More about the General Physical Examination.

You will be assessed on how you do the GPE in the short case for the FCPS 2 and also during the long case. In the first instance you have to depend on your clinical findings which must be careful and comprehensive. In the long case the history you have taken and the rest of the examination you do will give you some clues. Remember you do not have to follow any assigned list when you examine a patient.

The history gives you clues as to what to look for and you can always go back and examine the patient again if you have time, If you have missed an irregularity in the pulse initially but find that the heart rate is irregular then go back and assess the pulse again. If while you are presenting the case and say “the pulse is regular” the examiner says “would you like to look again?” the chances are that you missed a finding usually an atrial fibrillation or a series of  ectopic beats. Count the pulse for a full minute before sticking your neck out and saying that the pulse is regular. Several candidates missed an AF in the exams in a case of mitral regurgitation and mitral stenosis despite the examiner sending them back to check the pulse again. Correcting yourself will still get you the marks. Remember that the examiner is not trying to trick you but giving you a second chance.If you have diagnosed a mitral valve disease please look very carefully for AF. In older patients with ischemic heart disease AF is a common finding. IHD is probably the commonest cause of an arrhythmia, usually AF, found these days in aging population. If you have failed to pick up the AF while counting the pulse you will find that the heart rate will be irregular. Learn to correlate your findings.

Another lack of correlation is between the BP and the pulse. If the pulse is high volume then the pulse pressure must be high and conversely if the pulse pressure is less than 40 mm Hg the pulse cannot be high volume. If there is a high volume pulse you must be able to give a reason for it being so. Most candidates are unprepared to answer the why question and think that having picked up a finding is enough. It is difficult to assess the volume of the pulse clinically and probably unnecessary unless looking for the effects of atherosclerosis in diabetes or in smokers or when assessing for peripheral vascular disease. Absence of a radial pulse is probably more important; the most likely cause being a coronary angiogram carried out using the radial artery. Less likely causes are a congenital absence of the radial artery, peripheral vascular disease or arteritis,  atherosclerosis, Takayasu’s disease. Loss of a pulse at other sites may be from atherosclerosis which is accelerated in diabetes, hypertension and in smokers or peripheral artery disease. Perhaps we should no longer be teaching that the pulse volume be assessed manually. The following information is from UpToDate.

A variety of noninvasive examinations are available to assess the presence and severity of arterial disease. Physiologic tests include segmental limb pressures and the calculation of pressure index values (eg, ankle-brachial index, wrist-brachial index), exercise testing, segmental volume plethysmography, transcutaneous oxygen measurements, and photoplethysmography.

Ultrasound is the mainstay for preliminary investigative and noninvasive vascular imaging, with each mode (eg, B-mode, duplex) providing specific information that is useful depending on the vascular disorder.

When you are checking the BP of an adult you are permitted to ask “have you taken any medicine to lower the blood pressure?”. If you find the BP high do check it on the other arm. A difference  in the BP on two sides is expected in atherosclerosis, peripheral vascular disease and Takayasu’s disease. Making the patient stand up and looking for a postural drop in the BP is also a good idea specially in diabetics where autonomic neuropathy and peripheral vascular disease may co-exist.

When you look at the patient see if the patient looks obese or undernourished to the eye. If so ask for a weighing machine, ask the patient his/her height and work out the BMI/ A low BMI predicts susceptibility to disease as does a high BMI only different diseases

Remember the word “pallor” is a noun so the correct usage is “the patient has pallor” It is better to say “the patient is pale” and mention where you saw this pallor: in the conjunctivae or the tongue or the nail beds. Looking for anemia in the palmar creases is not a good idea in colored races as we all have pigment deposited there. If there is anemia look for other evidence of malnutrition; low weight, sagging skin, wasted muscles with poor tone, edema from hypoalbuminemia. In the third world countries simple lack of access to food is the main cause of nutritional anemia. If there is nutritional anemia then look for evidence of other vitamin deficiencies like a red sore tongue, angular stomatitis, peripheral neuropathy, bone pains and proximal myopathy. Remember nutritional anemia is seen in malabsorption, malignancy and even psychiatrist illnesses such as anorexia nervosa. While taking the dietary history please do not ask non-specific questions like “What do you eat at home”. An emaciated girl said “I eat everything”. When her mother was asked to elaborate she said “We are able to provide milk, eggs, chicken, meat and seasons fruit as well as vegetables and lentils but for the last 6 months she has been turning down all her food and refuses to eat. She barely gets a 1/2 chapati and some soup down her throat in 24 hours”. The girl was starving in the midst of plenty because she had such a poor appetite because of the disease. The candidates presentation was “She eats everything in her diet so has no malnutrition”. The 14-year-old girl, with a height of 5 feet weighed 28 kg!!!! This showed not only a lack of clinical judgment but also that the candidate was not accustomed to assessing patient’s nutritional status at all !!.

