
Clubbing
Examination
Fluctuation test
Clubbing
Examination
Fluctuation test
Extend the patient’s finger
Support the pulp of patient’s finger with your thumb
Fix the patient’s proximal interphalangeal joint with
your middle fingers
Place your index fingers on the base of the nailbed
Press with one of your index finger and feel for the
fluctuation with other index finger
Clubbing
Examination
Fluctuation test
Clubbing
Examination
Schamroth’s sign/window
Clubbing
Examination
Schamroth’s sign/window
Normal Clubbing
Cyanosis
Cyanosis
Blueish discoloration of skin and mucous membrane
due to excess accumulation of reduced
hemoglobin in blood (>5 g/dL)
Cyanosis
Sites
Margins of tongue
Inner aspects of lips
Mucous membrane of gums, palate and cheeks
Tip of nose
Ear lobules
Outer aspects of cheeks, lips and chin
Tip of finger and toes and nail bed
Palm and soles
Cyanosis
Cyanosis
Cyanosis
Cyanosis
Cyanosis
Types
Central cyanosis
Peripheral cyanosis
Cyanosis
Types
Central cyanosis
Due to marked decrease in oxygen tension in arterial
blood because of either poor oxygenation in the lungs
or mixing of venous blood
Usually detected when PaO2 < 80-85%
Cyanosis
Types
Central cyanosis
Causes
◼ Cyanotic heart diseases
◼ Tetralogy of Fallot
◼ TGA
◼ Eisenmenger syndrome
◼ Acute pulmonary edema
◼ Pulmonary disorders
◼ COPD, asthma, pneumonia, etc
Cyanosis
Types
Peripheral Cyanosis
PaO2 is normal but there is oxygen unsaturation at the
venous end of the capillary
Occurs due to excessive extraction of oxygen from
normally saturated arterial blood
Cyanosis
Types
Peripheral Cyanosis
Mechanisms
◼ Decreased cardiac output
◼ Peripheral vasoconstriction
◼ Stasis of blood in the extremities
Cyanosis
Types
Peripheral Cyanosis
Causes
◼ Exposure to cold water or environment (most common)
◼ Frost bite
◼ Raynaud’s phenomenon
◼ CCF
◼ Shock
◼ Hyperviscosity syndromes
◼ Polycythemia, multiple myeloma
THANK YOU
Physical diagnosis
THE COMPREHENSIVE
PHYSICAL
EXAMINATION
Dr. Samir Lamichhane, MD Clinical Pharmacology
GENERAL EXAMINATION
PILCCOD
or
JALCyClOD
PILCCOD
Pallor
Icterus
Lymphadenopathy
Clubbing
Cyanosis
Oedema
Dehydration
JALCyClOD
Jaundice
Anemia
Lymphadenopathy
Cyanosis
Clubbing
Oedema
Dehydration
Edema
Edema
Definition: Abnormal and excessive accumulation of
fluid in the subcutaneous tissue due to increase in
interstitial fluid collection.
If involves the peritoneal cavity: Ascites
If generalized: Anasarca
Edema
Causes
Increased capillary hydrostatic pressure
Decreased plasma oncotic pressure
Decreased interstitial hydrostatic pressure
Increased interstitial oncotic pressure
Increased blood vessel wall permeability
Lymphatic obstruction
Increased water retaining capacity of the body
Edema
Demonstration
Site: Lower end of tibia slightly above the medial
malleolus
Procedure
Gently press with your thumb
Apply pressure for 15-30 seconds
Release pressure
Observe pitting
Feel with the pulp of the thumb for pitting
Edema
Types and causes
Pitting edema
CCF, DCM
Nephrotic syndrome
Cirrhosis of liver
Hypoproteinemias: protein losing enteropathies
Kwashiorkor (PEM)
Drugs: Amlodipine, steroids
Edema
Types and causes
Non pitting edema
Myxedema
Lymphatic obstruction: Filariasis
Angioneurotic edema: ACE inhibitors
Scleroderma
Pitting edema
Edema
Types and causes
Localized
Generalized (anasarca)
Fluid accumulation in tissues and body cavities
Edema
Types and causes
Some common pathologies
Localized
◼ Trauma
◼ Localized inflammation
◼ Local lymphatic obstruction
◼ [[
Generalized (anasarca)
◼ Congestive cardiac failure
◼ Renal failure
◼ Nephrotic syndrome
◼ Liver cirrhosis
Edema
Cardiac vs renal edema
Cardiac edema
Dependent edema: starts from
◼ Legs in ambulatory patient
◼ Sacral region in bed ridden patients
Renal edema
Non-dependent edema
Starts from face
Edema due to renal cause
Nephrotic syndrome
Ascites
Anasarca
Dehydration
Dehydration
Refers to a state of volume depletion of the body
Dehydration
Causes
Decreased intake
Fasting
Increased loss
Diarrhea
Dysentery
Vomiting
Excessive sweating
Dehydration
Site
Adults
◼ Dorsum of tongue
Dehydration
Site
Adults
◼ Dorsum of tongue
Children
◼ Abdomen skin pinch
Dehydration
Dehydration
Dehydration
Dehydration
Symptoms/Signs
Lethargy/irritability
Eagerness to drink
Sunken eyes
Dry tongue
Skin pinch goes back slowly
Dehydration
Dehydration
Dehydration
“Medicine is learned at the bedside and
not in the classroom”.
➢ (Sir William Osler 1849 – 1919)
THANK YOU
