General patient examination and differential diagnosis

Posture and gait

In the outpatient or primary care setting, observe your patient from the moment you meet him in the waiting area. Does he rise easily from a chair? Does he walk freely, stiffly or with a limp; confidently or apparently fearful of falling; aided or unaided? In the hospital setting, note the patient’s posture in bed. Healthy people adjust their position at will, without difficulty. In disease, this ability is lost to variable degrees, and severely ill patients may be sufficiently helpless that they adopt positions that are very uncomfortable. Patients with left-sided heart failure typically find that lying horizontally worsens their sense of breathlessness (orthopnoea). The pain of peritonitis typically compels patients to lie supine, sometimes with the legs drawn up, still and quiet, with shallow breathing movements in order to minimize the pain that movement induces. This contrasts with the restlessness of renal colic, in which the patient often rolls around in a futile attempt to find a position free from pain. With acute inflammatory or infective joint disease, the affected limbs often lie motionless. In severe cases of meningitis, the neck may bend backwards and appear to burrow into the pillow.

Speech and interaction

Much information comes from the first interaction. The face, particularly the eyes, indicate real feelings better than words. Did your patient smile when you introduced yourself? Was it symmetrical or was there obvious facial weakness? Did he make eye contact? Was the face animated or expressionless, as in Parkinson’s disease? Was the voice hoarse because of laryngeal disease, recurrent laryngeal nerve palsy or myxoedema? Was the speech pressured, as in thyrotoxicosis or mania or monotonous, and expressionless, as in severe depression? Was it slurred from cerebellar disease or a previous stroke?

Physique and nutrition

The nutritional state of a patient may provide an important indicator of disease, and prompt correction of a deficient nutritional state may improve recovery. The more detailed methodologies available for nutritional assessment and management in the context of complex gastrointestinal disease are covered in Chapter 14 . In the general survey, note if the patient is cachectic, slim, overweight or obese ( Box 2.1 ). If obese, is it generalized or centrally distributed? Wasting of the temporalis muscle leads to a gaunt appearance, and recent weight loss may result in prominence of the ribs ( Fig. 2.1 ). Other clues to poor nutrition include cracked skin, loss of scalp and body hair and poor wound healing. Malnutrition, together with acute or chronic illness, often leads to hypoalbuminaemia with associated oedema, making overall body weight an unreliable marker of malnutrition. A smooth, often sore tongue without papillae (atrophic glossitis, Fig. 2.2 ) suggests important vitamin B deficiencies. Angular stomatitis (cheilosis, a softening of the skin at the angles of the mouth followed by cracking) may occur with a severe deficiency of iron or B vitamins. Niacin deficiency, if profound, may cause the typical skin changes of pellagra ( Fig. 2.3 ).

Temperature

Body temperature may be recorded in the mouth, axilla, ear or rectum. A ‘normal’ mouth temperature is 35.8° to 37°C. Those in the ear and rectum are 0.5°C higher and in the axilla 0.5°C lower. There is a diurnal variation in temperature; the lowest values are recorded in the early morning with a maximum between 6 and 10 pm. In women, ovulation is associated with a 0.5°C rise in temperature. In hospitalized patients, regular temperature measurements may identify certain characteristic patterns of disturbance. A persistent fever is one that does not fluctuate by more than 1°C during 24 hours; a remittent fever oscillates by 2°C during the course of a day; and an intermittent or spiking fever is present for only several hours at a time before returning to normal. None has great sensitivity or specificity for any particular diagnosis, but changes over time may provide useful information about the course of a disease.

Hands

Examine the hands carefully because diagnostic information from a variety of pathologies may be evident. The strength of the patient’s handshake may be informative with regard to underlying neurological or musculoskeletal disorders. Characteristic patterns of muscular wasting may accompany various neuropathies and radiculopathies (see Chapter 16 ). Make note of any tremor, taking care to distinguish the fine tremor of thyrotoxicosis or recent beta-adrenergic therapy from the rhythmical ‘pill rolling’ tremor of Parkinsonism (see Chapter 16 ) and from the coarse jerky tremor of hepatic or uraemic failure (sufficiently slow to be referred to as a metabolic ‘flap’) or the intention tremor of cerebellar disease.

Feel for Dupuytren’s contracture in both hands, the first sign of which is usually a thickening of tissue over the flexor tendon of the ring finger at the level of the distal palmar crease. With time, skin puckering in this area develops, together with a thick fibrous cord, leading to flexion contracture of the metacarpophalangeal and proximal interphalangeal joints. Flexion contracture of the other fingers may follow ( Fig. 2.4 ).

