General Physical Examination (GPE) - History & Findings

Clinical Posting mein kaise approach karein

1. PALLOR (Anaemia)

History mein poochne wale points:

• Duration - Kitne time se paleness notice ki hai?
• Onset - Sudden tha ya gradually aaya?
• Fatigue/weakness - Thakaan, kamzori?
• Breathlessness - Chhoti chhoti saans chhadna, especially exertion pe?
• Palpitations - Dil ki dhadkan tez ya uneven feel hoti hai?
• Dietary history - Vegetarian/non-vegetarian? Iron-rich foods khaate hain?
• Menstrual history (females) - Heavy periods? Irregular cycles?
• Blood loss - Kala pakhana (melena), khoon aana pakhane mein, urine mein?
• Worm infestation - Hookworm area mein rehte hain?
• Bone marrow disease symptoms - Infections baar baar hoti hain? Easy bruising?
• Family history - Koi aur ghar mein anaemia mein tha? (thalassemia, sickle cell)
• Drug history - NSAIDs, chloramphenicol, chemotherapy?
• Jaundice ke saath - Haemolytic anaemia suggest karta hai

Relative Negative Findings (jo specifically poochhein aur negative milein to liken):

• No history of haematemesis (khoon ki ulti)
• No melena (kala pakhana)
• No heavy menstrual bleeding
• No family history of haematological disorder
• No drug intake known to cause anaemia
• No h/o worm infestation
• No bone pains (rules out marrow pathology / malignancy)

Examination:

• Conjunctival pallor (lower lid pull karein)
• Palmar pallor
• Tongue, nail beds

2. ICTERUS (Jaundice)

History mein poochne wale points:

• Duration - Kitne din se peela dikhna shuru hua?
• Onset - Sudden ya gradual?
• Urine colour - Dark yellow/tea-coloured urine? (obstructive / hepatocellular)
• Stool colour - Clay-coloured/pale stools? (obstructive jaundice)
• Itching (pruritus) - Kharish hoti hai? (obstructive jaundice mein zyada)
• Abdominal pain - Right upper quadrant mein dard? (gallstones, hepatitis)
• Fever - Chills ke saath? (cholangitis / hepatitis A)
• Vomiting - Nausea/ulti?
• Contact history - Jaundice wale koi the paas mein? (Hepatitis A/E - faeco-oral)
• Blood transfusion - Kabhi? (Hepatitis B/C)
• Sexual history - High-risk behaviour? (Hepatitis B)
• Drug/alcohol history - Paracetamol overdose, alcohol intake?
• Travel history - Malaria endemic area?
• Weight loss - Unintentional weight loss? (malignancy)

Relative Negative Findings:

• No h/o blood transfusion
• No contact with jaundice patient
• No drug intake causing hepatotoxicity
• No alcohol intake
• No pale stools or dark urine (pre-hepatic jaundice mein yeh nahi hota)
• No itching
• No weight loss

Examination:

• Scleral icterus (best site - natural daylight mein dekhen)
• Subingual icterus
• Skin yellowing

3. CYANOSIS

History mein poochne wale points:

• Duration & onset - Birth se hai ya baad mein aaya? (congenital vs acquired)
• Type - Lips, tongue (central) ya sirf haath-paer ki ungliyan (peripheral)?
• Breathlessness - Chhoti saans? At rest ya exertion pe?
• Cardiac symptoms - Chest pain, palpitations, syncope?
• Respiratory symptoms - Cough, sputum, wheeze? (COPD, chronic bronchitis)
• Squatting episodes - Bacha play ke baad baithh jaata hai? (Tetralogy of Fallot)
• Exercise tolerance - Kitna chal pata hai?
• Cold exposure - Thand mein fingers neeli padh jaati hain? (Raynaud's - peripheral)
• High altitude stay - Pahadon pe rehte hain?
• Drug/toxin history - Dapsone, nitrates (methaemoglobinaemia)

Relative Negative Findings:

• No h/o cardiac disease / congenital heart disease
• No respiratory disease
• No drug exposure causing methaemoglobinaemia
• No high altitude stay
• Not present since birth (rules out congenital cause)
• No cold intolerance or Raynaud's phenomenon

Examination:

• Central cyanosis - tongue, lips, mucous membranes (warm areas)
• Peripheral cyanosis - fingertips, nail beds, tip of nose (cold areas)

4. CLUBBING

History mein poochne wale points:

