Comprehensive Physical Examination: Vital Signs, Face, Neck, and Extremities.

Pulse

Comprehensive pulse examination is covered under the section on the cardiovascular system. Its regularity and rate should be mentioned in GPE.

Blood Pressure

Each patient's blood pressure needs to be taken. While some doctors prefer to measure it after the examination, others prefer to do so during the general physical examination. As long as the blood pressure is measured and not overlooked, it makes no difference. Under the heading of cardiovascular system examination, technique is covered.

Face

Physical manifestations of cyanosis that need to be closely monitored on the face include puffiness, pallor of the lower conjunctiva in cases of anemia, yellow discoloration of the sclera in cases of jaundice, bluish discoloration of the tip of the nose and ear lobules in cases of cyanosis, bluish discoloration of the inner surface of the lower lip in cases of cyanosis, dryness, and yellowness of the tongue's underside. It is relatively rare to have symptoms of xanthelasmas, exophthalmos, butterfly rash, hirsutism, and Cushing syndrome.

Typical facial symptoms to watch out for include puffiness, pallor of the lower conjunctiva, and yellow staining of the sclera.

• Bluish staining of the inner area of the lower lip.
• Bluish discoloration of the lobules in the nose and ears.
• The tongue's underside is yellow; the tongue's dorsum is dry, pale, and cyanotic.

General Appearance

Certain facial features are recognizable, such as the mask-like (expressionless) face of Parkinsonism and the moon-like face of Cushing's syndrome.

Puffiness

Caused by periorbital edema, this condition is seen in acute glomerulonephritis, nephrotic syndrome, and renal failure. Additionally, myxedema and angioedema could be to blame. Face puffiness in right heart failure is rare and only happens when the patient is able to lie flat.

Proptosis (exophthalmos)

This term refers to the eyeball protruding. Examine eyes from above if they appear significantly larger than   usual. As you approach the seated patient from behind, gently lift the top lids and observe how the corneas and lower lids relate to one another. If the cornea extends past the lower lid, exophthalmos is evident. Exophthalmos in Grave's disease is typically bilateral, though it might start out unilateral. Unilateral exophthalmos can also be caused by orbital tumors. Additional ocular indicators of Grave's disease include lid retraction and lid lag. Ask the patient to stare straight after retracting their lids. Normally, the sclera beneath and above the cornea are invisible. Due to lid retraction, sclera above the cornea may be visible in thyrotoxicosis, whereas both above and below the cornea are visible in significant proptosis.

Lid lag

Have the patient stare at your finger directly before guiding their gaze downward. The upper eyelid may move more slowly in thyrotoxicosis than the eyeball does normally.

Xanthelasmas

Lipid deposition causes yellow plaques to form on the eyelids. These can be linked to hyperlipidemia, but older people with normal cholesterol can also have them.

Conjunctiva color

Have the patient raise their head, then gently pull down their lower eyelid to reveal the conjunctiva and check for pallor. Subconjunctival hemorrhages are characterized by bright patches on the eyeball and may be caused by bleeding diseases or trauma. Sclera color: Have the patient look down and lift their top eyelid. White sclera is the norm. Jaundice causes it to turn yellow. 

Rash:

The cheek and nose bridge may get rashy in people with systemic lupus erythematosis, sometimes known as "butterfly rash."

Skin color

Cyanosis causes bluish coloring of the ear lobules and tip of the nose. Malar flush, or redness in the cheeks, can occur in people with mitral stenosis but can also occur in healthy people.

Hirsutism

Excessive hair growth on the face (beard and mustache area), limbs, and trunk in females is known as hirsutism.

Parotid glands

Parotid gland swelling can result from tumors (unilateral) or the mumps (typically bilateral).

Lips

Pull the lower lip and check for cyanosis-related bluish discoloration on the inner surface of the lip. On the interior of the lips, phaethous ulcers (yellow base, red hollow) can also form.

Tongue

Check for cyanosis, pallor, and dryness on the dorsum of the tongue (which is indicative of dehydration and mouth breathing). Additional symptoms include redness from inflammation, white patches from candida infection, and baldness from villi atrophy. Examine the underside of the tongue for signs of jaundice. Examine the tongue's size enlarged tongues are a sign of acromegaly and amyloidosis. Neck Look for lymph nodes, neck veins, and the thyroid.

The thyroid

It is made up of two lobes that are joined to one another by an isthmus and are located on either side of the trachea. Goiter is the term for thyroid enlargement.

Examination

Request that the patient extend their neck in order to check for any noticeable swelling in front of or on either side of the trachea. Request that the patient swallow. When swallowing, the welling goes up with the laryngeal cartilage, indicating an enlarged thyroid. Observe its dimensions, whether nodular or widespread, unilateral or bilateral.

Palpation

It can be done from the front as well as the back. Place both hands on the area of swelling and feel with them. As the swelling slides beneath your fingers, ask the patient to swallow and observe different features. The following should be noted: 

• Size
• Diffuse
• Consistency
• Tenderness

Thyroid Retrosternally

A thyroid that is either fully or partially retrosternal cannot reach its bottom limit. Pemberton's sign is characterized by stridor, a congested face, and dilated neck veins when the patient is requested to raise his arms above his head.

