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 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 minimise 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 out of the first interaction. 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 due to laryngeal disease or recurrent laryngeal nerve palsy? 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 12. In the general survey, note if the patient is cachectic, slim, plump or obese. If obese, is it generalised or centrally distributed? Wasting of the temporalis muscle leads to a gaunt appearance and recent weight loss may result in prominence of the ribs. Other clues to poor nutrition include cracked skin, loss of scalp and body hair and poor wound healing. Malnutrition accompanying illness results in blood albumin being low leading to oedema, making overall body weight an unreliable marker of malnutrition. A smooth, often sore tongue without papillae (atrophic glossitis, Fig. 2.1) 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 (Fig. 2.1). Niacin deficiency, if profound, may cause the typical skin changes of pellagra (Fig. 2.2).

Figure 2.1 Atrophic glossitis in a patient with severe vitamin B₁₂ deficiency. There is also angular stomatitis from severe iron deficiency.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

Figure 2.2 Pellagra as a result of niacin deficiency.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

Temperature

Body temperature may be recorded in the mouth, axilla, ear or rectum. A ‘normal’ mouth temperature is 35.8-37°C. Those in the ear and rectum are 0.5°C higher and 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 may provide useful information about the course of a disease.

Hands

Examine the hands carefully as diagnostic information from a variety of pathologies may be evident. The strength of the patient’s grip may be informative with regard to underlying neurological or musculoskeletal disorders. Characteristic patterns of muscular wasting may accompany various neuropathies and radiculopathies (see Ch. 14). 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 Ch. 14), and from the coarse jerky tremor of hepatic or uraemic failure (sufficiently slow to be referred to as a metabolic ‘flap’).

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, puckering of the skin 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. 2.3).

Figure 2.3 Dupuytren’s contracture.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

In clubbing of the fingers, the tissues at the base of the nail are thickened and the angle between the base of the nail and the adjacent skin of the finger is lost. The nail becomes convex both transversely and longitudinally and, in gross cases (usually due to severe cyanotic heart disease, bronchiectasis or empyema), the volume of the finger pulp increases (Fig. 2.4). 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 due to dermal infarcts from septic cardiac vegetations (Fig. 2.5). Splinter haemorrhages (Fig. 2.6) and nail-fold infarctions (Fig. 2.7) may be signs of a vasculitic process, but may also be the result of trauma in normal individuals and are therefore rather non-specific.

Figure 2.4 Clubbing of the fingers. This case is very marked.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

Figure 2.5 Small dermal infarcts in infective endocarditis.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

Figure 2.6 Splinter haemorrhages.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

Figure 2.7 Nail-fold infarction.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

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 due to arteriolar dilatation and reactive hyperaemia (Fig. 2.8).

Figure 2.8 Raynaud’s syndrome in the acute phase with severe blanching of the tip of one finger.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

In koilonychia the nails are soft, thin, brittle and the normal convexity replaced by a spoon-shaped concavity (Fig. 2.9). It is usually due to longstanding iron-deficient anaemia. Leuconychia (opaque white nails) may occur in chronic liver disease and other conditions associated with hypoalbuminaemia (Fig. 2.10).

Figure 2.9 Koilonychia.

(Reproduced with permission from Mir 2003 Atlas of Clinical Diagnosis, 2nd edn, Saunders, Edinburgh.)

Figure 2.10 Leuconychia in a patient with chronic liver disease.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

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 those with gingivitis due to poor dental hygiene. As with all smells, they are difficult to describe but can be characteristic when previously experienced and learnt.

Lymph glands and lymphadenopathy

Details pertaining to the examination of specific lymph node groups may be found in the relevant chapters (e.g. Ch. 20 for cervical lymphadenopathy). Here, the principles of palpating for lymphadenopathy will be covered. Lymph nodes are interposed along the course of lymphatic channels and their enlargement should always be noted. Lymph from the arm drains into the axillary nodes. These should be routinely examined, but particularly in conjunction with examination of the breast (see below). Lymph from the lower limbs drains via deep and superficial inguinal nodes, although only the latter can be palpated and, in turn, comprise a vertical and horizontal group. The vertical inguinal nodes lie close to the upper part of the long saphenous vein and drain the leg. The horizontal group lies above the inguinal ligament and drains the lower abdominal skin, anal canal, external genitalia (excluding the testes), buttocks and lower vagina.

