Clinical Skills
Continuing our systematic approach, Part 2 explores the oral cavity, skin manifestations, endocrine findings, and lymphatic system. The general examination connects physical signs across systems to form coherent clinical hypotheses.
👄 The Mouth: More Than Just Teeth
Oral Cavity Assessment
Lip Examination:
🎯 Angular Cheilitis (Stomatitis)
- Cracks/fissures at mouth corners
- Associations: Iron deficiency, B-vitamin deficiency
- Nutritional status indicator
Gum Assessment:
🎯 Gum Hypertrophy
- Gingival overgrowth
- Classic cause: Phenytoin (anti-seizure medication)
🎯 Spongy & Bleeding Gums
- Diagnosis: Vitamin C deficiency (Scurvy)
- Tender, hemorrhagic gingiva
🎯 Burton's Line
- Blue-grey gum line
- Cause: Chronic lead poisoning
Tongue Examination:
🎯 Glossitis
- Smooth, beefy red appearance
- Loss of papillae
- Causes: Iron, B12, or Folate deficiency
🎯 Fasciculations
- Fine, worm-like muscle twitches
- Significance: Lower Motor Neuron disease (e.g., ALS)
🎯 Tongue Deviation
- Protrusion deviation toward affected side
- Indicates: CN XII (Hypoglossal) nerve lesion
🎯 Central Cyanosis
- Most reliable site: Undersurface of tongue
- Blue discoloration from hypoxemia
Buccal Mucosa & Oral Pathology:
🎯 Koplik's Spots
- Tiny white spots on red background
- Pathognomonic for: Measles
🎯 Buccal Pigmentation
- Brown mucosal spots
- Association: Addison's disease
🎯 Oral Thrush
- White, cottage-cheese-like patches
- Adherent plaques (cannot wipe away)
- Causes: Candida infection in immunocompromised, infants, antibiotic/steroid use
🦠 The Skin: A Canvas of Internal Disease
Dermatological Manifestations
Examination Sequence:
🎯 Step 1: Inspection
- Visual assessment of entire skin surface
- Color, texture, lesions, distribution
🎯 Step 2: Palpation
- Texture, temperature, moisture
- Lesion consistency and mobility
Key History for Skin Lesions:
🎯 Onset & Progression
- "Where did it start?"
- "How has it spread?"
🎯 Symptom Assessment
- "Does it itch?" (Pruritus)
- Systemic causes: Lymphoma, liver disease, polycythemia
🎯 Treatment History
- "What have you put on it?"
- Topical treatments alter appearance
Key Dermatological Signs:
🎯 Acanthosis Nigricans
- Velvety, dark pigmentation in body folds
- Axillae, neck, groin involvement
- Marker for: Internal malignancy (especially gastric cancer)
🎯 Pyoderma Gangrenosum
- Rapidly progressing, painful ulcers
- Violaceous, undermined borders
- Associations: Ulcerative Colitis, autoimmune conditions
🧬 Key Endocrine Findings
Endocrine System Manifestations
Cushing's Syndrome:
🎯 Characteristic Findings
- "Moon face" appearance
- Central obesity with thin limbs
- Purple abdominal striae
- Thin, fragile skin with easy bruising
🎯 Etiology
- Common: Iatrogenic (steroid medications)
- Endogenous: Pituitary or adrenal tumors
Addison's Disease (Adrenal Insufficiency):
🎯 Cutaneous Findings
- Diffuse hyperpigmentation
- Deep tan-like appearance
- Prominent in palmar creases, scars, buccal mucosa
🎯 Systemic Manifestations
- Hypotension (orthostatic)
- Weight loss and wasting
- Fatigue and weakness
🔄 The Reticuloendothelial System: Lymph Nodes & Blood
Lymphatic & Haematological Assessment
Lymph Node Palpation Protocol:
🎯 Descriptive Parameters
- Location: Anatomical region
- Size: Measurements in centimeters
- Consistency: Soft, rubbery, hard, firm
- Tenderness: Pain on palpation
- Mobility: Fixed vs. mobile
Key Lymph Node Patterns:
🎯 Cervical Nodes
- Common: Head/neck infections
- Concerning: Malignancy in older adults (nasopharyngeal cancer)
🎯 Virchow's Node
- Left supraclavicular location
- High suspicion: Abdominal malignancy (gastric cancer)
🎯 Generalized Lymphadenopathy
- Multiple region involvement
- Causes: HIV, Lymphoma, Leukemia, TB, Sarcoidosis
🎯 Lymphoma Patterns
- Hodgkin's: Often starts in neck nodes
- Non-Hodgkin's: Often widespread early
Haematological Disease Clues:
🎯 Leukaemia
- Pallor (anaemia)
- Petechiae/purpura (thrombocytopenia)
- Gum hypertrophy and bleeding
- Recurrent infections
🎯 Sickle Cell Disease
- Jaundice (hemolysis)
- Frontal bossing (marrow expansion)
- Chronic leg ulcers
🎯 Thalassaemia
- "Mongoloid" facies (marrow expansion)
- Massive splenomegaly
- Growth retardation
📋 The Golden Rule: IPPA Sequence
Systematic Examination Framework
IPPA Sequence:
🎯 I - Inspection
- Visual assessment first
- Scars, deformities, movements
🎯 P - Palpation
- Texture, temperature, masses
- Apex beat, thrills, tenderness
🎯 P - Percussion
- Organ borders and density
- Cardiac dullness, liver span
🎯 A - Auscultation
- Heart sounds, breath sounds
- Bruits, bowel sounds
Critical Reminder: Do NOT grab your stethoscope first! The IPPA sequence ensures comprehensive assessment and prevents missed findings.
Cardiovascular Example:
- Inspection: Scars, chest deformities, heaves
- Palpation: Apex beat location, thrills
- Percussion: Heart borders
- Auscultation: Heart sounds, murmurs
Pro Technique: Always examine from the patient's right side. Develop this habit for consistency and thoroughness in your clinical approach.
🎯 Clinical Synthesis
Bringing It All Together
General Examination Purpose:
- Forms initial clinical hypothesis
- Connects physical signs across systems
- Guides focused system-by-system examination
- Reveals the story the body is telling
Systematic Approach Areas:
🎯 Assessment Domains
- Facial characteristics and expressions
- Hand findings and nail pathology
- Oral cavity and mucosal examination
- Skin manifestations and texture
- Lymph node patterns and characteristics