Research methods in patients with digestive diseases. Raxsquare. The main complaints. Mechanism of development of symptoms and their diagnostic value.General examination. Examination of the oral cavity, examination of the abdomen.
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This topic can be organized into:
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Clinical research methods in digestive diseases
- History taking, physical examination, laboratory testing, endoscopy, imaging, functional studies, and biopsy.
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Main gastrointestinal complaints
- Abdominal pain, dyspepsia, heartburn, nausea and vomiting, dysphagia, diarrhea, constipation, gastrointestinal bleeding, jaundice, weight loss, and abdominal distension.
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Mechanisms and diagnostic value of symptoms
- How each symptom develops and how its pattern helps localize disease to the esophagus, stomach, intestine, liver, biliary tract, or pancreas.
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General examination
- General appearance, nutritional state, pallor, jaundice, dehydration, edema, lymph nodes, skin signs, and vital signs.
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Oral-cavity examination
- Lips, tongue, teeth, gums, mucosa, breath odor, ulcers, pigmentation, and nutritional deficiencies.
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Abdominal examination
- Inspection, auscultation, percussion, palpation, detection of organ enlargement, ascites, masses, tenderness, and peritoneal irritation.
High-level overview: Diagnosis in digestive disease begins with a focused history and careful examination. Symptoms such as pain, vomiting, altered bowel habits, bleeding, and jaundice suggest particular anatomical sites and disease mechanisms, but require confirmation by investigations such as blood and stool tests, ultrasound, endoscopy, CT/MRI, and histology.
Physical examination can identify systemic consequences of gastrointestinal disease, including anemia, malnutrition, dehydration, chronic liver disease, obstruction, inflammation, and malignancy. Abdominal examination is particularly important for recognizing localized tenderness, hepatosplenomegaly, ascites, bowel obstruction, and peritonitis.
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Examination of patients with digestive diseases: pathology-based approach
The purpose of clinical assessment is to connect symptoms and physical signs with the underlying pathological process: inflammation, ulceration, obstruction, dysmotility, malabsorption, infection, bleeding, fibrosis, vascular disease, or tumor.
1. Methods of investigation
A. History taking
Establish:
- Onset, duration, progression, and relation of symptoms to food and defecation
- Previous gastrointestinal disease, abdominal operations, infections, alcohol use, smoking, and drugs, especially NSAIDs, antibiotics, anticoagulants, and iron
- Diet, travel, family history of colorectal cancer, inflammatory bowel disease, celiac disease, and liver disorders
- Constitutional symptoms: fever, fatigue, anorexia, weight loss, night sweats
The history guides anatomical localization. For example, dysphagia suggests esophageal disease, while jaundice suggests hepatobiliary disease. Alarm features such as progressive dysphagia, bleeding, recurrent vomiting, anemia, fever, weight loss, a palpable mass, or jaundice require prompt investigation for organic disease, including cancer or severe inflammation (Harrison's approach).
B. Laboratory tests
Chosen according to suspected pathology:
- Complete blood count: anemia from chronic bleeding, macrocytosis from malabsorption, leukocytosis in infection/inflammation
- CRP and ESR: inflammatory activity, for example inflammatory bowel disease
- Liver profile: bilirubin, AST/ALT, alkaline phosphatase, GGT, albumin, INR
- Amylase/lipase: pancreatic injury
- Stool testing: occult blood, culture/PCR, ova and parasites, fecal calprotectin, fecal fat
- Serology: celiac antibodies; hepatitis markers; autoimmune liver antibodies where indicated
C. Imaging and procedures
- Ultrasound: hepatomegaly, gallstones, biliary dilatation, ascites, portal hypertension.
- Upper GI endoscopy: esophagitis, peptic ulcer, tumor, varices, gastritis; enables biopsy.
- Colonoscopy: colitis, polyps, cancer, bleeding, inflammatory bowel disease.
- CT/MRI: obstruction, mass, perforation, pancreatic disease, abscess, vascular lesions.
- Biopsy and histopathology: confirms inflammation, dysplasia, malignancy, celiac disease, granulomas, and specific infections.
- Functional studies: pH monitoring and manometry for reflux/motility disorders; gastric emptying studies for gastroparesis.
2. Main complaints: pathological mechanisms and diagnostic value
| Complaint | Main pathological mechanisms | Diagnostic value |
|---|---|---|
| Abdominal pain | Visceral distension or spasm, inflammation, ischemia, traction on mesentery, or peritoneal irritation | Colicky pain suggests obstruction or biliary/ureteric spasm. Constant, severe pain with guarding suggests inflammation or peritonitis. Pain that is disproportionate to examination raises concern for mesenteric ischemia. |
| Heartburn and regurgitation | Reflux of gastric contents because of transient lower-esophageal-sphincter relaxation, hiatal hernia, impaired clearance, or delayed gastric emptying | Typical of gastroesophageal reflux disease. Regurgitation with dysphagia may suggest stricture, achalasia, or esophageal tumor. |
| Dysphagia | Mechanical narrowing due to cancer, peptic stricture, web, or ring; impaired motility due to achalasia or systemic sclerosis | Progressive dysphagia, especially solids first then liquids, favors mechanical obstruction. Dysphagia to solids and liquids from onset favors motility disorder. |
| Odynophagia | Esophageal mucosal inflammation/ulceration, such as pill esophagitis, Candida, viral infection, reflux, or tumor | Indicates esophageal injury rather than simple reflux; endoscopy is commonly needed. |
| Dyspepsia/epigastric discomfort | Gastritis, peptic ulcer disease, reflux, impaired gastric accommodation, visceral hypersensitivity, delayed emptying, or malignancy | Meal-related epigastric pain may occur in ulcer disease. Early satiety can result from impaired gastric accommodation, gastroparesis, or gastric cancer. |
| Nausea and vomiting | Stimulation of the vomiting center by visceral afferents, toxins, CNS stimuli, metabolic disorders, or obstruction | Feculent vomiting suggests distal intestinal obstruction. Bilious vomiting suggests obstruction distal to the ampulla. Vomiting undigested food hours after meals suggests gastroparesis or gastric outlet obstruction. |
| Diarrhea | Secretory fluid loss, osmotic retention of solutes, mucosal inflammation/exudation, malabsorption, or rapid intestinal transit | Nocturnal diarrhea and inflammatory diarrhea suggest organic disease. Blood, fever, and urgency suggest colitis. Bulky greasy stool indicates steatorrhea and malabsorption. |
| Constipation | Slow colonic transit, outlet dysfunction, dehydration, medications, metabolic disease, or mechanical obstruction | New constipation with weight loss, anemia, rectal bleeding, or a mass requires exclusion of colorectal cancer or stricture. |
| GI bleeding | Mucosal ulceration, tumor, varices, vascular malformation, diverticular disease, or colitis | Hematemesis and melena usually indicate upper-GI bleeding. Hematochezia usually indicates lower-GI bleeding, but brisk upper-GI bleeding can also cause it. |
| Jaundice | Hyperbilirubinemia from hemolysis, hepatocellular dysfunction, or biliary obstruction | Dark urine, pale stool, pruritus, and raised alkaline phosphatase suggest obstructive cholestasis. Jaundice with fever and right-upper-quadrant pain suggests acute biliary infection. |
| Abdominal distension | Gas, ascites, mass, pregnancy, obesity, enlarged organs, or intestinal obstruction | Tympany favors gas or obstruction; shifting dullness suggests ascites; a localized, fixed distension may indicate a mass or enlarged organ. |
| Weight loss | Malignancy, chronic inflammation, malabsorption, chronic infection, persistent vomiting, or reduced intake | An important alarm symptom. It should prompt assessment for cancer, inflammatory bowel disease, celiac disease, pancreatic insufficiency, and chronic liver disease. |
3. General examination
Observe the patient before examining the abdomen.
General appearance
- Pallor: iron-deficiency anemia from chronic GI blood loss, malabsorption, or malignancy.
- Jaundice: hepatic dysfunction or biliary obstruction.
- Cachexia and muscle wasting: malignancy, malabsorption, chronic pancreatitis, advanced liver disease, chronic inflammatory disease.
- Dehydration: vomiting, diarrhea, intestinal obstruction, or poor intake.
- Fever and toxic appearance: infection, cholangitis, abscess, severe colitis, peritonitis.
- Tachycardia, hypotension, cold clammy skin: hypovolemia due to bleeding, sepsis, or dehydration.
Skin and peripheral signs
- Spider angiomas, palmar erythema, bruising, edema, gynecomastia: chronic liver disease and portal hypertension.
- Scratch marks: pruritus from cholestasis.
- Hyperpigmentation: may occur in chronic liver disease or hemochromatosis.
- Erythema nodosum, pyoderma gangrenosum, oral ulcers, arthritis: extraintestinal inflammatory bowel disease manifestations.
- Virchow node, left supraclavicular lymphadenopathy: possible metastatic abdominal malignancy.
- Peripheral edema: hypoalbuminemia due to liver failure, protein-losing enteropathy, or malnutrition.
4. Examination of the oral cavity
Inspect the lips, oral mucosa, gums, teeth, tongue, palate, and pharynx.
| Finding | Pathological implication |
|---|---|
| Dry mouth, dry tongue, reduced saliva | Dehydration |
| Angular cheilitis, glossitis, mouth ulcers | Iron, folate, or vitamin B12 deficiency; may reflect malabsorption or chronic blood loss |
| Smooth red tongue | Atrophic glossitis, classically nutritional deficiency |
| Aphthous ulcers | Crohn disease, ulcerative colitis, celiac disease, Behçet disease, nutritional deficiency |
| Oral candidiasis | Immunosuppression, diabetes, antibiotics, malnutrition; can coexist with esophageal candidiasis |
| Dental erosion | Chronic vomiting or gastroesophageal reflux due to acid exposure |
| Fetor hepaticus | Advanced hepatic failure with portosystemic shunting |
| Pigmentation of lips/oral mucosa | Consider Peutz-Jeghers syndrome, Addison disease, or drug-related pigmentation |
The oropharynx should also be examined for hydration, ulcers, and inflammation as part of GI assessment (Merck Manual examination guidance).
5. Examination of the abdomen
The patient should lie supine with knees slightly flexed and arms by the side. Examine painful areas last. The sequence is:
A. Inspection
Look for:
- Contour and distension
- Generalized distension: ascites, obstruction, ileus, gaseous distension.
