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 14. In the general survey, note if the patient is cachectic, slim, plump or obese (Box 2.1). If obese, is it generalized 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 together with acute or chronic illness results in blood albumin being low, leading to oedema and making overall body weight an unreliable marker of malnutrition. A smooth, often sore tongue
General patient examination and differential diagnosis 17
Check for clubbing of the fingers. Normally, the angle of the fingernail and the nail base (Lovibond’s angle) is approximately 180° and the base feels firm to palpation (Fig. 2.4). As clubbing develops, the tissues at the base of the nail are thickened and Lovibond’s angle is lost. Subsequently, the nail becomes more convex both transversely and longi-tudinally and seems to ‘float’ in a softened nailbed.
In normal nails, when both thumbnails are apposed, a diamond-shaped gap is created, called Schamroth’s window. With clubbing, a combination of the thick-ened nail bed and the loss of Lovibond’s angle dictates that this window is reduced or even obliterated. In gross cases (usually due to severe cyanotic heart disease, bronchiectasis or empyema), the volume of the finger pulp increases (Fig. 2.5) and becomes bulbous like the end of a drumstick. The toes may also be affected. Lesser degrees of clubbing may be seen in bronchial carcinoma, fibrosing alveolitis, 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.)
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.)
Normal nail Normal angle
<180°
Clubbed nail
Figure 2.4 Lovibond’s angle refers to the angulation between the nail plate and the skin below the nail, when viewed laterally.
Normally it is less than 180°. When clubbing is present, the angle is at least 180°, or more.
variation in temperature; the lowest values are recorded in the early morning with a maximum between 6 and 10 pm. In women, ovulation is associ-ated 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 handshake may be informative with regard to underlying neurological or musculo-skeletal disorders. Characteristic patterns of muscular wasting may accompany various neuropathies and radiculopathies (see Ch. 16). Make note of any tremor, taking care to distinguish the fine tremor of thyro-toxicosis or recent beta-adrenergic therapy from the rhythmical ‘pill rolling’ tremor of Parkinsonism (see Ch. 16) and from the coarse jerky tremor of hepatic or uraemic failure (sufficiently slow to be referred to as a metabolic ‘flap’) or the intention tremor of cerebellar disease.
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).
General patient examination and differential diagnosis 18
2
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. 2.6).
Splinter haemorrhages (Fig. 2.7) and nail-fold infarc-tions (Fig. 2.8) may be signs of a vasculitic process
Figure 2.5 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 2.6 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 2.7 Splinter haemorrhages. (From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)
Figure 2.8 Nail-fold infarction. (From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)
but may also be the result of trauma in normal individuals and are therefore rather non-specific.
Trophic changes may be evident in the skin in certain neurological diseases and in peripheral circula-tory 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. 2.9).
In koilonychia the nails are soft, thin and brittle and the normal convexity replaced by a spoon-shaped concavity (Fig. 2.10). It is a rare feature of longstanding iron-deficiency. Leuconychia (opaque white nails) may occur in chronic liver disease and other conditions associated with hypoalbuminaemia (Fig. 2.11) but are not particularly useful for making a clinical diagnosis of chronic liver disease.
Beau’s lines are horizontal (transverse) depressions in the nail that may result from any disease process, illness, chemotherapy or malnutrition that constitutes a sufficient insult to affect the growth plate of the
General patient examination and differential diagnosis 19
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 subjec-tive 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.