Examination of lymph nodes involves inspection and palpation. Inflammation of the overlying skin and associated pain usually implies an infective aetiology, whereas malignant lymphadenopathy is usually non-tender. To palpate for lymphadenopathy, use the pulps of your fingers (usually the index and middle but, for large nodes, the ring as well) to move the skin overlying the potentially enlarged node(s). Determine the size, position, shape, consistency, mobility, tenderness and whether it is an isolated lymph node or whether several coalesce. For the head and neck nodes, it is often helpful to tilt the head slightly towards the side of examination in order to relax the overlying muscles. Feel for each of the groups shown in Figure 2.11 in whatever order you find most efficient and reliable. Muscles and arteries in the neck and groin may be mistaken for lymph nodes. If in doubt, try to move the structure in question in two directions (laterally and superior to inferior). It should be possible to move a lymph node in two directions, but not an artery or muscle.

Figure 2.11 The cervical lymph node groups.

Determining whether a lymph node is pathological can be difficult and requires practice and experience. In general, small, mobile, discrete lymph nodes are frequently found in normal individuals, particularly those who are slim and have little overlying adipose tissue. The finding of an enlarged lymph node should prompt the question ‘Is this consequent upon local pathology, for example infection or malignancy, or is it part of a more generalized abnormality of the reticuloendothelial system (including other lymph node groups, liver and spleen)?’ (Fig. 2.12).

Figure 2.12 Gross enlargement of supraclavicular and cervical lymph nodes.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

Axillae

Most information from examination of the axillae comes from palpation for possible lymphadenopathy (Fig. 2.13), but inspection may reveal an absence/paucity of secondary sexual hair in either gender (most commonly in association with chronic liver disease, but also in certain endocrinopathies), abnormal skin colouring, such as the dark velvety appearance of acanthosis nigricans, or (very rarely and almost always in the presence of café au lait spots elsewhere) the characteristic freckling of von Recklinghausen’s disease.

Figure 2.13 Gross (in this case, painless) axillary lymph node enlargement.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

Support the weight of the patient’s arm by holding his arm at the elbow with your non-examining hand, so that the patient’s pectoral muscles are relaxed. With the fingers of your right hand cupped together, probe the apex of the left axilla, then slide them downwards against the chest wall to feel for lymphadenopathy. Next, ‘sweep’ your fingers along the inside of the anterior and posterior axillary folds, feeling for enlargement of the pectoral and subscapular lymph nodes respectively. Use your left hand in the same way to examine the right axilla.

Skin

Examination of the skin with respect to specific dermatological diagnoses is covered in Chapter 15. In the context of the general examination, the most important features relate to temperature, hydration, pallor, colour/pigmentation and cyanosis. Use the back of your fingers to assess the temperature of the skin. This complements rather than replaces the formal measurement with a thermometer. There may be generalized warmth in febrile illness or thyrotoxicosis, or localized warmth if there is regional inflammation. Cold skin may be localized, such as when a limb is deprived of its blood supply, or generalized in states of circulatory failure, when the skin feels clammy and sweaty.

Lift a fold of skin and make note of its thickness, mobility and how easily it returns to its original position (turgor). The skin on the back of the hand is often thin and fragile in elderly patients, may show decreased mobility in scleroderma (Fig. 2.14) or in oedematous states, and have reduced turgor in the presence of dehydration. The skin of acromegalic patients is typically thick and greasy.

Figure 2.14 Advanced scleroderma.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

An important determinant of skin colour is the relative amount of oxyhaemoglobin and deoxyhaemoglobin. Oxyhaemoglobin is a bright red pigment. An increase in its flow beneath thinned facial skin causes the characteristic plethora of Cushing’s syndrome (Fig. 2.15