- Localized mass or asymmetry: enlarged organ, tumor, cyst.
- Scars: prior laparotomy may cause adhesions and later bowel obstruction.
- Dilated veins/caput medusae: portal hypertension with collateral circulation.
- Striae: ascites, obesity, pregnancy, or Cushing syndrome.
- Hernias: umbilical, incisional, inguinal.
- Visible peristalsis: may indicate intestinal obstruction, especially gastric outlet obstruction or thin patients with obstructed bowel.
- Pulsation: expansile pulsation may indicate abdominal aortic aneurysm.
B. Auscultation
Do this before palpation because palpation can alter bowel sounds.
- High-pitched, frequent, tinkling sounds: mechanical intestinal obstruction.
- Absent or markedly reduced sounds: paralytic ileus or diffuse peritonitis.
- Bruit over liver/epigastrium: may suggest vascular lesion, tumor, or arterial stenosis.
- Venous hum: occasionally in portal hypertension.
C. Percussion
- Tympany: gas-filled bowel, gastric distension, or bowel obstruction.
- Generalized dullness with shifting dullness: ascites.
- Localized dullness: mass, enlarged liver/spleen, full bladder, or fecal loading.
- Liver span: estimates hepatomegaly or a small cirrhotic liver.
D. Palpation
Superficial palpation
Detect:
- Localized tenderness
- Cutaneous hyperesthesia
- Voluntary guarding due to anxiety or pain
- Involuntary rigidity, which suggests peritoneal inflammation
Deep palpation
Assess:
- Masses: site, size, surface, mobility, consistency, pulsation, tenderness
- Liver and spleen enlargement
- Kidneys and bladder
- Aortic pulsation
- Fecal masses
Important pathological signs
- Rebound tenderness and involuntary guarding: peritoneal irritation, for example perforated ulcer, appendicitis, diverticulitis, or peritonitis.
- Right-upper-quadrant tenderness/Murphy sign: acute cholecystitis.
- Epigastric tenderness: gastritis, ulcer disease, pancreatitis, or upper-GI malignancy.
- Left-lower-quadrant tenderness: diverticulitis or colitis.
- Hepatomegaly: hepatitis, congestion, fatty liver, infiltration, metastatic tumor, or biliary obstruction.
- Splenomegaly: portal hypertension, hematologic disease, infection, or infiltrative disease.
- Fluid thrill or shifting dullness: clinically significant ascites.
- Palpable gallbladder with painless jaundice: raises suspicion of distal biliary obstruction, often pancreatic or periampullary malignancy.
E. Completion of examination
Do not omit:
- Digital rectal examination: rectal mass, tenderness, fecal impaction, melena, fresh blood, fissure, hemorrhoids.
- Examination of hernial orifices: obstruction can arise from an incarcerated hernia.
- Pelvic examination when indicated: gynecological pathology can mimic GI disease.
A standard abdominal examination proceeds from inspection to auscultation, percussion, and systematic palpation. Tympany supports bowel gas or obstruction, while dullness may indicate ascites; deep palpation identifies masses or organ enlargement (Merck Manual GI evaluation).
Key pathological principle
Symptoms and signs are not diagnoses by themselves. They indicate the likely anatomical site and mechanism, then must be correlated with laboratory tests, imaging, endoscopy, and histopathology. For example:
- Pain + fever + guarding: inflammatory or perforative intra-abdominal pathology.
- Jaundice + dark urine + pale stool + pruritus: obstructive cholestasis.
- Chronic diarrhea + anemia + weight loss: malabsorption, inflammatory bowel disease, infection, or malignancy.
- Ascites + splenomegaly + abdominal-wall collateral veins: portal hypertension, often due to cirrhosis.
Infection diseases
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For infectious diseases, the corresponding examination topic can be studied as:
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Methods of investigation in infectious diseases
- Epidemiological history, clinical examination, microbiological tests, serology, PCR, cultures, imaging, and biopsy where required.
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Main complaints
- Fever, chills, sweating, weakness, headache, myalgia, rash, sore throat, cough, dyspnea, diarrhea, vomiting, abdominal pain, jaundice, and lymph-node enlargement.
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Mechanisms and diagnostic value of symptoms
- Fever from pyrogen-mediated cytokines.
- Rash from microbial toxins, vascular injury, or immune reactions.
- Diarrhea from enteric infection, toxin action, mucosal inflammation, or malabsorption.
- Jaundice from viral hepatitis, hemolysis, or sepsis-related cholestasis.
- Lymphadenopathy and hepatosplenomegaly from reticuloendothelial and immune activation.
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General examination
- Temperature pattern, consciousness, hydration, nutritional state, pallor, cyanosis, jaundice, edema, rash, hemorrhages, and signs of shock or sepsis.
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Oral cavity and pharynx
- Enanthem, tonsillitis, pharyngeal exudate, oral ulcers, thrush, Koplik spots, strawberry tongue, and dehydration.
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Abdominal examination
- Tenderness, distension, bowel sounds, liver and spleen enlargement, ascites, guarding, and signs of peritonitis.
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Disease-specific clinical syndromes
- Acute respiratory infection, acute gastroenteritis, viral hepatitis, meningitis/encephalitis, exanthematous infections, sepsis, zoonoses, malaria, and HIV-related infections.
Core principle: infectious-disease diagnosis combines the clinical syndrome with epidemiological exposure and pathogen confirmation. Fever alone is nonspecific. Its diagnostic value becomes much greater when assessed together with the pattern of onset, exposure history, rash, organ involvement, blood count, inflammatory markers, and microbiological testing.
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General Examination in Infectious Diseases
Definition and objectives
General examination is the systematic assessment of the patient's overall condition before detailed examination of individual organ systems. In suspected infection, it helps to:
- Assess severity and identify emergencies such as sepsis, shock, meningitis, respiratory failure, and severe dehydration.
- Recognize characteristic syndromes, for example fever with rash, lymphadenopathy, jaundice, or hepatosplenomegaly.
- Detect the probable focus of infection.
- Identify signs of complications and underlying immunosuppression.
- Direct microbiological tests and further examination.
A comprehensive examination should be interpreted together with the epidemiological history, including travel, animal or insect exposure, food and water exposure, contact with ill persons, vaccination status, medications, and immune status. Goldman-Cecil Medicine emphasizes that in fever syndromes, targeted testing should follow clues from a complete history and physical examination. Goldman-Cecil Medicine, p. 2937.
1. First impression: assess the severity of illness
Observe the patient on entering the room.
A. General condition
Classify as:
- Satisfactory/stable: alert, comfortable, normal perfusion and breathing.
- Moderately severe: febrile, weak, toxic-looking, dehydrated, tachycardic.
- Severe/critical: altered consciousness, cyanosis, severe dyspnea, hypotension, cold extremities, bleeding, seizures, oliguria, or signs of shock.
B. Position and behavior
| Finding | Possible significance |
|---|---|
| Restless, anxious, confused | Hypoxemia, sepsis, encephalopathy, meningitis, severe pain |
| Lethargic or drowsy | Sepsis, dehydration, metabolic disturbance, encephalitis |
| Neck held stiffly or patient avoids flexing neck | Meningeal irritation |
| Lying still with flexed hips/knees | Peritonitis |
| Sitting upright, using accessory muscles | Respiratory distress |
| Rigors/shivering | Acute bacteremia, malaria, severe febrile illness |
C. Level of consciousness
Assess orientation to person, place, and time, and assess response to voice or pain if impaired.
Altered mental status may occur in sepsis, meningitis, encephalitis, cerebral malaria, severe hypoglycemia, hepatic encephalopathy, or hypoxemia. It is an urgent warning sign.
2. Vital signs
Measure and document:
- Temperature
- Pulse rate and rhythm
- Blood pressure
- Respiratory rate
- Oxygen saturation
- Urine output when illness is severe
A. Temperature
Fever occurs when exogenous or endogenous pyrogens stimulate cytokines such as IL-1, IL-6, and TNF, increasing hypothalamic prostaglandin E2 and raising the temperature set point.
A temperature above approximately 37.8 degrees C can be considered fever, although normal temperature varies with time of day and measurement method. Goldman-Cecil Medicine, p. 2937.
Fever patterns and their significance
| Pattern | Description | Examples |
|---|---|---|
| Continuous | Daily variation less than 1 degree C; temperature does not return to normal | Typhoid fever, lobar pneumonia, severe bacterial infection |
| Remittent | Fluctuates by more than 1 degree C but never becomes normal | Infective endocarditis, viral and bacterial infections |
| Intermittent | Returns to normal between spikes | Malaria, sepsis, abscess |
| Relapsing | Febrile episodes separated by afebrile periods of days | Relapsing fever, some malaria syndromes |
| Pel-Ebstein-like | Cyclical periods of fever and no fever | Not specific; classically described with lymphoma |
| Biphasic/saddleback | Fever subsides then recurs | Dengue and some viral infections |
Important: Fever pattern alone rarely establishes a diagnosis. It must be correlated with exposure history, symptoms, examination, and laboratory data.
B. Pulse
- Tachycardia: fever, dehydration, pain, sepsis, hypovolemia.
- Bradycardia relative to fever: may be seen in typhoid fever, brucellosis, leptospirosis, some viral infections, and drug effect, but it is not diagnostic.
- Weak, rapid pulse: shock, dehydration, or major blood loss.
C. Respiratory rate and oxygen saturation
Tachypnea may result from:
- Pneumonia
- Sepsis
- Metabolic acidosis
- Pulmonary edema or acute respiratory distress syndrome
- Severe anemia
Hypoxemia, cyanosis, or respiratory distress requires immediate assessment and management.
D. Blood pressure and peripheral perfusion
Hypotension, cool extremities, delayed capillary refill, oliguria, and confusion suggest shock, especially septic or hypovolemic shock. Normal blood pressure does not exclude early sepsis.
3. Nutritional state, hydration, and body habitus
A. Nutritional state
Look for:
- Weight loss
- Temporal muscle wasting
- Loss of subcutaneous fat
- Reduced muscle bulk
- Poor wound healing
These may occur in chronic infections such as tuberculosis, HIV-associated disease, chronic parasitic infection, infective endocarditis, and disseminated fungal disease.