Severe malnutrition will occur in starvation (lack of access to food because of poverty, being locked up in prison or a refugee camp or in the face of a natural disaster like a flood or famine). In a country like Pakistan you should be aware of floods and famines which periodically attack the country. Here asking “Where do you come from originally? How long have you been living at your current abode?” will be of help.

Severe malnutrition will also occur in children in coeliac disease, other diseases causing malabsorption like ulcerative colitis, Crohn’s disease, Tropical sprue which is found in tropical countries including India, Pakistan, and to a lesser degree in Burma, Indonesia, Borneo, Malaysia, Singapore, and Vietnam (tropical sprue is a diarrhoeal illness of unknown origin, which results in deficiency of vitamin B 12 and folic acid). Severe calorie deficient malnutrition can be seen in untreated Type 1 diabetes, untreated thyrotoxicosis. Chronic illnesses like tuberculosis specially TB of the gut or peritoneum, the kidneys and disseminated TB, can present with severe malnutrition. Other chronic illnesses that have not been treated can also be a cause of malnutrition.

The point I want to make is that the state of nutrition is very important and a clue which you ignore at your own peril.

Some stories to illustrate my point. At a teaching session a young boy (14 years-of age) was presented by the trainee registrar. The story was that the boy had suffered from fever for 1 year. The fever did not fit the pattern of recurrent malaria. He had lost weight to the point of emaciation but had no cough or symptoms related to the lungs, no diarrhea or increased thirst or polyuria and had no enlarged lymph nodes only a spleen of 4 cm below the costal margin. The bio-social history was that he was the 7th son of a well to do trader who lived in a crowded middle class suburb of Karachi. There was no lack of food, and no animals or birds in the house, the house itself was airy and with adequate accommodation. No family member had tuberculosis. The accompanying older brother was well fed and healthy. This was the history presented.

The boy had been unwell for a year but there were no prescriptions from previous doctors visits and only an X-ray chest done some 5 months ago. Why?

He was accompanied by his father who was very concerned for him. So apparently there was no parental neglect. So why had the boy not been brought to a hospital before?

On asking the boy about his life we learnt that the child had been adopted by his uncle “cha cha” who was childless. The adopted father was a farmer who earned a subsistence living from the small piece of land he owned and by selling the milk of the cow and 2 goats that he owned. The adoptive parents lived in a village in interior Sind. The boy helped take care of the animals. Food was scarce in the village home. The adoptive father could not afford to have the boy treated, the adoptive mother had been treated at a government facility 2 years ago for pulmonary tuberculosis. The biological father visited the village and had brought his son back home and was now paying to have him treated. This is a very different story. Both tuberculosis (disseminated) and brucellosis were strong possibilities followed by Hodgkin’s lymphoma. This story had been missed by the trainee registrar. In an exam situation this would be fatal for the candidate appearing in the exams.

Another cautionary tale. A 41 year-old woman was brought in with advanced heart failure, atrial fibrillation and mitral valvular disease. She had been so unwell that she could not do her household chores for at least 3 years. She had three children, each delivery taking place at home with no access to prenatal care except by a traditional birth attendant. When she fainted or her feet got really swollen up her husband who was a very poor farmer would take her to the dispenser, who substituted for a doctor, in the village. The man usually gave her an injection and no written prescription. She was currently in the private ward of an expensive hospital with access to all needed investigations and treatment. The candidate missed the reason for the change in her financial circumstances! Her younger brother had returned from the USA after 11 years with enough money to be able to afford the best treatment for her. Valve replacement surgery could now be included in her management.

 

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shaheenmoin

I am a Professor of Medicine and a Nephrologist. Having served in the Army Medical College, Pakistan Army for 27 years I eventually became the Dean and Principal of the Bahria University Medical and Dental College Karachi from where I retired in 2016. My passion is teaching and mentoring young doctors. I am associated with the College of Physicians and Surgeons Pakistan as a Fellow and an examiner. I find that many young doctors make mistakes because they do not understand how they should answer questions; basically they do not understand why a question is being asked. My aim is to help them process the information they acquire as part of their education to answer questions, pass examinations and to best take care of patients without supervision of a consultant. Read my blog, interact and ask questions so that I can help you more.

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