Clinical Physical examination

• • 0: fully active and is able to carryout normal activities without any restriction.
• • 1: Symptoms restrict strenuous activity but is able to carryout light sedentary activities.
• • 2: Ambulatory but unable to carryout normal activities.. Up and about >50% waking hours.
• • 3: only limited self care. confined to bed for >50% of waking hours.
• • 4: completely confined to bed , disabled, needs assistance.

[@ 0 is g00d in EC0G]

• • Able to carry on normal activity and to work; no special care needed (100–80).
• − 100: normal no complaints; no evidence of disease.
• − 90: Able to carry on normal activity; minor signs or symptoms of disease.
• − 80: normal activity with effort; some signs or symptoms of disease.

• • Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed (70–50).
• − 70: cares for self; unable to carry on normal activity or to do active work.
• − 60: Requires occasional assistance, but is able to care for most of his personal needs.
• − 50: Requires considerable assistance and frequent medical care.

• • Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly (40–0).
• − 40: Disabled; requires special care and assistance.
• − 30: Severely disabled; hospital admission is indicated although death not imminent.
• − 20: very sick; hospital admission necessary; active supportive treatment necessary.
• − 10: Moribund; fatal processes progressing rapidly.
• − 0: Dead

• − Underweight : BMI—<18. 5
• − normal : BMI—18. 5–24. 9
• − overweight : BMI—25–29. 9
• − obese : BMI—30 or higher

When the nail of two normal fingers are apposed there is a diamond shaped gap. in clubbing this diamond shaped gap disappears.

• When the nail is viewed from the side, the skin fold of the nail and the base of the nail makes an angle known as Lovibond angle. normally this angle is less than 165 degrees. in case of clubbing the angle between the skin of the nail fold and the base of the nail is more than 180 degrees 
• 

• The left supraclavicular lymph node lying between the two heads of sternocleidomastoid. This lymph node may be involved by metastasis from carcinoma of stomach, testicular tumor, carcinoma of esophagus and bronchogenic carcinoma.
• Enlargement of lymph nodes is due to retrograde permeation of the tumor cells.

• Continuous fever: The daily fluctuation of temperature is less than 1. 5°f and the temperature does not touch the baseline. It is found in pneumococcal pneumonia, in second week of enteric fever and rheumatic fever
• Remittent fever: The daily fluctuation is more than 2°f and the temperature does not touch the baseline. This is found in urinary tract infection and pulmonary tuberculosis.
• Intermittent fever: fever continues for several hours and returns to normal during the day.
• This may be:
• • Quotidian: The paroxysm of intermittent fever occurs daily
• • Tertian: The paroxysm of intermittent fever occurs on alternate days
• • Quartan: The paroxysm of intermittent fever occurs every three days
• • Relapsing fever: There cyclic periods of fever and periods of apyrexia

• This is a type of relapsing fever when there is fever for a period of 14 days and there is apyrexial
• period of 14 days. found in Brucellosis and Hodgkin’s lymphoma.

• „ number
• „ Site
• „ extent
• „ Shape
• „ Size
• „ Surface
• „ Margin
• „ Skin over the swelling
• • Scar
• • venous prominence
• • Pigmentation
• • Ulcer, any discharge
• • Peau d’orange
• • Satellite nodule
• „ impulse on cough (for hernias and meningocele)
• „ Any pressure effect
• • Swelling of limbs
• • Muscle wasting

• „ temperature
• „ tenderness
• „ Site
• „ extent
• „ Shape
• „ Size
• „ Surface - smooth, irregular
• „ Margin - well defined/ill defined, regular/irregular,
• „ consistency
• „ fluctuation, if the swelling is cystic
• „ transillumination, if swelling is cystic
• „ Reducibility: Reducible or not
• „ compressible or not
• „ Palpable impulse on cough
• „ fixity of the swelling to skin
• „ fixity of the swelling to deeper structure
• • Muscle: test mobility with muscle relaxed and contracted
• • tendon: test mobility with tendon relaxed and after tendon is made taut with contraction of muscle
• • Bones: Swelling is fixed as such
• • vessel compression effect: Absence of pulse distal to the swelling
• • nerve compression effect: test for muscle power and sensation
• „ Pulsation: if present, transmitted or expansile pulsation
• „ Any thrill on palpation

• „ Soft (feel of a relaxed muscle) or
• „ firm (feel of a contracted muscle).
• „ Hard (feel of bone)

• Try to pick up the skin from the underlying swelling. If the skin can be picked up from the swelling, the swelling is not fixed to skin.
• If the skin cannot be picked up from the swelling, the swelling is said to be fixed to the skin.
• The malignant swelling may infiltrate the skin and the overlying skin may be fixed to the swelling.

• Ask the patient to contract the muscle.
• If the swelling becomes more prominent, the swelling
• lies superficial to the muscle.
• If the the swelling becomes less prominent, it lies deep to the muscle.
• If the swelling remains same or becomes less prominent and becomes immobile, it may arise from the muscle.

The right sternocleidomastoid muscle is contracted by asking the patient to look to the opposite side against resistance and the mobility is tested again.

• „ vaginal hydrocele
• „ cystic hygroma
• „ encysted hydrocele of the cord
• „ Hydrocele in the canal nuck
• „ congenital hernia in infants may show positive transillumination.

• Hemangiomas
• Lymphangiomas
• Meningocele
• Meningomyelocele

• Dermoid cyst
• Sebaceous cyst

• Inspection
• „ number
• „ Site: Describe in relation to the region or bony landmark.
• „ extent
• „ Shape: circular, oval, irregular or serpiginous
• „ Size
• „ Margin
• • Sloping
• • Undermined
• • Punched out
• • Sloping
• • Raised and rolled out
• • Raised and beaded
• „ floor of ulcer
• „ Discharge character, amount, smell
• „ Adjacent area:
• • Any swelling
• • Any skin change
• • Any secondary changes, pigmentation, pallor.
• • Any associated venous diseases

• Margin - junction of normal skin and the periphery of the edge of the ulcer
• Edge - Area of the ulcer between the floor and the margin.
• Floor - Exposed portion of the ulcer
• Base

• „ temperature: Palpate the area adjacent to the ulcer for any rise of local temperature
• „ tenderness: over the ulcer and adjacent area
• „ Size of the ulcer: Measure with a tape from one margin to the other.
• „ Margin and edge of ulcer: type, any induration
• „ Base: The area on which ulcer rests (fig. 1.36) (feel the base by picking up the ulcer in between the thumb, index and middle finger)
• „ test mobility of ulcer over the deeper structure
• „ Any discharge during palpation: Bleeding or mucus discharge

• Sinus is a blind tract having an opening on one side.
• A fistula is a tract having opening at both ends of the tract.

• This is tested by rising test. Patient lies supine on the bed. He is asked either to lift the head and chest or both the legs above the bed. If there is weakness of abdominal muscles, the flank will bulge out.
• This is called Malgaigne’s bulging. The contracting muscle may be palpated with the hand placed on the abdominal wall.