B. Hydration
Assess:
- Dry tongue and oral mucosa
- Reduced skin turgor, especially useful in children
- Sunken eyes
- Tachycardia
- Postural hypotension
- Reduced urine output
Dehydration is frequent in acute gastroenteritis, cholera, persistent fever, vomiting, and sepsis.
4. Examination of the skin and mucous membranes
A complete skin examination is essential because infectious diseases may cause rash, hemorrhage, eschars, ulcers, vesicles, and signs of vector bites. CDC specifically emphasizes examination for skin signs, jaundice, altered mental state, nuchal rigidity, pulmonary consolidation, and lymphadenopathy in patients with possible travel-related parasitic disease (CDC Yellow Book).
A. Skin color
| Sign | Diagnostic implication |
|---|---|
| Pallor | Anemia, hemolysis, chronic disease, hemorrhage |
| Jaundice | Viral hepatitis, leptospirosis, malaria-related hemolysis, severe sepsis, biliary infection |
| Cyanosis | Severe pneumonia, respiratory failure, shock |
| Flushing | Fever, toxin-mediated illness, scarlet fever |
| Hyperpigmentation | May suggest chronic adrenal disease, but is not a usual acute infection sign |
B. Rash or exanthem
Describe the rash precisely:
- Type: macule, papule, vesicle, pustule, wheal, petechia, purpura, eschar.
- Distribution: face, trunk, limbs, palms, soles, mucosa.
- Timing: relation to fever and disease day.
- Blanching or non-blanching.
- Pruritic or painful.
- Progression: localized or generalized.
| Rash/lesion | Important infectious considerations |
|---|---|
| Maculopapular/morbilliform rash | Measles, rubella, EBV, acute HIV, dengue, enteroviruses, rickettsial disease |
| Vesicular rash | Varicella, herpes simplex, herpes zoster, hand-foot-mouth disease |
| Petechiae or purpura | Meningococcemia, dengue, severe sepsis, viral hemorrhagic disease, infective endocarditis |
| Eschar | Tick-borne rickettsial infection, anthrax, scrub typhus |
| Diffuse erythematous sandpaper rash | Scarlet fever |
| Urticaria | Viral, parasitic, or allergic causes |
| Jaundice with fever | Hepatitis, leptospirosis, cholangitis, severe malaria, sepsis-associated cholestasis |
Non-blanching rash with fever is an emergency, particularly if rapidly progressive or accompanied by hypotension, altered consciousness, or neck stiffness. Consider meningococcal sepsis until proven otherwise.
C. Hemorrhagic signs
Look for:
- Petechiae and purpura
- Ecchymoses
- Gum bleeding
- Epistaxis
- Conjunctival hemorrhage
- Bleeding from injection sites
These can indicate thrombocytopenia, disseminated intravascular coagulation, viral hemorrhagic disease, dengue, severe sepsis, or liver failure.
5. Head, eyes, mouth, and throat
A. Eyes
Look for:
- Conjunctival injection: viral infection, leptospirosis, Kawasaki disease.
- Conjunctival suffusion: classically associated with leptospirosis.
- Scleral icterus: jaundice.
- Pallor: anemia.
- Retinal hemorrhages or Roth spots: possible infective endocarditis.
- Photophobia: meningitis or encephalitis.
B. Oral cavity and pharynx
Inspect lips, gums, tongue, buccal mucosa, tonsils, palate, and posterior pharynx.
| Finding | Possible infectious significance |
|---|---|
| Dry mucosa, cracked lips | Dehydration |
| Pharyngeal erythema and tonsillar exudate | Streptococcal pharyngitis, infectious mononucleosis, diphtheria |
| Gray adherent pseudomembrane | Diphtheria, requires urgent action |
| Oral thrush | Candida infection, immunosuppression, HIV, diabetes, recent antibiotics |
| Oral ulcers | HSV, hand-foot-mouth disease, HIV, Behçet-like syndromes |
| Koplik spots | Measles |
| Strawberry tongue | Scarlet fever, toxic shock syndrome, Kawasaki disease |
| Gingival bleeding | Thrombocytopenia, hematological infection-related complication |
6. Lymph-node examination
Palpate systematically:
- Occipital
- Preauricular
- Submental and submandibular
- Cervical chains
- Supraclavicular
- Axillary
- Epitrochlear
- Inguinal nodes
Record:
- Site and distribution
- Size
- Tenderness
- Consistency
- Mobility
- Matting
- Skin changes
- Presence of draining lesion
Diagnostic significance
| Pattern | Likely implication |
|---|---|
| Tender, soft, mobile regional nodes | Acute bacterial infection in drainage area |
| Generalized lymphadenopathy | EBV, CMV, acute HIV, rubella, toxoplasmosis, secondary syphilis, disseminated TB, hematologic malignancy |
| Posterior cervical nodes | Infectious mononucleosis, rubella, toxoplasmosis |
| Matted nodes | Tuberculosis, lymphoma, chronic bacterial infection |
| Fluctuant node | Suppurative lymphadenitis/abscess |
| Hard fixed node | Consider malignancy rather than infection |
Fever, rash, lymphadenopathy, and hepatosplenomegaly together may occur in several infections, including EBV infection, toxoplasmosis, acute HIV, rickettsial illness, and disseminated infections. These signs must not be assumed to be infectious because hematological malignancy and autoimmune disease can produce the same syndrome.
7. Abdomen and reticuloendothelial system
Even during a general examination, palpate for liver and spleen enlargement.
A. Hepatomegaly
May occur in:
- Viral hepatitis
- Malaria
- Leptospirosis
- Infectious mononucleosis
- Liver abscess
- Disseminated tuberculosis
- Sepsis
- Congestive or infiltrative disorders
Assess liver size, edge, surface, tenderness, and consistency. A tender liver may suggest hepatitis, hepatic congestion, liver abscess, or acute cholangitis.
B. Splenomegaly
May occur in:
- Malaria
- Visceral leishmaniasis
- Infectious mononucleosis
- Typhoid fever
- Infective endocarditis
- Disseminated tuberculosis
- Schistosomiasis with portal hypertension
Clinical caution: In infectious mononucleosis and malaria, splenic enlargement increases the risk of splenic rupture. Avoid contact sport or abdominal trauma until the risk is assessed.
C. Abdominal tenderness and distension
- Diffuse tenderness: gastroenteritis, peritonitis, sepsis.
- Right-upper-quadrant pain/tenderness: hepatitis, liver abscess, cholecystitis, cholangitis.
- Left-upper-quadrant tenderness: splenic enlargement or infarction.
- Distension and ascites: chronic liver disease, peritonitis, severe hypoalbuminemia, tuberculosis.
8. Peripheral edema and signs of chronic systemic disease
Look for:
- Pedal edema
- Sacral edema in bedridden patients
- Ascites
- Generalized edema
Possible causes include severe sepsis with capillary leak, malnutrition, nephrotic syndrome, renal disease, heart failure, and chronic liver disease.
Also inspect the hands and feet for:
- Peripheral cyanosis
- Clubbing, which may be seen in chronic pulmonary infection or infective endocarditis
- Splinter hemorrhages, Osler nodes, Janeway lesions, and petechiae in suspected infective endocarditis
- Hand or foot swelling and desquamation in selected exanthematous illnesses
9. Neurological warning signs
During general examination, specifically look for:
- Confusion, agitation, drowsiness, coma
- Neck stiffness
- Photophobia
- Seizures
- Focal weakness
- Cranial nerve deficit
- Abnormal posture
- New rash with neurological symptoms
These raise concern for meningitis, encephalitis, cerebral malaria, brain abscess, severe sepsis, or toxic-metabolic encephalopathy. Do not delay urgent evaluation for a prolonged examination.
10. Red flags requiring urgent action
Immediate escalation is required when infection is associated with:
- Hypotension, mottled/cold skin, reduced urine output, or altered consciousness
- Severe respiratory distress, cyanosis, or low oxygen saturation
- Petechial or purpuric rash with fever
- Neck stiffness, seizures, focal neurological deficit, or reduced consciousness
- Severe dehydration or persistent vomiting/diarrhea
- Jaundice with confusion, bleeding, or shock
- Rapidly progressive soft-tissue pain, swelling, blistering, or skin necrosis
- Suspected diphtheria, meningococcal disease, severe malaria, cholera, viral hemorrhagic fever, or sepsis
Examination sequence for exams
Use this short sequence in an OSCE or written answer:
- General appearance: consciousness, distress, nutritional state, hydration, posture.
- Vitals: temperature, pulse, BP, respiratory rate, oxygen saturation.
- Hands and skin: pallor, cyanosis, jaundice, rash, petechiae, peripheral perfusion.
- Face and eyes: conjunctivae, sclera, facial rash, photophobia.
- Oral cavity and pharynx: hydration, ulcers, thrush, tonsils, exudate, membrane.
- Lymph nodes: cervical, axillary, inguinal, generalized versus localized.
- Abdomen: hepatomegaly, splenomegaly, tenderness, ascites.
- Peripheral edema and signs of endocarditis.
- Rapid neurological screening: mental state, neck stiffness, focal deficits.
- Examine the likely focus: respiratory, urinary, gastrointestinal, skin/soft tissue, CNS, or genital tract.
One-line conclusion for an exam answer
In infectious diseases, general examination assesses the severity of systemic illness and detects diagnostic syndromes such as fever, rash, jaundice, lymphadenopathy, hepatosplenomegaly, dehydration, shock, and neurological impairment, thereby guiding urgent treatment, infection-control measures, and targeted microbiological investigation.
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General Examination in Infectious Diseases Only
Purpose
General examination in a patient with suspected infectious disease aims to:
- Assess the severity of infection.
- Identify the probable site and type of infection.
- Detect signs of dehydration, sepsis, shock, meningitis, hemorrhage, or organ involvement.
- Recognize characteristic infectious syndromes such as fever with rash, jaundice, lymphadenopathy, and hepatosplenomegaly.
1. General condition and consciousness
Assess whether the patient is:
- Comfortable, ill-looking, toxic, or moribund
- Alert, drowsy, confused, agitated, stuporous, or unconscious
- Able to drink, eat, walk, and communicate
Diagnostic value
- Toxic appearance, confusion, drowsiness, cold extremities, or reduced urine output suggest severe infection or sepsis.
- Altered consciousness may occur in meningitis, encephalitis, cerebral malaria, severe sepsis, or severe viral infection.
