Describe the general examination of clinical examination?

It is always to better to ask the patient to help himself/herself in setting on to the examination table and rename some dress if required it provides a good opportunity to observing the patient's general state of health, functional abilities, gait and balance etc.

a) Built: Like short or tall: tall person with thin built with long upper limb and long fingers suggest Marfan's Syndrome when span of out stretched upper limbs exceeds the height.

b) Height and Weight: In children if it is below normal percentile indicates under development end user to disease process. In adults these are often used to find out Body Mass Index when weight in Kg is divided by height in metre2 normal being 25kgm/m2: higher figures indicate obesity and low figures denotes undernutrition.

c) Posture: Lying comfortably, being propped up due to dyspnea.

d) Facies: Indicate facial expression and like anxious facies, moon facies, contour of face like wide inter epicanthic fold distance indicate hyperteleorism.

e) Pallor: Presence of significant anemia can be a precipitating factor for decomposition, or a part of chronic infection.

f) Cyanosis: It is important to differentiate between central and peripheral cyanosis. In peripheral cyanosis, tip of fingers, toes, tip of nose will have bluish discolouration in fair complexion but darkening of complexion noticed in person with dark colour, as it is in most of us. In case of central cyanosis besides the above sites blue discolouration is seen in coi~junctivaet,o ngue, inner part of lips and buccal mucosa. Central cyanosis is associated with central shunt i.e., s11unt at cardiac or aortopulmonary level. Occasionally R-L shunts in lung via pulmonary Arteriovenous (A-V). Fistula can cause central cyanosis and parenchymal lung disease like COPD. Central cyanosis can be differential, i.e., the intensity of cynosis is higher either in upper limb or lower limb. In case of shunt reversal via PDA due to pulmonary hypertension presence of cyanosis initially noted in lower limb.

g) Clubbing: Mainly seen in nails of finger and toes. Depending on severity it is , classified into:
i) Class I - due to subungual proliferation of tissue, causing excessive movement of nail on nail bed.
ii) Class I1 - when the angle sustained between nail and nail bed becomes obtuse.
iii) Class 111 - as parrot betaking of nails.
iv) Class IV -Pulmonary Osteodystrophy: when beside the change in nail bed there is swelling of wrist joint with tenderness due to mucopolysaccharide deposition around wrist joint.

h) Oedema: Swelling of parts of body due to subcutaneous accumulation of fluid as over ankle, lower part of legs and over the sacrum in bed ridden patient.
Pressure is applied over the part for 10-20 seconds, if indents and the indentation is seen lasting more than 1O sec on release of pressure oedema is present. It can also be classified as mild - involving the lower part of leg, dosum of feet and or over the sacrum. In moderate cases it extends upto thigh level, the face may look puffy and oedema may be found in dependant parts like back. Severe oedema is associated with ascites and/or pleural effusion and is called Anasarca.
Other signs of congenital defects especially in congenital heart disease like polydactyl, webbing of neck or fingers, low set ears, high arched palate and abnormal dental setting should be noted. Often chest wall abnormalities are to be noted like kyphosis, scoliosis, retraction of lower chest wall (pectus excavatum), precordial fullness or bulge denoting cardiac enlargement during growth period.
Normally abdomen is of scaphoid shape but fullness or bulge of abdomen could be due to accumulation of fluid in peritoneal cavity (ascites).