Sound Detection

If the thyroid is overactive, there may be a bruit, or murmur like sound. While using the bell to auscultate for thyroid bruit, ask the patient to hold his breath. It is not to be mistaken with a venous hum, carotid bruit, or a murmur emanating from the heart.

Venereal Neck Lesions

A fairly accurate way to estimate the right atrial pressure (also known as central venous pressure or jugular venous pressure) is to look at the pulsations in the jugular veins. With the head of the bed raised to a 45-degree angle, examine the patient from the right side. Measure the vertical distance from the maximum point of the venous pulsations to the sternal angle. Look for venous pulsations in the internal jugular vein at the anterior border of the sternomastoid. It is abnormal if it is greater than 3 cm.

Nodes Of Lymph

The groups of neck lymph nodes are as follows:

• Pre and postauricular
• Occipital.
• Submental (under the chin).
• Submandibular (under the jaw).
• Lymph nodes of the posterior triangle behind the sternomastoid.
• Lymph nodes of the anterior triangle in front of the sternomastoid.

Palpation Technique

Place yourself behind the patient, bend his neck, and press his ring and middle fingers beneath his chin. To palpate the submental and submandibular groups, move the fingers backward. Next, palpate over the occiput, in front of, and behind the auricle. For the posterior triangle lymph nodes, move your fingertips lower past the sternomastoid and toward the collarbone. The supraclavicular fossa can be palpated by placing your fingers behind the clavicle. Lastly, for the anterior triangle lymph nodes, slide the fingers upward between the trachea and the sternomastoid. If lymph nodes are palpable, take note of the following characteristics:

• Site.
• Size.
• Number.
• Consistency.
• Mobility in relation to one another (matted or distinct); to the skin on top and beneath the structures.
• Soreness.
• Sinuses or discharge.

In cases of acute infection, lymph nodes are tender; in tuberculosis, they are matted together and may also have sinuses; in Hodgkin's disease, they are distinct and have a rubbery feel; in metastases, they are hard in consistency.

Nodes of Axillary Lymph

The groupings are as follows: apical, lateral medial, anterior, posterior, and central.

Apex Axilla

Raise the patient's arm above his head and press the left hand's fingers up in the axilla, palm down against the patient's chest. Return the patient's arm to his chest. Slide your fingers down the wall of your chest. Enlarged lymph nodes will slide between your fingers and the patient's chest. Reaching the axilla's apex requires elevating the patient's arm. The medial, central, and apical groups are palpated in this manner. Hold the anterior axillary fold between your thumb and left hand's fingers to palpate the anterior group. Place the palmar aspects of your right hand's fingers along the medial side of the humerus to perform the lateral group. Hold the posterior axillary folds of the matching hand, from behind the patient, between the thumb and fingers for the posterior groups on both sides.

Axilla on the left

The same procedure is performed, but the left hand palpates the lateral group while the right hand palpates the apical, central, and medial groups.

Nodes of Epitrochlear Lymph

The epitrochlear lymph nodes are palpated

Nodes Lymphatic of Groin

If swollen, these are easily perceptible above the inguinal ligament. Compared to other groups, this group's isolated expansion is less important.

Take Note

An infection or cancerous growth in the drainage area is often the cause of swollen lymph nodes. In order to rule out any pathology, you should investigate the lymph node's drainage area if you find an enlarged lymph node. Examine the upper limb in the case of axillary lymph nodes, the lower limb in the case of inguinal lymph nodes, and the scalp, face, and oral cavity in the case of cervical lymph nodes.

Reasons Why Lymph Nodes Grow

1. Malignancy or infection in the drainage area
2. The disease tuberculosis
3. Cancers of the lymph nodes
4. Cancers of the Leukemias

Feet

Additionally, check for cyanosis in the feet, clubbing, and koilonychia. Peripheral vascular disease frequently causes ischemia in the feet; early symptoms include hair loss and glossy skin.

Swelling

Examine the foot's dorsum behind the medial malleolus and over the shin for any signs of edema. In a three-bed patient, also inspect the sacrum. Compare the two sides. Thumb press for a minimum of five seconds. In the event of edema, a pit forms and progressively fills in. The lower body is where edema is most noticeable in cardiovascular conditions. In hypoproteinemia, pitting is visible over the top part of the body in addition to generalized anasarca.