- Restlessness and severe weakness can occur with high fever, dehydration, hypoxia, or bacteremia.
2. Body temperature and fever
Measure the temperature and note its pattern.
Mechanism
Microbial products and inflammatory cytokines, particularly IL-1, IL-6, and TNF, stimulate prostaglandin E2 formation in the hypothalamus, raising the body's temperature set point.
Fever patterns in infections
| Pattern | Description | Infectious examples |
|---|---|---|
| Continuous fever | Temperature remains raised with little daily variation | Typhoid fever, pneumonia |
| Remittent fever | Temperature fluctuates but does not become normal | Many bacterial and viral infections |
| Intermittent fever | Fever spikes with normal temperature between episodes | Malaria, bacteremia, abscess |
| Relapsing fever | Febrile episodes separated by afebrile days | Relapsing fever, some malaria infections |
| Biphasic fever | Fever improves then returns | Dengue and some viral infections |
Fever is common but not universal. Infants, elderly patients, immunocompromised patients, and severely septic patients may have normal temperature or hypothermia.
3. Pulse, blood pressure, respiration, and oxygenation
Pulse
- Tachycardia: fever, dehydration, pain, sepsis.
- Weak, rapid pulse: hypovolemia, severe dehydration, septic shock.
- Relative bradycardia: may be observed in typhoid fever, brucellosis, leptospirosis, and some viral infections, but is not diagnostic.
Blood pressure and perfusion
Look for hypotension, delayed capillary refill, cold or mottled skin, reduced urine output, and confusion.
These are signs of sepsis or septic shock.
Respiration
Observe respiratory rate, work of breathing, cyanosis, and oxygen saturation.
- Tachypnea may indicate pneumonia, sepsis, hypoxemia, or metabolic acidosis.
- Cyanosis and severe dyspnea indicate serious respiratory involvement.
4. Skin and mucous membranes
Examine the whole skin, including palms, soles, skin folds, scalp, and mucosa.
A. Skin color
| Sign | Infectious significance |
|---|---|
| Pallor | Anemia in malaria, chronic infection, or hemolysis |
| Jaundice | Viral hepatitis, leptospirosis, severe malaria, sepsis-related liver dysfunction |
| Cyanosis | Severe pneumonia, respiratory failure, septic shock |
| Flushing | High fever, scarlet fever, toxin-mediated infection |
B. Rash
Describe the type, distribution, onset, progression, and whether it blanches on pressure.
| Type of rash | Common infectious associations |
|---|---|
| Maculopapular rash | Measles, rubella, dengue, acute HIV, EBV infection, rickettsial infections |
| Vesicular rash | Varicella, herpes simplex, herpes zoster, hand-foot-mouth disease |
| Petechiae/purpura | Meningococcemia, dengue, severe sepsis, viral hemorrhagic fever |
| Eschar | Scrub typhus and other rickettsial infections; anthrax |
| Sandpaper-like rash | Scarlet fever |
| Rose spots | Typhoid fever |
The classic rickettsial triad is fever, headache, and rash, but all three signs may not be present. CDC rickettsial guidance notes that this triad is not sufficiently reliable on its own for diagnosis.
C. Hemorrhagic manifestations
Look for:
- Petechiae, purpura, ecchymoses
- Gum bleeding, epistaxis
- Hematemesis, melena, or hematuria
- Bleeding from injection sites
These suggest thrombocytopenia, coagulopathy, dengue, severe sepsis, or viral hemorrhagic illness.
5. Face, eyes, oral cavity, and pharynx
Eyes
Look for:
- Conjunctival injection or conjunctival suffusion: possible leptospirosis
- Scleral icterus: hepatitis, malaria, leptospirosis
- Conjunctival hemorrhage: hemorrhagic infection or thrombocytopenia
- Photophobia: meningitis or encephalitis
Mouth and throat
| Finding | Possible infectious disease |
|---|---|
| Dry lips and tongue | Dehydration from fever, diarrhea, vomiting |
| Tonsillar exudate | Streptococcal pharyngitis, infectious mononucleosis |
| Gray adherent pharyngeal membrane | Diphtheria |
| Oral candidiasis | Candida infection, HIV, immunosuppression |
| Koplik spots | Measles |
| Strawberry tongue | Scarlet fever |
| Oral ulcers | Herpes simplex, hand-foot-mouth disease, acute HIV infection |
6. Lymph nodes
Palpate cervical, supraclavicular, axillary, epitrochlear, and inguinal lymph nodes.
Record site, size, tenderness, consistency, mobility, matting, and overlying skin change.
| Finding | Infectious interpretation |
|---|---|
| Tender regional nodes | Acute bacterial infection in the draining area |
| Posterior cervical lymphadenopathy | Infectious mononucleosis, rubella, toxoplasmosis |
| Generalized lymphadenopathy | Acute HIV, EBV, CMV, rubella, toxoplasmosis, secondary syphilis |
| Matted nodes | Tuberculous lymphadenitis |
| Fluctuant nodes | Suppurative bacterial lymphadenitis |
The triad of fever, sore throat, and lymphadenopathy is characteristic of infectious mononucleosis. Goldman-Cecil Medicine, section “Acute infection”.
7. Hepatomegaly and splenomegaly
Palpate the liver and spleen in all febrile patients when relevant.
Hepatomegaly
May occur in:
- Viral hepatitis
- Malaria
- Leptospirosis
- Infectious mononucleosis
- Liver abscess
- Typhoid fever
- Disseminated tuberculosis
Splenomegaly
May occur in:
- Malaria
- Visceral leishmaniasis
- Infectious mononucleosis
- Typhoid fever
- Infective endocarditis
- Disseminated tuberculosis
Clinical importance: an enlarged spleen in malaria or infectious mononucleosis is vulnerable to rupture. Avoid abdominal trauma and contact sport.
8. Signs of dehydration
Common in cholera, acute gastroenteritis, severe vomiting, and prolonged fever.
Look for:
- Thirst
- Dry tongue and mucosa
- Sunken eyes
- Poor skin turgor
- Tachycardia
- Hypotension or postural fall in blood pressure
- Oliguria or anuria
- Lethargy
9. Signs of meningeal and neurological infection
Assess for:
- Neck stiffness
- Headache and photophobia
- Confusion or reduced consciousness
- Seizures
- Focal neurological deficit
- Cranial-nerve palsies
These findings suggest meningitis, encephalitis, cerebral malaria, or brain abscess and require urgent evaluation.
10. Signs of severe infection requiring immediate action
Urgent intervention is required if there is:
- Hypotension, cold peripheries, confusion, or oliguria
- Severe respiratory distress or cyanosis
- Fever with petechiae or purpura
- Neck stiffness, seizures, or reduced consciousness
- Severe dehydration
- Jaundice with bleeding, altered sensorium, or shock
- Rapidly spreading skin redness, necrosis, bullae, or disproportionate pain
Short exam conclusion
General examination in infectious diseases includes assessment of general condition, consciousness, fever, pulse, blood pressure, respiration, hydration, skin rash, jaundice, hemorrhagic signs, lymph nodes, liver, spleen, and neurological signs. These findings help identify the severity, systemic involvement, and probable infectious syndrome, while guiding urgent treatment and confirmatory microbiological testing.
What is infectious diseases
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WHO infectious diseases definition pathogens bacteria viruses fungi parasites
Infectious diseases are illnesses caused by disease-producing microorganisms, called pathogens. The main pathogens are:
- Bacteria: tuberculosis, cholera, typhoid fever
- Viruses: influenza, measles, hepatitis, HIV
- Fungi: candidiasis, histoplasmosis
- Parasites: malaria, amoebiasis, leishmaniasis
- Prions: rare infectious proteins causing diseases such as Creutzfeldt-Jakob disease
They can spread:
- Directly between people through droplets, contact, blood, or sexual contact
- Through contaminated food or water
- Through vectors such as mosquitoes and ticks
- From animals to humans
- Through contaminated objects, soil, or medical instruments
Some infections are contagious, but not all infectious diseases spread person-to-person. For example, tetanus is an infectious disease acquired from environmental spores entering a wound, but it is not contagious.
Common signs include fever, fatigue, chills, cough, diarrhea, rash, swollen lymph nodes, jaundice, and pain. The specific symptoms depend on the organism and body system affected. The WHO definition describes infectious diseases as illnesses caused by pathogenic bacteria, viruses, parasites, or fungi.
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This topic can be organized into:
-
Clinical research methods in digestive diseases
- History taking, physical examination, laboratory testing, endoscopy, imaging, functional studies, and biopsy.
-
Main gastrointestinal complaints
- Abdominal pain, dyspepsia, heartburn, nausea and vomiting, dysphagia, diarrhea, constipation, gastrointestinal bleeding, jaundice, weight loss, and abdominal distension.
-
Mechanisms and diagnostic value of symptoms
- How each symptom develops and how its pattern helps localize disease to the esophagus, stomach, intestine, liver, biliary tract, or pancreas.
-
General examination
- General appearance, nutritional state, pallor, jaundice, dehydration, edema, lymph nodes, skin signs, and vital signs.
-
Oral-cavity examination
- Lips, tongue, teeth, gums, mucosa, breath odor, ulcers, pigmentation, and nutritional deficiencies.
-
Abdominal examination
- Inspection, auscultation, percussion, palpation, detection of organ enlargement, ascites, masses, tenderness, and peritoneal irritation.
High-level overview: Diagnosis in digestive disease begins with a focused history and careful examination. Symptoms such as pain, vomiting, altered bowel habits, bleeding, and jaundice suggest particular anatomical sites and disease mechanisms, but require confirmation by investigations such as blood and stool tests, ultrasound, endoscopy, CT/MRI, and histology.
Physical examination can identify systemic consequences of gastrointestinal disease, including anemia, malnutrition, dehydration, chronic liver disease, obstruction, inflammation, and malignancy. Abdominal examination is particularly important for recognizing localized tenderness, hepatosplenomegaly, ascites, bowel obstruction, and peritonitis.
Which topic should I expand into a detailed exam-style note?## Examination of patients with digestive diseases: pathology-based approach
The purpose of clinical assessment is to connect symptoms and physical signs with the underlying pathological process: inflammation, ulceration, obstruction, dysmotility, malabsorption, infection, bleeding, fibrosis, vascular disease, or tumor.