• Duration - Kitne time se hain? Birth se? (congenital)
• Associated respiratory symptoms - Chronic cough, blood in sputum, breathlessness? (bronchiectasis, lung abscess, lung carcinoma, fibrosing alveolitis)
• Cardiac symptoms - Cyanosis since birth? (congenital cyanotic heart disease - Tetralogy of Fallot, Eisenmenger's)
• GI symptoms - Chronic diarrhoea, blood in stools, weight loss? (Crohn's, UC, liver cirrhosis, malabsorption)
• Family history - Ghar mein kisi ko? (idiopathic/familial clubbing)
• Fever - Prolonged fever? (IE - infective endocarditis)

Grades of Clubbing (poochte time dhyaan rakhein):

• Grade 1 - Fluctuation of nail bed (spongy feel)
• Grade 2 - Loss of nail bed angle (Lovibond angle >180°)
• Grade 3 - Parrot beak / drumstick appearance
• Grade 4 - Hypertrophic pulmonary osteoarthropathy (HPOA) - wrist/ankle pain

Relative Negative Findings:

• No h/o chronic respiratory disease
• No h/o cyanotic heart disease
• No GI symptoms (diarrhoea, blood in stools)
• No family history of clubbing
• No prolonged fever suggestive of infective endocarditis

Causes mnemonic - "CLUBBING":

5. EDEMA (Oedema)

History mein poochne wale points:

• Site - Paon se shuru hua ya face se? (Pedal = cardiac/hepatic/renal; facial = nephrotic, anaphylaxis)
• Duration - Kitne time se?
• Progression - Paon se upar chadh raha hai? (Ascending pattern = CCF)
• Pitting ya non-pitting - Dabane se mark padta hai ya nahi? (Non-pitting = hypothyroid, lymphedema)
• Timing - Subah zyada ya shaam ko? (Cardiac - evening mein worse; Renal - morning worse, facial puffiness)
• Breathlessness - Orthopnoea? PND? (cardiac failure)
• Decreased urine output - Oliguria? (Renal cause - nephrotic / nephritic)
• Frothy urine - Jhagwali peshab? (Proteinuria - nephrotic syndrome)
• Abdominal distension - Pet mein paani? (Ascites - hepatic cause, CCF)
• Diet history - Protein intake kaisa hai? (Nutritional hypoalbuminaemia)
• Drug history - CCB (amlodipine), steroids, NSAIDs cause oedema
• Weight gain - Sudden weight badha? (fluid retention)
• Fever - Ek taraf per mein lali + dard? (Cellulitis, DVT)

Relative Negative Findings:

• No h/o cardiac disease (rules out CCF)
• No frothy urine or decreased urine output (rules out renal cause)
• No jaundice or abdominal distension (rules out hepatic cause)
• No h/o drug intake causing oedema
• No prolonged standing/varicose veins (rules out venous oedema)
• Non-pitting vs pitting clearly mentioned

6. LYMPHADENOPATHY

History mein poochne wale points:

• Site - Kahan pe hain? Cervical, axillary, inguinal, generalized?
• Duration - Kitne time se hain?
• Onset - Sudden ya gradually badhe?
• Size progression - Badh rahe hain, same hain, ya chote ho rahe hain?
• Pain - Dard hai? (Tender = reactive/infective; Non-tender = malignant / TB)
• Fever - Low-grade continuous fever? (TB, lymphoma, HIV)
• Night sweats - Raat ko pasina aata hai? (TB, lymphoma - "B symptoms")
• Weight loss - Unexplained weight loss? (B symptoms of lymphoma)
• Throat/skin infection - Koi infection recently? (Reactive lymphadenopathy)
• Contact with TB patient - Koi ghar ya karib mein TB ka patient?
• Skin rash - Koi rash? (SLE, infectious mono, HIV)
• Pruritus (itching) - (Hodgkin's lymphoma)
• Alcohol-induced pain - Sharab peene pe nodes mein dard? (pathognomonic of Hodgkin's)
• Sexual history - HIV risk factors?
• Cat scratch / animal contact - (Cat scratch disease)
• Travel history - Filariasis endemic area?

Relative Negative Findings:

• No fever or night sweats
• No unexplained weight loss
• No contact with TB patient
• No h/o recent infection / sore throat
• No skin rash
• Nodes not tender
• No generalized lymphadenopathy (sirf localized hai to likhen)
• No hepatosplenomegaly associated

Clinical Posting Ka Practical Format

• Pallor - Present/Absent (if present: mild/moderate/severe; conjunctival, palmar)
• Icterus - Present/Absent (if present: mild/moderate/deep; scleral)
• Cyanosis - Present/Absent (if present: central/peripheral)
• Clubbing - Present/Absent (if present: Grade I/II/III/IV)
• Edema - Present/Absent (if present: site, pitting/non-pitting, Grade +/++)
• Lymphadenopathy - Present/Absent (if present: site, size, consistency, tender/non-tender, mobile/fixed, skin over it)

Quick Relative Negatives Summary