The reasons behind edema

Pitting edema
Bilateral and generalized
A. Cardiovascular (limited to the lower limbs)

• Failure of the right heart
• Pericarditis with constriction
• Emboli around the heart
• Fourth, inferior vena cava blockage

B. Renal (more superficial, but generalized)

• Failure of the kidneys
• Syndrome of nephrotic kidney
• Syndrome of nephropathy

C. Hypoproteinemia, excluding generalized nephrotic syndrome

• Liver cirrhosis (reduced albumin production)
• Undernourishment
• Inadequate Absorption

limited (to the area that is impacted)

• Blockage of veins
• A bedridden, immobile patient, such as one who has paralysis
• Infection (such as cellulitis)

Non-pitting edema

A. Blockage of lymphatic flow

• The disease filariasis
• Syndrome Milroy
• Irradiation or surgical excision of lymph nodes

B. Edema
C. Myxedema

Hydration Level

• Sunken eyes are a sign of dehydration, which is defined as the body losing fluid.
• The tongue feels parched.
• Skin suppleness declined. Pinching a skin fold between the thumb and fingers can be used to demonstrate it; it will subside unnaturally slowly. This signal is less dependable in the elderly.)
• Urine output is reduced; the pulse is quick and blood pressure is low with postural hypotension.

Heart Rate

The complete minute of abdominal and thoracic movements should be counted. Usually, between 14 and 16 minutes pass.

Temperature

A thermometer can be positioned in the groin, rectum, axilla, or beneath the tongue, among other places, to take a person's body temperature. Usually the mouth or the axilla. The mouth temperature is 0.9°F higher than the axillary temperature, and the rectal temperature is 0.9°F higher than that. Rectal readings are more trustworthy than oral or axillary readings. The typical oral temperature ranges from 98.4°F to 99.4°F, with a daily difference of 1.0°F between morning (low) and evening (high).

The patient ought not to have consumed hot or cold

A portion of the body seems enlarged, masking the veins, tendons, and bones, but there is no pressure-induced pitting. It is important to distinguish non-pitting edema from obesity, in which the skin is thicker and the foot (or hand) is swollen but the skin is normal in the former case and the upper limb spared.
Before taking an oral temperature reading, drink right away. Shake the thermometer well below 98.4°F and leave it in place for one to two minutes (a little longer than the manufacturer's recommended time).

Pallor

Pallor is most commonly caused by anemia, or a decreased hemoglobin concentration. Other causes include hypopituitarism and vasoconstriction (due to shock, heart failure, exposure to cold, or Raynaud's phenomenon). You can search for it at the following websites:

• Toenails
• Dorsum of the tongue
• Lower conjunctiva
• Palmar skin

When anemia is present, vasodilatation may deceptively produce a pink color.

The cyanosis

A blue tint is observed in the skin and mucous membranes when the blood's lowered hemoglobin concentration surpasses 5 grams per milliliter; this condition is known as cyanosis. The following areas should be checked for cyanosis: nails, nose tip, ear lobule, inner lip, tongue

Cyanosis in the periphery

Peripheral cyanosis is the term used when the lips and tongue have normal color but the nails, nose, and ear lobules are cyanotic. It results from either a compromised venous drainage system or a decreased blood supply. When this occurs, the hands are typically cold.

Cause

• Cold exposure
• Extremely low blood pressure
• The phenomenon of Raynaud
• Blockage of veins

Central Cyanosis

It is referred to as central cyanosis if the lips and tongue are also affected. The combination of venous and arterial blood inside or outside the heart, or the lungs' incapacity to oxygenate the blood, could be the cause. Usually, the patient has dyspnea

Reasons

• Failure of the respiratory system
• Cyanotic cardiac conditions (such as Eisenmenger's syndrome, transposition of the great arteries, and Fallot's tetralogy)

Slight Jaundice

The final byproduct of hemoglobin metabolism is bilirubin. It is known as jaundice and is clinically visible as a yellow coloring of numerous tissues when its concentration in the serum climbs above 2 mg%. As moderate jaundice may go unnoticed in artificial light, it should be checked for in bright daylight.

• Skin
• Sclera (the most trustworthy place)
• The tongue's underside
• It's important to distinguish jaundice from hypercarotenemia, a rare disorder that affects people who consume an excessive amount of carrots. Sclera is white, yet skin is yellow.

Underlying Emphysema

Palpation of the afflicted skin produces crackling sensations. It can be caused by an esophageal rupture, an inadvertent lung damage during thoracic paracentesis, air escaping during chest intubation for pneumothorax, or a penetrating chest injury that causes air to seep out of the chest. It is found in gas gangrene as well.

Distribution of Hair

The distribution of hair in males and females is distinct. In females, pubic hair is confined to the pubic region and has a horizontal upper border; in males, it extends in a triangle pattern further up the abdomen towards the umbilicus.

Discoloration

In Addison's disease (lower adrenal gland cortisol production), there are new scars, axilla palmar wrinkles, and brown discoloration on exposed areas. The buccal mucosa also exhibits bluish pigmentation, albeit this may be typical in African Americans. One of the characteristics of hemochromatosis is a widespread greyish-bronze coloring. Mask-like pigmentation, often known as chloasma, can develop during pregnancy and can also affect women using estrogen-containing birth control pills. Patients suffering from albinism may exhibit these brown areas of pigmentation: A widespread congenital lack of melanin pigment exists. Skin that is both white and darkly pigmented in spots is known as vitiligo. It has a connection to autoimmune diseases.