1. Methods of investigation
A. History taking
Establish:
- Onset, duration, progression, and relation of symptoms to food and defecation
- Previous gastrointestinal disease, abdominal operations, infections, alcohol use, smoking, and drugs, especially NSAIDs, antibiotics, anticoagulants, and iron
- Diet, travel, family history of colorectal cancer, inflammatory bowel disease, celiac disease, and liver disorders
- Constitutional symptoms: fever, fatigue, anorexia, weight loss, night sweats
The history guides anatomical localization. For example, dysphagia suggests esophageal disease, while jaundice suggests hepatobiliary disease. Alarm features such as progressive dysphagia, bleeding, recurrent vomiting, anemia, fever, weight loss, a palpable mass, or jaundice require prompt investigation for organic disease, including cancer or severe inflammation (Harrison's approach).
B. Laboratory tests
Chosen according to suspected pathology:
- Complete blood count: anemia from chronic bleeding, macrocytosis from malabsorption, leukocytosis in infection/inflammation
- CRP and ESR: inflammatory activity, for example inflammatory bowel disease
- Liver profile: bilirubin, AST/ALT, alkaline phosphatase, GGT, albumin, INR
- Amylase/lipase: pancreatic injury
- Stool testing: occult blood, culture/PCR, ova and parasites, fecal calprotectin, fecal fat
- Serology: celiac antibodies; hepatitis markers; autoimmune liver antibodies where indicated
C. Imaging and procedures
- Ultrasound: hepatomegaly, gallstones, biliary dilatation, ascites, portal hypertension.
- Upper GI endoscopy: esophagitis, peptic ulcer, tumor, varices, gastritis; enables biopsy.
- Colonoscopy: colitis, polyps, cancer, bleeding, inflammatory bowel disease.
- CT/MRI: obstruction, mass, perforation, pancreatic disease, abscess, vascular lesions.
- Biopsy and histopathology: confirms inflammation, dysplasia, malignancy, celiac disease, granulomas, and specific infections.
- Functional studies: pH monitoring and manometry for reflux/motility disorders; gastric emptying studies for gastroparesis.
2. Main complaints: pathological mechanisms and diagnostic value
| Complaint | Main pathological mechanisms | Diagnostic value |
|---|---|---|
| Abdominal pain | Visceral distension or spasm, inflammation, ischemia, traction on mesentery, or peritoneal irritation | Colicky pain suggests obstruction or biliary/ureteric spasm. Constant, severe pain with guarding suggests inflammation or peritonitis. Pain that is disproportionate to examination raises concern for mesenteric ischemia. |
| Heartburn and regurgitation | Reflux of gastric contents because of transient lower-esophageal-sphincter relaxation, hiatal hernia, impaired clearance, or delayed gastric emptying | Typical of gastroesophageal reflux disease. Regurgitation with dysphagia may suggest stricture, achalasia, or esophageal tumor. |
| Dysphagia | Mechanical narrowing due to cancer, peptic stricture, web, or ring; impaired motility due to achalasia or systemic sclerosis | Progressive dysphagia, especially solids first then liquids, favors mechanical obstruction. Dysphagia to solids and liquids from onset favors motility disorder. |
| Odynophagia | Esophageal mucosal inflammation/ulceration, such as pill esophagitis, Candida, viral infection, reflux, or tumor | Indicates esophageal injury rather than simple reflux; endoscopy is commonly needed. |
| Dyspepsia/epigastric discomfort | Gastritis, peptic ulcer disease, reflux, impaired gastric accommodation, visceral hypersensitivity, delayed emptying, or malignancy | Meal-related epigastric pain may occur in ulcer disease. Early satiety can result from impaired gastric accommodation, gastroparesis, or gastric cancer. |
| Nausea and vomiting | Stimulation of the vomiting center by visceral afferents, toxins, CNS stimuli, metabolic disorders, or obstruction | Feculent vomiting suggests distal intestinal obstruction. Bilious vomiting suggests obstruction distal to the ampulla. Vomiting undigested food hours after meals suggests gastroparesis or gastric outlet obstruction. |
| Diarrhea | Secretory fluid loss, osmotic retention of solutes, mucosal inflammation/exudation, malabsorption, or rapid intestinal transit | Nocturnal diarrhea and inflammatory diarrhea suggest organic disease. Blood, fever, and urgency suggest colitis. Bulky greasy stool indicates steatorrhea and malabsorption. |
| Constipation | Slow colonic transit, outlet dysfunction, dehydration, medications, metabolic disease, or mechanical obstruction | New constipation with weight loss, anemia, rectal bleeding, or a mass requires exclusion of colorectal cancer or stricture. |
| GI bleeding | Mucosal ulceration, tumor, varices, vascular malformation, diverticular disease, or colitis | Hematemesis and melena usually indicate upper-GI bleeding. Hematochezia usually indicates lower-GI bleeding, but brisk upper-GI bleeding can also cause it. |
| Jaundice | Hyperbilirubinemia from hemolysis, hepatocellular dysfunction, or biliary obstruction | Dark urine, pale stool, pruritus, and raised alkaline phosphatase suggest obstructive cholestasis. Jaundice with fever and right-upper-quadrant pain suggests acute biliary infection. |
| Abdominal distension | Gas, ascites, mass, pregnancy, obesity, enlarged organs, or intestinal obstruction | Tympany favors gas or obstruction; shifting dullness suggests ascites; a localized, fixed distension may indicate a mass or enlarged organ. |
| Weight loss | Malignancy, chronic inflammation, malabsorption, chronic infection, persistent vomiting, or reduced intake | An important alarm symptom. It should prompt assessment for cancer, inflammatory bowel disease, celiac disease, pancreatic insufficiency, and chronic liver disease. |
3. General examination
Observe the patient before examining the abdomen.
General appearance
- Pallor: iron-deficiency anemia from chronic GI blood loss, malabsorption, or malignancy.
- Jaundice: hepatic dysfunction or biliary obstruction.
- Cachexia and muscle wasting: malignancy, malabsorption, chronic pancreatitis, advanced liver disease, chronic inflammatory disease.
- Dehydration: vomiting, diarrhea, intestinal obstruction, or poor intake.
- Fever and toxic appearance: infection, cholangitis, abscess, severe colitis, peritonitis.
- Tachycardia, hypotension, cold clammy skin: hypovolemia due to bleeding, sepsis, or dehydration.
Skin and peripheral signs
- Spider angiomas, palmar erythema, bruising, edema, gynecomastia: chronic liver disease and portal hypertension.
- Scratch marks: pruritus from cholestasis.
- Hyperpigmentation: may occur in chronic liver disease or hemochromatosis.
- Erythema nodosum, pyoderma gangrenosum, oral ulcers, arthritis: extraintestinal inflammatory bowel disease manifestations.
- Virchow node, left supraclavicular lymphadenopathy: possible metastatic abdominal malignancy.
- Peripheral edema: hypoalbuminemia due to liver failure, protein-losing enteropathy, or malnutrition.
4. Examination of the oral cavity
Inspect the lips, oral mucosa, gums, teeth, tongue, palate, and pharynx.
| Finding | Pathological implication |
|---|---|
| Dry mouth, dry tongue, reduced saliva | Dehydration |
| Angular cheilitis, glossitis, mouth ulcers | Iron, folate, or vitamin B12 deficiency; may reflect malabsorption or chronic blood loss |
| Smooth red tongue | Atrophic glossitis, classically nutritional deficiency |
| Aphthous ulcers | Crohn disease, ulcerative colitis, celiac disease, Behçet disease, nutritional deficiency |
| Oral candidiasis | Immunosuppression, diabetes, antibiotics, malnutrition; can coexist with esophageal candidiasis |
| Dental erosion | Chronic vomiting or gastroesophageal reflux due to acid exposure |
| Fetor hepaticus | Advanced hepatic failure with portosystemic shunting |
| Pigmentation of lips/oral mucosa | Consider Peutz-Jeghers syndrome, Addison disease, or drug-related pigmentation |
The oropharynx should also be examined for hydration, ulcers, and inflammation as part of GI assessment (Merck Manual examination guidance).
5. Examination of the abdomen
The patient should lie supine with knees slightly flexed and arms by the side. Examine painful areas last. The sequence is:
A. Inspection
Look for:
- Contour and distension
- Generalized distension: ascites, obstruction, ileus, gaseous distension.
- Localized mass or asymmetry: enlarged organ, tumor, cyst.
- Scars: prior laparotomy may cause adhesions and later bowel obstruction.
- Dilated veins/caput medusae: portal hypertension with collateral circulation.
- Striae: ascites, obesity, pregnancy, or Cushing syndrome.
- Hernias: umbilical, incisional, inguinal.
- Visible peristalsis: may indicate intestinal obstruction, especially gastric outlet obstruction or thin patients with obstructed bowel.
- Pulsation: expansile pulsation may indicate abdominal aortic aneurysm.
B. Auscultation
Do this before palpation because palpation can alter bowel sounds.
- High-pitched, frequent, tinkling sounds: mechanical intestinal obstruction.
- Absent or markedly reduced sounds: paralytic ileus or diffuse peritonitis.
- Bruit over liver/epigastrium: may suggest vascular lesion, tumor, or arterial stenosis.
- Venous hum: occasionally in portal hypertension.
C. Percussion
- Tympany: gas-filled bowel, gastric distension, or bowel obstruction.
- Generalized dullness with shifting dullness: ascites.
- Localized dullness: mass, enlarged liver/spleen, full bladder, or fecal loading.
- Liver span: estimates hepatomegaly or a small cirrhotic liver.
D. Palpation
Superficial palpation
Detect:
- Localized tenderness
- Cutaneous hyperesthesia
- Voluntary guarding due to anxiety or pain
- Involuntary rigidity, which suggests peritoneal inflammation
Deep palpation
Assess:
- Masses: site, size, surface, mobility, consistency, pulsation, tenderness
- Liver and spleen enlargement
- Kidneys and bladder
- Aortic pulsation
- Fecal masses
Important pathological signs
- Rebound tenderness and involuntary guarding: peritoneal irritation, for example perforated ulcer, appendicitis, diverticulitis, or peritonitis.
- Right-upper-quadrant tenderness/Murphy sign: acute cholecystitis.
- Epigastric tenderness: gastritis, ulcer disease, pancreatitis, or upper-GI malignancy.
- Left-lower-quadrant tenderness: diverticulitis or colitis.
