OutlineTHEGENERALEXAMINATIONTHESKINTHELYMPHATICSYSTEMTHEHEADTHENECKTHE-GENERAL-EXAMINATION緒論THEGENERALEXAMINATIONBeginsassoonasthepatiententerstheconsulting-roomorthedoctorapproachesthebedside.Earlyimpressionwillcertainlybeformedwhiletakingthepatient’shistory.Atthestart,demeanor,complexion,physiqueandtheotherfeatureswhichtogetherconstitutehisappearance.THE-GENERAL-EXAMINATION緒論THEGENERALEXAMINATION(cont…)Atfirstyoumustbepreparedtotakeitstimeanddevelopamethodicalroutine.Withincreasingfamiliarityandexperience,youwillgraduallyacquirefacilityandspeedaswellastheabilitytodiscriminatebetweenthedetailsofexaminationthatarevitalinonecaseandsuperfluousinanother.Tocompromisetooearlyinthisrespectistoinvitedisaster.THE-GENERAL-EXAMINATION緒論GENERALOBSERVATIONS

---DemeanorEarlyimpressionsbynotinghowhestandsordresses,hisgreetingandhishandshakeHisgaitmayindicatethepresenceofaneurologicalorlocomotordisturbanceIsheabletoadjusthispositionindependentlyorhashetobehelpedtodoso?Doeshesituporlifthisheadspontaneouslywhenaddressed?THE-GENERAL-EXAMINATION緒論Demeanor(cont.)Facialexpressionmayserveasaninitialguidetophysicalormentaldisorder.TheagitationofhyperthyroidismorhypomaniaTheapathyofhypothyroidismDepressionandthepovertyoffacialmovementinParkinsonism.Thedoctorshouldavoidadoptingthepatient’slight-heartedattitude,ontheotherhand,shouldnotbetooponderous.THE-GENERAL-EXAMINATION緒論ComplexionComplexionmaybecomearemarkablysensitiveindexofdisease.Theeffectoflightonthecomplexionisnotsowidelyappreciated.jaundicedeepenoughtobeobvioustoanyoneindaylight,maybeundetectableinartificiallight.Thecolorofthefacedependsuponvariationsin:Oxyhemoglobin,reducedhemoglobin,melanin,caroteneTHE-GENERAL-EXAMINATION緒論Complexion(cont.)Unusualcolors,duetoabnormalpigments:sulphemoglobinmethemoglobin(bluishtinge)carboxyhemoglobinincarbonmonoxidepoisoning(pink)jaundice(yelloworgreenish)uremia(sallowwithabrownishtinge)THE-GENERAL-EXAMINATION緒論HemoglobinAbnormalpallormaybeduetovasoconstrictionasinfright,ormaybeduetoanemia.Anundulyplethoriccomplexionmaybeseenin:somechronicalcoholicsCushing’ssyndromepolycythemiaTHE-GENERAL-EXAMINATION緒論MelaninThecolorislargelydeterminedbyhereditaryinfluencesbutmaybemodifiedbyanumberoffactors.Thepigmentdiminishesorincreasesinamountwithwithdrawalfromorexposuretoultravioletlight.Vitiligo,absenceofmelaninfromtheskinoccurinpatches.