Check for clubbing of the fingers. Normally, the angle of the fingernail and the nail base (Lovibond’s angle) is approximately 180° and the base feels firm to palpation ( Fig. 2.5 ). As clubbing develops, the tissues at the base of the nail are thickened and Lovibond’s angle is lost. Subsequently, the nail becomes more convex, both transversely and longitudinally, and seems to ‘float’ in a softened nail bed. In normal nails, when both thumbnails are apposed, a diamond- shaped gap is created, called Schamroth’s window. With clubbing, a combination of the thickened nail bed and the loss of Lovibond’s angle indicates that this window is reduced or even obliterated. In gross cases (usually owing to severe cyanotic heart disease, bronchiectasis or empyema), the volume of the finger pulp increases ( Fig. 2.6 ) and becomes bulbous like the end of a drumstick. The toes may also be affected. Lesser degrees of clubbing may be seen in bronchial carcinoma, fibrosing alveolitis, inflammatory bowel disease and infective endocarditis. The last of these may also be associated with Osler’s nodes—transient, tender swellings caused by dermal infarcts from septic cardiac vegetations ( Fig. 2.7 ). Splinter haemorrhages ( Fig. 2.8 ) and nail-fold infarctions ( Fig. 2.9 ) may be signs of a vasculitic process, but may also be the result of trauma in normal individuals and are therefore rather non-specific.

Trophic changes may be evident in the skin in certain neurological diseases and in peripheral circulatory disorders, such as Raynaud’s syndrome, in which vasospasm of the digital arterioles causes the fingers to become white and numb, followed by blue/purple cyanosis and then redness owing to arteriolar dilatation and reactive hyperaemia ( Fig. 2.10 ).

In koilonychia the nails are soft, thin and brittle and the normal convexity replaced by a spoon-shaped concavity ( Fig. 2.11 ). It is a rare feature of longstanding iron deficiency and is owing to defective collagen formation, which can also cause blue sclerae. Leuconychia (opaque white nails) may occur in chronic liver disease and other conditions associated with hypoalbuminaemia ( Fig. 2.12 ), but are not particularly useful for making a clinical diagnosis of chronic liver disease.

Beau’s lines are horizontal (transverse) depressions in the nail that may result from any disease process, illness, chemotherapy or malnutrition that constitutes a sufficient insult to affect the growth plate of the nail. Fingernails grow at a rate of 0.1 mm per day, so the timing of the disease onset can be estimated by measuring the distance from the Beau’s line to the nail bed. They disappear over several months as the nail grows out.

Odours

Certain odours may provide diagnostic clues. The odour of alcohol on the patient’s breath is easily recognizable, but do not assume that an alcoholic foetor implies alcoholism or that all the patient’s current symptoms and signs are related to alcohol intoxication. Patients with alcohol dependence may have reversible problems, such as hypoglycaemia or a subdural haematoma. The odour of diabetic ketoacidosis resembles acetone (‘pear drops’ or nail varnish remover) and those of hepatic failure and uraemia have been described as ‘ammonia-like’ or ‘mousy,’ respectively, but such terms are rather subjective and their use is limited. Halitosis (bad breath) is common in patients with suppurative lung diseases and in those with gingivitis owing to poor dental hygiene. As with all smells, they are difficult to describe but can be characteristic when previously experienced and learned.

Face and neck

In addition to the important expressions and features of mood and attitude noted above, important diagnostic clues may easily be apparent on inspection of the face. Examination of the cranial nerves is covered in Chapter 16 , but palsies of the III ( Fig. 16.5 ) and VII ( Fig. 2.13 ) nerves may be obvious simply on inspection. Parotid swellings are usually easily apparent; the tender bilateral parotid swelling of mumps or the unilateral swelling with reddening of the skin from acute parotitis contrasts with the non-tender bilateral enlargement that sometimes accompanies chronic alcohol use (and possibly accompanying liver disease). Some patients with mitral stenosis have a bright, circumscribed flush over the malar bones, and in some patients with systemic lupus erythematosus there is a red raised eruption on the bridge of the nose extending onto the cheeks in a ‘butterfly’ distribution ( Fig. 2.14 ). Telangiectasias, minute capillary tortuosities, may be seen on the face of patients with liver disease and, rarely, as a hereditary disorder ( Fig. 2.15 ). In systemic sclerosis, radial puckering (furrows) may be seen around the mouth ( Fig. 2.16 ) that, as the skin becomes tighter, limits the extent to which the mouth may be opened ( Fig. 2.17 ).

The neck should be inspected and palpated. Examination of the jugular venous pulse is described in detail in Chapter 13 , but it is an important part of the examination in all patients, not just those with suspected cardiovascular disease. It may contribute useful information regarding the severity of lung disease, and its careful assessment is particularly important in patients suspected of having a disturbance of fluid and electrolyte balance.

Neck swellings are usually best felt from behind the patient. The general principles of lymph node palpation are described below, and the details of examination of the thyroid are covered in Chapter 19 .