- Hepatomegaly: hepatitis, congestion, fatty liver, infiltration, metastatic tumor, or biliary obstruction.
- Splenomegaly: portal hypertension, hematologic disease, infection, or infiltrative disease.
- Fluid thrill or shifting dullness: clinically significant ascites.
- Palpable gallbladder with painless jaundice: raises suspicion of distal biliary obstruction, often pancreatic or periampullary malignancy.
E. Completion of examination
Do not omit:
- Digital rectal examination: rectal mass, tenderness, fecal impaction, melena, fresh blood, fissure, hemorrhoids.
- Examination of hernial orifices: obstruction can arise from an incarcerated hernia.
- Pelvic examination when indicated: gynecological pathology can mimic GI disease.
A standard abdominal examination proceeds from inspection to auscultation, percussion, and systematic palpation. Tympany supports bowel gas or obstruction, while dullness may indicate ascites; deep palpation identifies masses or organ enlargement (Merck Manual GI evaluation).
Key pathological principle
Symptoms and signs are not diagnoses by themselves. They indicate the likely anatomical site and mechanism, then must be correlated with laboratory tests, imaging, endoscopy, and histopathology. For example:
- Pain + fever + guarding: inflammatory or perforative intra-abdominal pathology.
- Jaundice + dark urine + pale stool + pruritus: obstructive cholestasis.
- Chronic diarrhea + anemia + weight loss: malabsorption, inflammatory bowel disease, infection, or malignancy.
- Ascites + splenomegaly + abdominal-wall collateral veins: portal hypertension, often due to cirrhosis.For infectious diseases, the corresponding examination topic can be studied as:
-
Methods of investigation in infectious diseases
- Epidemiological history, clinical examination, microbiological tests, serology, PCR, cultures, imaging, and biopsy where required.
-
Main complaints
- Fever, chills, sweating, weakness, headache, myalgia, rash, sore throat, cough, dyspnea, diarrhea, vomiting, abdominal pain, jaundice, and lymph-node enlargement.
-
Mechanisms and diagnostic value of symptoms
- Fever from pyrogen-mediated cytokines.
- Rash from microbial toxins, vascular injury, or immune reactions.
- Diarrhea from enteric infection, toxin action, mucosal inflammation, or malabsorption.
- Jaundice from viral hepatitis, hemolysis, or sepsis-related cholestasis.
- Lymphadenopathy and hepatosplenomegaly from reticuloendothelial and immune activation.
-
General examination
- Temperature pattern, consciousness, hydration, nutritional state, pallor, cyanosis, jaundice, edema, rash, hemorrhages, and signs of shock or sepsis.
-
Oral cavity and pharynx
- Enanthem, tonsillitis, pharyngeal exudate, oral ulcers, thrush, Koplik spots, strawberry tongue, and dehydration.
-
Abdominal examination
- Tenderness, distension, bowel sounds, liver and spleen enlargement, ascites, guarding, and signs of peritonitis.
-
Disease-specific clinical syndromes
- Acute respiratory infection, acute gastroenteritis, viral hepatitis, meningitis/encephalitis, exanthematous infections, sepsis, zoonoses, malaria, and HIV-related infections.
Core principle: infectious-disease diagnosis combines the clinical syndrome with epidemiological exposure and pathogen confirmation. Fever alone is nonspecific. Its diagnostic value becomes much greater when assessed together with the pattern of onset, exposure history, rash, organ involvement, blood count, inflammatory markers, and microbiological testing.
Which section do you need in detailed exam-note form: 1) methods of investigation, 2) symptoms and mechanisms, 3) general examination, 4) oral cavity and abdomen, or 5) all major infectious syndromes?# General Examination in Infectious Diseases
Definition and objectives
General examination is the systematic assessment of the patient's overall condition before detailed examination of individual organ systems. In suspected infection, it helps to:
- Assess severity and identify emergencies such as sepsis, shock, meningitis, respiratory failure, and severe dehydration.
- Recognize characteristic syndromes, for example fever with rash, lymphadenopathy, jaundice, or hepatosplenomegaly.
- Detect the probable focus of infection.
- Identify signs of complications and underlying immunosuppression.
- Direct microbiological tests and further examination.
A comprehensive examination should be interpreted together with the epidemiological history, including travel, animal or insect exposure, food and water exposure, contact with ill persons, vaccination status, medications, and immune status. Goldman-Cecil Medicine emphasizes that in fever syndromes, targeted testing should follow clues from a complete history and physical examination. Goldman-Cecil Medicine, p. 2937.
1. First impression: assess the severity of illness
Observe the patient on entering the room.
A. General condition
Classify as:
- Satisfactory/stable: alert, comfortable, normal perfusion and breathing.
- Moderately severe: febrile, weak, toxic-looking, dehydrated, tachycardic.
- Severe/critical: altered consciousness, cyanosis, severe dyspnea, hypotension, cold extremities, bleeding, seizures, oliguria, or signs of shock.
B. Position and behavior
| Finding | Possible significance |
|---|---|
| Restless, anxious, confused | Hypoxemia, sepsis, encephalopathy, meningitis, severe pain |
| Lethargic or drowsy | Sepsis, dehydration, metabolic disturbance, encephalitis |
| Neck held stiffly or patient avoids flexing neck | Meningeal irritation |
| Lying still with flexed hips/knees | Peritonitis |
| Sitting upright, using accessory muscles | Respiratory distress |
| Rigors/shivering | Acute bacteremia, malaria, severe febrile illness |
C. Level of consciousness
Assess orientation to person, place, and time, and assess response to voice or pain if impaired.
Altered mental status may occur in sepsis, meningitis, encephalitis, cerebral malaria, severe hypoglycemia, hepatic encephalopathy, or hypoxemia. It is an urgent warning sign.
2. Vital signs
Measure and document:
- Temperature
- Pulse rate and rhythm
- Blood pressure
- Respiratory rate
- Oxygen saturation
- Urine output when illness is severe
A. Temperature
Fever occurs when exogenous or endogenous pyrogens stimulate cytokines such as IL-1, IL-6, and TNF, increasing hypothalamic prostaglandin E2 and raising the temperature set point.
A temperature above approximately 37.8 degrees C can be considered fever, although normal temperature varies with time of day and measurement method. Goldman-Cecil Medicine, p. 2937.
Fever patterns and their significance
| Pattern | Description | Examples |
|---|---|---|
| Continuous | Daily variation less than 1 degree C; temperature does not return to normal | Typhoid fever, lobar pneumonia, severe bacterial infection |
| Remittent | Fluctuates by more than 1 degree C but never becomes normal | Infective endocarditis, viral and bacterial infections |
| Intermittent | Returns to normal between spikes | Malaria, sepsis, abscess |
| Relapsing | Febrile episodes separated by afebrile periods of days | Relapsing fever, some malaria syndromes |
| Pel-Ebstein-like | Cyclical periods of fever and no fever | Not specific; classically described with lymphoma |
| Biphasic/saddleback | Fever subsides then recurs | Dengue and some viral infections |
Important: Fever pattern alone rarely establishes a diagnosis. It must be correlated with exposure history, symptoms, examination, and laboratory data.
B. Pulse
- Tachycardia: fever, dehydration, pain, sepsis, hypovolemia.
- Bradycardia relative to fever: may be seen in typhoid fever, brucellosis, leptospirosis, some viral infections, and drug effect, but it is not diagnostic.
- Weak, rapid pulse: shock, dehydration, or major blood loss.
C. Respiratory rate and oxygen saturation
Tachypnea may result from:
- Pneumonia
- Sepsis
- Metabolic acidosis
- Pulmonary edema or acute respiratory distress syndrome
- Severe anemia
Hypoxemia, cyanosis, or respiratory distress requires immediate assessment and management.
D. Blood pressure and peripheral perfusion
Hypotension, cool extremities, delayed capillary refill, oliguria, and confusion suggest shock, especially septic or hypovolemic shock. Normal blood pressure does not exclude early sepsis.
3. Nutritional state, hydration, and body habitus
A. Nutritional state
Look for:
- Weight loss
- Temporal muscle wasting
- Loss of subcutaneous fat
- Reduced muscle bulk
- Poor wound healing
These may occur in chronic infections such as tuberculosis, HIV-associated disease, chronic parasitic infection, infective endocarditis, and disseminated fungal disease.
B. Hydration
Assess:
- Dry tongue and oral mucosa
- Reduced skin turgor, especially useful in children
- Sunken eyes
- Tachycardia
- Postural hypotension
- Reduced urine output
Dehydration is frequent in acute gastroenteritis, cholera, persistent fever, vomiting, and sepsis.
4. Examination of the skin and mucous membranes
A complete skin examination is essential because infectious diseases may cause rash, hemorrhage, eschars, ulcers, vesicles, and signs of vector bites. CDC specifically emphasizes examination for skin signs, jaundice, altered mental state, nuchal rigidity, pulmonary consolidation, and lymphadenopathy in patients with possible travel-related parasitic disease (CDC Yellow Book).
A. Skin color
| Sign | Diagnostic implication |
|---|---|
| Pallor | Anemia, hemolysis, chronic disease, hemorrhage |
| Jaundice | Viral hepatitis, leptospirosis, malaria-related hemolysis, severe sepsis, biliary infection |
| Cyanosis | Severe pneumonia, respiratory failure, shock |
| Flushing | Fever, toxin-mediated illness, scarlet fever |
| Hyperpigmentation | May suggest chronic adrenal disease, but is not a usual acute infection sign |
B. Rash or exanthem
Describe the rash precisely:
- Type: macule, papule, vesicle, pustule, wheal, petechia, purpura, eschar.
- Distribution: face, trunk, limbs, palms, soles, mucosa.
- Timing: relation to fever and disease day.
- Blanching or non-blanching.
- Pruritic or painful.
- Progression: localized or generalized.
| Rash/lesion | Important infectious considerations |
|---|---|
| Maculopapular/morbilliform rash | Measles, rubella, EBV, acute HIV, dengue, enteroviruses, rickettsial disease |
| Vesicular rash | Varicella, herpes simplex, herpes zoster, hand-foot-mouth disease |
| Petechiae or purpura | Meningococcemia, dengue, severe sepsis, viral hemorrhagic disease, infective endocarditis |
| Eschar | Tick-borne rickettsial infection, anthrax, scrub typhus |
| Diffuse erythematous sandpaper rash | Scarlet fever |
| Urticaria | Viral, parasitic, or allergic causes |
| Jaundice with fever | Hepatitis, leptospirosis, cholangitis, severe malaria, sepsis-associated cholestasis |
Non-blanching rash with fever is an emergency, particularly if rapidly progressive or accompanied by hypotension, altered consciousness, or neck stiffness. Consider meningococcal sepsis until proven otherwise.