THE-GENERAL-EXAMINATION緒論Melanin(cont.)Albinism,totalfailureofpigmentation(geneticallydeterminedfailuretoformtyrosinaseinthemelanocytes).Hypopituitarism:anacquiredformoffailuretosynthesizepigmentAddison’sdisease:reductionintheoutputofadrenocorticalhormonesexcessiveproductionofmelanocyte-stimulatinghormonebythepituitary.THE-GENERAL-EXAMINATION緒論Melanin(cont.)Pregnancymask:ablotchypigmentationofthefaceMelaninisalsoformedintheareola,thelineaalbaandaroundthegenitalia.Increasedmelaninformationisalsoinducedbyheavymetalsdepositedintheskin.Frecklesandthepigmentationofmoles:localover-productionofmelanin.THE-GENERAL-EXAMINATION緒論CaroteneUnevenlydistributedintheface,palmsandsolesbutnotinthesclerae.AdistinctyellowcolorofthefacemayappearinhypothyroidismbecauseofimpairedmetabolismofcaroteneintheliverCarotenaemiaoccasionallyoccursinvegetariansorinfoodfaddists.THE-GENERAL-EXAMINATION緒論BilirubinInhemolyticjaundice,thescleraeandtheskinarealemon-yellowcolor.Thestoolsaredarkandtheurinelooksnormal,butcontainsanexcessofurobilinogen.Thisformofjaundiceisduetoanincreaseinserumbilirubinattachedtoalbuminwhichisnotexcretedintheurine.THE-GENERAL-EXAMINATION緒論Bilirubin(cont…)Inhepatocellularorobstructivejaundice,bilirubinhasbeensplitfromthealbuminandconjugatedwithglucuronicacidbytheliver.Theurineisbrownlikebeerandthestoolstendtobepaleincolorlikeputty.Distinctgreenishcolorduetothedevelopmentofbiliverdin.Scratchmarksasaresultoftheprurituswhichoccursinobstructivejaundice.THE-GENERAL-EXAMINATION緒論AbnormalMovementsThe‘flappingtremor’ofencephalopathyduetohepaticfailure.The‘uremictwitchings’,irregulartwitchingmovementsmayoccurinrenalfailureandinrespiratoryfailurewithcarbondioxideretention.InthyrotoxicosisthetremorismorefinethaninParkinsonism.Senilityandchronicalcoholismalsomaycauseafairlycoarseratherirregulartremor.THE-GENERAL-EXAMINATION緒論THE-GENERAL-EXAMINATION緒論AbnormalSoundsAttentiontopeculiaritiesofvoiceandspeech.Theproductionofthevoiceinclude:

theabilitytoexpelsufficientairfromthelungstheintegrityofthemucosa,musclesandnervesupplyofthelarynxthetongue,lips,palateandnose.Theothercauses:acleftpalate,nasalobstruction,loosedentures.apprehension,stomatitis,glossitis.THE-GENERAL-EXAMINATION緒論AbnormalSounds(cont.)Hoarsenessofthevoice:neurologicalcauseslaryngitisofinflammatoryoriginexcessivesmokingchronicalcoholicTHE-GENERAL-EXAMINATION緒論AbnormalSounds(cont.)Thevoiceinmyxedema:thenormalinflectionsoftonedisappearlow-pitched,slow,deliberateseemstorequiremoreeffortthannormalsounds‘thick’,flowslessfreelythannormalChangesareattributedto:infiltrationofthetissuesconcernedinvoiceproductionchangesincerebralcorticalfunctionTHE-GENERAL-EXAMINATION緒論AbnormalSounds(cont.)Othertypesofsoundinconnectionwiththerespiratorysystem.wheezingstridorrattlingcrowingnoisesTHE-GENERAL-EXAMINATION緒論AbnormalOdorsSomeodorsaresufficientlycharacteristicastobediagnostic‘foetorhepaticus’ofliverfailurethesweetsmellofacetoneinthebreathindiabeticcomathemajorsourcesofmalodor:dirtyclothinggeneralsoilingtheskin,theaxillae,underthebreasts,theexternalgenitalia,thefeet.

THE-GENERAL-EXAMINATION緒論AbnormalOdors(cont.)Halitosis:beassociatedwithde-composingfoodwedgedbetweentheteethuncleanorcariousteethgingivitis,stomatitis,atrophicrhinitistumorsofthenasalpassages,pulmonarysuppuration,bronchiectasisTHE-GENERAL-EXAMINATION緒論AbnormalOdors(cont.)Pyloricobstructionfromscarringorassociatedwithcarcinomaofthestomach,foul-smellingeructationsmayoccur.Agastro-colicfistula,duetothefecalcontentsofthestomach.Someindividualswithhalitosisforwhichnoadequateexplanationcanbefound.THE-GENERAL-EXAMINATION緒論AbnormalOdors(cont.)Thesmellofalcohol→thepatient’shabitsThesourceofothersmells:excessivesweatingofthefeetgangrenechronicsuppurationnecrotictumorsorsomeskindisorders.THE-GENERAL-EXAMINATION緒論AnthropometryAroutineexamination:weightheightOthermeasurements:spansittingheightpubistogroundheightTHE-GENERAL-EXAMINATION緒論Anthropometry(cont.)