C. Hemorrhagic signs
Look for:
- Petechiae and purpura
- Ecchymoses
- Gum bleeding
- Epistaxis
- Conjunctival hemorrhage
- Bleeding from injection sites
These can indicate thrombocytopenia, disseminated intravascular coagulation, viral hemorrhagic disease, dengue, severe sepsis, or liver failure.
5. Head, eyes, mouth, and throat
A. Eyes
Look for:
- Conjunctival injection: viral infection, leptospirosis, Kawasaki disease.
- Conjunctival suffusion: classically associated with leptospirosis.
- Scleral icterus: jaundice.
- Pallor: anemia.
- Retinal hemorrhages or Roth spots: possible infective endocarditis.
- Photophobia: meningitis or encephalitis.
B. Oral cavity and pharynx
Inspect lips, gums, tongue, buccal mucosa, tonsils, palate, and posterior pharynx.
| Finding | Possible infectious significance |
|---|---|
| Dry mucosa, cracked lips | Dehydration |
| Pharyngeal erythema and tonsillar exudate | Streptococcal pharyngitis, infectious mononucleosis, diphtheria |
| Gray adherent pseudomembrane | Diphtheria, requires urgent action |
| Oral thrush | Candida infection, immunosuppression, HIV, diabetes, recent antibiotics |
| Oral ulcers | HSV, hand-foot-mouth disease, HIV, Behçet-like syndromes |
| Koplik spots | Measles |
| Strawberry tongue | Scarlet fever, toxic shock syndrome, Kawasaki disease |
| Gingival bleeding | Thrombocytopenia, hematological infection-related complication |
6. Lymph-node examination
Palpate systematically:
- Occipital
- Preauricular
- Submental and submandibular
- Cervical chains
- Supraclavicular
- Axillary
- Epitrochlear
- Inguinal nodes
Record:
- Site and distribution
- Size
- Tenderness
- Consistency
- Mobility
- Matting
- Skin changes
- Presence of draining lesion
Diagnostic significance
| Pattern | Likely implication |
|---|---|
| Tender, soft, mobile regional nodes | Acute bacterial infection in drainage area |
| Generalized lymphadenopathy | EBV, CMV, acute HIV, rubella, toxoplasmosis, secondary syphilis, disseminated TB, hematologic malignancy |
| Posterior cervical nodes | Infectious mononucleosis, rubella, toxoplasmosis |
| Matted nodes | Tuberculosis, lymphoma, chronic bacterial infection |
| Fluctuant node | Suppurative lymphadenitis/abscess |
| Hard fixed node | Consider malignancy rather than infection |
Fever, rash, lymphadenopathy, and hepatosplenomegaly together may occur in several infections, including EBV infection, toxoplasmosis, acute HIV, rickettsial illness, and disseminated infections. These signs must not be assumed to be infectious because hematological malignancy and autoimmune disease can produce the same syndrome.
7. Abdomen and reticuloendothelial system
Even during a general examination, palpate for liver and spleen enlargement.
A. Hepatomegaly
May occur in:
- Viral hepatitis
- Malaria
- Leptospirosis
- Infectious mononucleosis
- Liver abscess
- Disseminated tuberculosis
- Sepsis
- Congestive or infiltrative disorders
Assess liver size, edge, surface, tenderness, and consistency. A tender liver may suggest hepatitis, hepatic congestion, liver abscess, or acute cholangitis.
B. Splenomegaly
May occur in:
- Malaria
- Visceral leishmaniasis
- Infectious mononucleosis
- Typhoid fever
- Infective endocarditis
- Disseminated tuberculosis
- Schistosomiasis with portal hypertension
Clinical caution: In infectious mononucleosis and malaria, splenic enlargement increases the risk of splenic rupture. Avoid contact sport or abdominal trauma until the risk is assessed.
C. Abdominal tenderness and distension
- Diffuse tenderness: gastroenteritis, peritonitis, sepsis.
- Right-upper-quadrant pain/tenderness: hepatitis, liver abscess, cholecystitis, cholangitis.
- Left-upper-quadrant tenderness: splenic enlargement or infarction.
- Distension and ascites: chronic liver disease, peritonitis, severe hypoalbuminemia, tuberculosis.
8. Peripheral edema and signs of chronic systemic disease
Look for:
- Pedal edema
- Sacral edema in bedridden patients
- Ascites
- Generalized edema
Possible causes include severe sepsis with capillary leak, malnutrition, nephrotic syndrome, renal disease, heart failure, and chronic liver disease.
Also inspect the hands and feet for:
- Peripheral cyanosis
- Clubbing, which may be seen in chronic pulmonary infection or infective endocarditis
- Splinter hemorrhages, Osler nodes, Janeway lesions, and petechiae in suspected infective endocarditis
- Hand or foot swelling and desquamation in selected exanthematous illnesses
9. Neurological warning signs
During general examination, specifically look for:
- Confusion, agitation, drowsiness, coma
- Neck stiffness
- Photophobia
- Seizures
- Focal weakness
- Cranial nerve deficit
- Abnormal posture
- New rash with neurological symptoms
These raise concern for meningitis, encephalitis, cerebral malaria, brain abscess, severe sepsis, or toxic-metabolic encephalopathy. Do not delay urgent evaluation for a prolonged examination.
10. Red flags requiring urgent action
Immediate escalation is required when infection is associated with:
- Hypotension, mottled/cold skin, reduced urine output, or altered consciousness
- Severe respiratory distress, cyanosis, or low oxygen saturation
- Petechial or purpuric rash with fever
- Neck stiffness, seizures, focal neurological deficit, or reduced consciousness
- Severe dehydration or persistent vomiting/diarrhea
- Jaundice with confusion, bleeding, or shock
- Rapidly progressive soft-tissue pain, swelling, blistering, or skin necrosis
- Suspected diphtheria, meningococcal disease, severe malaria, cholera, viral hemorrhagic fever, or sepsis
Examination sequence for exams
Use this short sequence in an OSCE or written answer:
- General appearance: consciousness, distress, nutritional state, hydration, posture.
- Vitals: temperature, pulse, BP, respiratory rate, oxygen saturation.
- Hands and skin: pallor, cyanosis, jaundice, rash, petechiae, peripheral perfusion.
- Face and eyes: conjunctivae, sclera, facial rash, photophobia.
- Oral cavity and pharynx: hydration, ulcers, thrush, tonsils, exudate, membrane.
- Lymph nodes: cervical, axillary, inguinal, generalized versus localized.
- Abdomen: hepatomegaly, splenomegaly, tenderness, ascites.
- Peripheral edema and signs of endocarditis.
- Rapid neurological screening: mental state, neck stiffness, focal deficits.
- Examine the likely focus: respiratory, urinary, gastrointestinal, skin/soft tissue, CNS, or genital tract.
One-line conclusion for an exam answer
In infectious diseases, general examination assesses the severity of systemic illness and detects diagnostic syndromes such as fever, rash, jaundice, lymphadenopathy, hepatosplenomegaly, dehydration, shock, and neurological impairment, thereby guiding urgent treatment, infection-control measures, and targeted microbiological investigation.## General Examination in Infectious Diseases Only
Purpose
General examination in a patient with suspected infectious disease aims to:
- Assess the severity of infection.
- Identify the probable site and type of infection.
- Detect signs of dehydration, sepsis, shock, meningitis, hemorrhage, or organ involvement.
- Recognize characteristic infectious syndromes such as fever with rash, jaundice, lymphadenopathy, and hepatosplenomegaly.
1. General condition and consciousness
Assess whether the patient is:
- Comfortable, ill-looking, toxic, or moribund
- Alert, drowsy, confused, agitated, stuporous, or unconscious
- Able to drink, eat, walk, and communicate
Diagnostic value
- Toxic appearance, confusion, drowsiness, cold extremities, or reduced urine output suggest severe infection or sepsis.
- Altered consciousness may occur in meningitis, encephalitis, cerebral malaria, severe sepsis, or severe viral infection.
- Restlessness and severe weakness can occur with high fever, dehydration, hypoxia, or bacteremia.
2. Body temperature and fever
Measure the temperature and note its pattern.
Mechanism
Microbial products and inflammatory cytokines, particularly IL-1, IL-6, and TNF, stimulate prostaglandin E2 formation in the hypothalamus, raising the body's temperature set point.
Fever patterns in infections
| Pattern | Description | Infectious examples |
|---|---|---|
| Continuous fever | Temperature remains raised with little daily variation | Typhoid fever, pneumonia |
| Remittent fever | Temperature fluctuates but does not become normal | Many bacterial and viral infections |
| Intermittent fever | Fever spikes with normal temperature between episodes | Malaria, bacteremia, abscess |
| Relapsing fever | Febrile episodes separated by afebrile days | Relapsing fever, some malaria infections |
| Biphasic fever | Fever improves then returns | Dengue and some viral infections |
Fever is common but not universal. Infants, elderly patients, immunocompromised patients, and severely septic patients may have normal temperature or hypothermia.
3. Pulse, blood pressure, respiration, and oxygenation
Pulse
- Tachycardia: fever, dehydration, pain, sepsis.
- Weak, rapid pulse: hypovolemia, severe dehydration, septic shock.
- Relative bradycardia: may be observed in typhoid fever, brucellosis, leptospirosis, and some viral infections, but is not diagnostic.
Blood pressure and perfusion
Look for hypotension, delayed capillary refill, cold or mottled skin, reduced urine output, and confusion.
These are signs of sepsis or septic shock.
Respiration
Observe respiratory rate, work of breathing, cyanosis, and oxygen saturation.
- Tachypnea may indicate pneumonia, sepsis, hypoxemia, or metabolic acidosis.
- Cyanosis and severe dyspnea indicate serious respiratory involvement.
4. Skin and mucous membranes
Examine the whole skin, including palms, soles, skin folds, scalp, and mucosa.
A. Skin color
| Sign | Infectious significance |
|---|---|
| Pallor | Anemia in malaria, chronic infection, or hemolysis |
| Jaundice | Viral hepatitis, leptospirosis, severe malaria, sepsis-related liver dysfunction |
| Cyanosis | Severe pneumonia, respiratory failure, septic shock |
| Flushing | High fever, scarlet fever, toxin-mediated infection |
B. Rash
Describe the type, distribution, onset, progression, and whether it blanches on pressure.
| Type of rash | Common infectious associations |
|---|---|
| Maculopapular rash | Measles, rubella, dengue, acute HIV, EBV infection, rickettsial infections |
| Vesicular rash | Varicella, herpes simplex, herpes zoster, hand-foot-mouth disease |
| Petechiae/purpura | Meningococcemia, dengue, severe sepsis, viral hemorrhagic fever |
| Eschar | Scrub typhus and other rickettsial infections; anthrax |
| Sandpaper-like rash | Scarlet fever |
| Rose spots | Typhoid fever |
The classic rickettsial triad is fever, headache, and rash, but all three signs may not be present. CDC rickettsial guidance notes that this triad is not sufficiently reliable on its own for diagnosis.
C. Hemorrhagic manifestations
Look for:
- Petechiae, purpura, ecchymoses
- Gum bleeding, epistaxis
- Hematemesis, melena, or hematuria
- Bleeding from injection sites
These suggest thrombocytopenia, coagulopathy, dengue, severe sepsis, or viral hemorrhagic illness.
5. Face, eyes, oral cavity, and pharynx
Eyes
Look for:
- Conjunctival injection or conjunctival suffusion: possible leptospirosis
- Scleral icterus: hepatitis, malaria, leptospirosis
- Conjunctival hemorrhage: hemorrhagic infection or thrombocytopenia
- Photophobia: meningitis or encephalitis
Mouth and throat
| Finding | Possible infectious disease |
|---|---|
| Dry lips and tongue | Dehydration from fever, diarrhea, vomiting |
| Tonsillar exudate | Streptococcal pharyngitis, infectious mononucleosis |
| Gray adherent pharyngeal membrane | Diphtheria |
| Oral candidiasis | Candida infection, HIV, immunosuppression |
| Koplik spots | Measles |
| Strawberry tongue | Scarlet fever |
| Oral ulcers | Herpes simplex, hand-foot-mouth disease, acute HIV infection |
6. Lymph nodes
Palpate cervical, supraclavicular, axillary, epitrochlear, and inguinal lymph nodes.
Record site, size, tenderness, consistency, mobility, matting, and overlying skin change.
| Finding | Infectious interpretation |
|---|---|
| Tender regional nodes | Acute bacterial infection in the draining area |
| Posterior cervical lymphadenopathy | Infectious mononucleosis, rubella, toxoplasmosis |
| Generalized lymphadenopathy | Acute HIV, EBV, CMV, rubella, toxoplasmosis, secondary syphilis |
| Matted nodes | Tuberculous lymphadenitis |
| Fluctuant nodes | Suppurative bacterial lymphadenitis |
The triad of fever, sore throat, and lymphadenopathy is characteristic of infectious mononucleosis. Goldman-Cecil Medicine, section “Acute infection”.
7. Hepatomegaly and splenomegaly
Palpate the liver and spleen in all febrile patients when relevant.
Hepatomegaly
May occur in:
- Viral hepatitis
- Malaria
- Leptospirosis
- Infectious mononucleosis
- Liver abscess
- Typhoid fever
- Disseminated tuberculosis
Splenomegaly
May occur in:
- Malaria
- Visceral leishmaniasis
- Infectious mononucleosis
- Typhoid fever
- Infective endocarditis
- Disseminated tuberculosis
Clinical importance: an enlarged spleen in malaria or infectious mononucleosis is vulnerable to rupture. Avoid abdominal trauma and contact sport.
8. Signs of dehydration
Common in cholera, acute gastroenteritis, severe vomiting, and prolonged fever.
Look for:
- Thirst
- Dry tongue and mucosa
- Sunken eyes
- Poor skin turgor
- Tachycardia
- Hypotension or postural fall in blood pressure
- Oliguria or anuria
- Lethargy
9. Signs of meningeal and neurological infection
Assess for:
- Neck stiffness
- Headache and photophobia
- Confusion or reduced consciousness
- Seizures
- Focal neurological deficit
- Cranial-nerve palsies
These findings suggest meningitis, encephalitis, cerebral malaria, or brain abscess and require urgent evaluation.
10. Signs of severe infection requiring immediate action
Urgent intervention is required if there is:
- Hypotension, cold peripheries, confusion, or oliguria
- Severe respiratory distress or cyanosis
- Fever with petechiae or purpura
- Neck stiffness, seizures, or reduced consciousness
- Severe dehydration
- Jaundice with bleeding, altered sensorium, or shock
- Rapidly spreading skin redness, necrosis, bullae, or disproportionate pain
Short exam conclusion
General examination in infectious diseases includes assessment of general condition, consciousness, fever, pulse, blood pressure, respiration, hydration, skin rash, jaundice, hemorrhagic signs, lymph nodes, liver, spleen, and neurological signs. These findings help identify the severity, systemic involvement, and probable infectious syndrome, while guiding urgent treatment and confirmatory microbiological testing.Infectious diseases are illnesses caused by disease-producing microorganisms, called pathogens. The main pathogens are:
- Bacteria: tuberculosis, cholera, typhoid fever
- Viruses: influenza, measles, hepatitis, HIV
- Fungi: candidiasis, histoplasmosis
- Parasites: malaria, amoebiasis, leishmaniasis
- Prions: rare infectious proteins causing diseases such as Creutzfeldt-Jakob disease
They can spread:
- Directly between people through droplets, contact, blood, or sexual contact
- Through contaminated food or water
- Through vectors such as mosquitoes and ticks
- From animals to humans
- Through contaminated objects, soil, or medical instruments
Some infections are contagious, but not all infectious diseases spread person-to-person. For example, tetanus is an infectious disease acquired from environmental spores entering a wound, but it is not contagious.
Common signs include fever, fatigue, chills, cough, diarrhea, rash, swollen lymph nodes, jaundice, and pain. The specific symptoms depend on the organism and body system affected. The WHO definition describes infectious diseases as illnesses caused by pathogenic bacteria, viruses, parasites, or fungi.
Quick answer
TB means tuberculosis.
It is an infectious disease caused mainly by the bacterium Mycobacterium tuberculosis.
- It most commonly affects the lungs - called pulmonary TB.
- It can also affect lymph nodes, brain, bones and joints, kidneys, abdomen, and other organs - called extrapulmonary TB.
- Pulmonary TB usually spreads through the air when a person with active infectious TB coughs, speaks, or sneezes.
Common symptoms of pulmonary TB
- Cough lasting 2 weeks or more
- Sputum production, sometimes blood-stained
- Fever, often low-grade
- Night sweats
- Loss of appetite and weight loss
- Tiredness
- Chest pain or shortness of breath
Diagnosis
TB is confirmed using sputum tests such as microscopy, molecular tests like GeneXpert/NAAT, culture, and chest X-ray. Tests may also assess drug resistance.
Treatment
TB is curable with a combination of anti-tuberculosis medicines taken for several months. The exact regimen depends on whether the strain is drug-sensitive or drug-resistant. Completing treatment is necessary to prevent relapse and drug-resistant TB.
Tb
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- Definition and causative organism
- Transmission and risk factors
- Symptoms and signs
- Diagnosis
- Treatment
- Prevention
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WHO tuberculosis spread through air not spread sharing dishes
TB spreads mainly through the air.
A person with active TB of the lungs or throat releases tiny droplets containing TB bacteria when they:
- Cough
- Sneeze
- Speak
- Sing
- Spit
Others can become infected by breathing these droplets, especially after close, prolonged contact in crowded or poorly ventilated places. WHO TB information
TB does not usually spread by:
- Shaking hands or touching
- Sharing food, cups, dishes, or clothes
- Using the same toilet
- Kissing
- Sharing bedding
People with latent TB infection do not spread TB. Extrapulmonary TB, such as TB in lymph nodes or bones, is generally not contagious.
Food born diseases
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WHO foodborne diseases definition causes prevention
Foodborne Diseases
Foodborne diseases are illnesses caused by eating or drinking contaminated food or water. The contamination may be due to microorganisms or their toxins, or due to harmful chemicals.
Causes
-
Bacteria
- Salmonella
- Escherichia coli (E. coli)
- Shigella
- Campylobacter
- Vibrio cholerae
- Staphylococcus aureus
- Clostridium botulinum
- Listeria monocytogenes
-
Viruses
- Norovirus
- Hepatitis A virus
- Rotavirus
-
Parasites
- Giardia
- Entamoeba histolytica
- Taenia species
- Toxoplasma gondii
-
Toxins and chemicals
- Bacterial toxins, for example staphylococcal toxin or botulinum toxin
- Poisonous mushrooms
- Pesticides, heavy metals, and contaminated seafood
The World Health Organization notes that foodborne illness may be infectious or toxic and commonly presents with gastrointestinal symptoms (WHO food safety fact sheet).
How infection occurs
Food becomes unsafe through:
- Poor hand hygiene by food handlers
- Contaminated water
- Raw or undercooked meat, eggs, fish, or shellfish
- Unpasteurized milk
- Improper storage at room temperature
- Cross-contamination between raw and cooked food
- Flies, insects, rodents, or contaminated utensils
Main symptoms
- Nausea and vomiting
- Abdominal cramps or pain
- Diarrhea, sometimes bloody
- Fever
- Weakness and dehydration
Some infections cause specific complications:
- Cholera: severe watery diarrhea and dehydration
- Botulism: blurred vision, difficulty swallowing, weakness, and paralysis
- Hepatitis A: fever, nausea, dark urine, and jaundice
- E. coli/Shigella: bloody diarrhea and abdominal pain
Prevention: five key measures
- Keep hands, utensils, and surfaces clean.
- Separate raw foods from cooked foods.
- Cook food thoroughly.
- Keep hot food hot and cold food cold.
- Use safe water and safe raw ingredients.
Important danger signs
Seek urgent medical care for severe dehydration, inability to drink, bloody diarrhea, persistent high fever, confusion, jaundice, breathing difficulty, or weakness/paralysis after food intake.
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