---theweight&heightTheweightbetaken:

intheoutpatientdepartment→includenormalindoorclothingwithoutshoes.inhospital→inbed-clothinganddressing-gownwithoutshoes.Theheightberecorded:withasuitablerigidarmslidingonaverticalscalewiththepatientstandingonanevenfloorsurfaceTHE-GENERAL-EXAMINATION緒論Anthropometry(cont.)Hyperpituitarism:giantismHypogonadism:thelimbscontinuetogrowforlongerthanisappropriatethesittingheightbelessthanhalftheheightofthestanding.theheightfromthetopofthesymphysispubistothegroundbetoexceedthesittingheightthespanofthearmsbetoexceedtheheightstandingTHE-GENERAL-EXAMINATION緒論THE-GENERAL-EXAMINATION緒論Anthropometry(cont…)

---Marfan’ssyndromeThelimbsaremuchlongerthanisappropriatetothelengthofthetrunkTodistinguishfromthehypogonadpatientlongslenderhandsnarrowfeetdislocationofthelensoftheeyeacardiaclesionTHE-GENERAL-EXAMINATION緒論Anthropometry(cont…)

---DwarfismDuetomanycauses:Achondroplasia:grossshorteningofallfourlimbswithanormaltrunklengthisaconstantandcharacteristicfinding.Thestuntedgrowthofrickets→knockkneeorbowlegCretinism,untreatedorinadequatelytreated,withothersignsofpersistenthypothyroidism(impairmentofmentaldevelopment).THE-GENERAL-EXAMINATION緒論NutritionalStatusAproperrelationshipbetweenheightandweight→thestandardtables.Tomeasuretheskinfoldthicknessusuallyoverthetricepsorbelowthescapula,includestwothicknessesofskinandsubcutaneousfat.Thecausesofmalnutrition:starvationspecificdeficiencies:protein,iron,vitaminsmalabsorptionindisordersofthesmallintestineTHE-GENERAL-EXAMINATION緒論AbnormalitiesofFatFatisstoredmainlyinthemesenteryandinthesubcutaneoustissues.Inthecommontypeofobesity,theabdomenispredominantlyaffected.Excessfatdepositsmaybesogreatastomakepalpationoftheabdomenuninformative.Thebreasts,thebuttocks,andthethighsusuallyshowsignsofundueaccumulationoffat.THE-GENERAL-EXAMINATION緒論THE-GENERAL-EXAMINATION緒論AbnormalitiesofFat(cont.)ThedistributionoffatinCushing’ssyndrome,beingtreatedwithcorticosteroids.thehormonesincreasetheappetiteleadtoamixtureofasimpleformofobesity‘buffaloobesity’‘mooningoftheface’THE-GENERAL-EXAMINATION緒論AbnormalitiesofFat(cont.)‘Buffaloobesity’:fatdepositionberestrictedtothetrunk,neckandfaceanincreaseofthenormalpadoffatoverthelowercervicalandupperthoracicvertebraethelimbsarethinorwasted‘Mooningoftheface’:thecomplexionbecomesfloridthefaceroundandtheneckthick.THE-GENERAL-EXAMINATION緒論THE-GENERAL-EXAMINATION緒論TheChangeinWeightAhistoryofarecentchangeinweightmustberegardedcriticallyuntilhasbeenexplainedLossofweight:carcinomaemaciationinyoungwomensufferingfromanorexianervosadiabetesorhyperthyroidism:increasedappetiteinadequateintake,malabsorptionorametabolicdisturbanceTHE-GENERAL-EXAMINATION緒論TheChangeinWeight(cont.)Weightlossunexplained,radiologicalexaminationofthechestfor:pulmonarytuberculosisprimarycarcinomaofthelungmetastaticdiseaseTHE-GENERAL-EXAMINATION緒論TheChangeinWeight(cont.)Againinweight:hypothyroidismtreatedwithcorticosteroidsendocrineadjustmentduringadolescencefollowingpregnancyatthemenopauseTHE-GENERAL-EXAMINATION緒論Temperature,Pulse,Respiration

andBloodpressureBodytemperature:estimatedfromtheskin(axilla),beneaththetongue,intherectum.Rectaltemperature0.5℃higherthanthemouthwhichinturn0.5℃higherthantheskin.Sublingualtemperatures→acompromisebetweenconvenienceandaccuracy,preventinfectionbeingspreadbythethermometer.Rectalreadingsaremorereliable.THE-GENERAL-EXAMINATION緒論NormaltemperaturerangesDifferentrangesofnormaltemperatureindifferenttextbooks.Axillatemperature:36.2～37.2℃Sublingualtemperature:36.7～37.7℃Rectaltemperature:36.9～37.9℃THE-GENERAL-EXAMINATION緒論Temperature(cont.)Feverorganicdiseasesinfection,carcinoma,rheumaticdiseasesmalingerersHypothermiaexposedtocoldaftertheonsetofacerebrovascularaccidenthypopituitarismorhypothyroidismincardiacsurgery.THE-GENERAL-EXAMINATION緒論Temperature,Pulse,Respiration

andBloodpressureExaminationofthepulse,respirationandbloodpressurewillbediscussedinotherChapters.THE-GENERAL-EXAMINATION緒論SummaryTHEGENERALEXAMINATIONDemeanorComplexionAbnormalMovementsAbnormalSoundsAbnormalOdorsAnthropometryNutritionalStatusTemperatureTHE-GENERAL-EXAMINATION緒論THESKINZhangShutian,M.D.,Ph.D.Professor&DirectorDept.ofGastroenterology&Hepatology,BeijingFriendshipHospital,CMUVisitingProfessorTheUniversityofHongKongTHE-GENERAL-EXAMINATION緒論THESKINPayaattentiontoabnormalitiesofitsstructureandfunctionPathologicallesionsdependlargelyuponinspectionTheskinshouldbescrutinizedasawholeTHE-GENERAL-EXAMINATION緒論ColorSimilartothecomplexionPigmentation:infestationwithbodylicevaricoseeczemafungalinfectionsDepigmentedanaestheticpatchesleprosyTHE-GENERAL-EXAMINATION緒論SweatingDiffusesweatinginhotatmospheres,duringexerciseinfeversorinhyperthyroidismFailuretosweatinahotclimatemaycausedeathfromhyperpyrexia(heatstroke).

THE-GENERAL-EXAMINATION緒論Sweating(cont.)Nervousnessontheface,palmsofthehands,solesofthefeetandintheaxillaeLocallossofsweating:Interruptionofthesympatheticnervesupply(Horner’ssyndrome)congenitalabsenceofsweatglands.THE-GENERAL-EXAMINATION緒論Sweating(cont.)Sweatcontainsmostofthesolutesofblood:sodiumchloridetheglucose↑indiabetes(predisposestoskininfections)Febrile:notvisiblesweating,butloseaconsiderableamountofwaterHyperhidrosis:excessiveandinappropriatesweating,confinedtotheaxillae,thepalmsofthehands,andthesolesofthefeet.THE-GENERAL-EXAMINATION緒論ErythemareddeningoftheskinPurpuraSpontaneousbleedingintotheskinThesizeandthedistribution→thecauseofthebleeding.THE-GENERAL-EXAMINATION緒論SpiderneviAcentralarterialdotfromwhichradiatenumerousdilatedvesselsAllofwhicharereadilyobliteratedbypressureRefillingcommencesfromthecentraldotThewholesystemcanbeemptiedbypressurewiththepointofapinonthecentralarteriolefeedingthevessels.THE-GENERAL-EXAMINATION緒論Spidernevi(cont.)Occurontheface,armsandupperpartofthebodyInpatientswithhepaticcirrhosis,pregnancyandhyperthyroidismOccasionallyinnormalpeople.THE-GENERAL-EXAMINATION緒論THE-GENERAL-EXAMINATION緒論THELYMPHATICSYSTEMZhangShutian,M.D.,Ph.D.Professor&DirectorDept.ofGastroenterology&Hepatology,BeijingFriendshipHospital,CMUVisitingProfessorTheUniversityofHongKongTHE-GENERAL-EXAMINATION緒論Theusualsites:pre-andpost-auricular,submental,tonsillar,occipital,andposteriorandanteriortrianglesoftheneck.THE-GENERAL-EXAMINATION緒論Thesupraclavicularfossaelymphnode’s