The hi and general princi CLINICAL EXAMINATION 1) History ofthe patient disability 3) a general cinical history b) a detailed clinical history 2) Physical examination 2) general assessment b) systemic examination AGENERAL CLINICAL HISTORY 1) The approach to the patient 2) The patients account of the current lines 3) Interrogation (interview) INTERROGATION (INTERVIEW) BY THE DOCTOR 1) The current ines 2) major complaints b) systemic enquiry ©) information from a third party 2) Previous illness and state of health 3) Drug history 4) Family history 5) Social history ©) _The psychological assessment ‘THE CURRENT ILLNESS. ‘Major complaints 1) please, tel! me about your present trouble. 2) when did your trouble start ?.." “what was the first thing you felt wrong?..” ‘what happened next 7." ‘can you show me where you get the pain 2..." ‘what colour is it 2." ‘Systemic enquiry: standard questions 1) Cardiovascular system: examination ankle swelling, palpitations, breathlessness when lying flat (orthopnoee), attacks of nocturnal breathlessness (paroxysmal nocturnal dyspnoea) chest pain on exertion, pain in legs on exertion 2) Respiratory system: shortness of breath: exercise tolerance, wheezing, cough, sputum production (colour, amount), chest pain Isolated to respiration or coughing, blood in sputum (haemoplysis) 3) Central nervous system:4) headaches, visual symptoms (e.g. double vision, lost of acuity or visual fields), fits, faints, tingling (paresthasize), numbness, muscle weakness, hearing symptoms (e.g. deafness, tinnitus), excessive thirst, sleep patterns. Urogenital: pain on passing urine (dysuria), frequency of passing urine (nocturia), abnormal colour of urine (e.9. blood), number of sexual partners, males: if appropriate age ask for prostatic symptoms such as difficulty in starting to pass urine, poor stream, terminal dribbling, if appropriate ask for mental attitude to sex (libido), moming erections, frequency of intercourse, ability to maintain erections, ejaculation, urethral discharge. female: if premenopausal, age of onset periods (menarche), regularity of periods (e.g. 28- days cycle), Tength of period, blood loss (9. clots, flooding), note of last period, contraception if relevant, presence ‘of vaginal discharge, stress and/ or urge incontinence, pain during intercourse (dyspareunia), post- ‘menopausal bleeding where relevant 5) Alimentary: condition of mouth (infected tongue or bleeding gums), diffculty with swallowing (dysphagia), indigestion, heartburn, abdominal pain, weight loss, change in bowel habits, colour of mation (e.g. pale, dark, tarry black, fresh blood) 6) Locomotor: joint pain or stiffness, muscle pain or weakness 7) Endocrine: heat intolerance, cold intolerance, change in sweating, prominence of eyes, swelling in neck Information from the third party relative or friend eye witness a search of patient's clothing and personal belongings‘ ep a hospital staf (students, nurses, social workers...tc.) PREVIOUS ILLNESS AND STATE OF HEALTH information about ilinesses, operations, accidents (ask for previous medical records) 2) residence or travel abroad 3) previous health: medical examination for insurance, record the blood pressure, previous radiological examination DRUG HISTORY 1) Information about drugs that have been taken previously = itmay provide a diagnosis war about drug interaction and adverse effects '» indicate how effective or ineffective previous treatments have been 2) What medicines the patients is currently taking 3) Previous adverse experience 4) Information regarding drugs of addiction Medicines should be identified 1 FAMILY HISTORY » 2) Information regarding the age and health or cause of death of patients’ relatives: parents, siblings Information about more intimate matters: alcoholism, emotional disturbances.SOCIAL HISTORY 1) description how the patient spend the average day 2) The homme (co-operation with the social worker) 3) Occupation 4) Personal interest (physical exercise, intellectual activities) 5) Habits (tobacco, alcohol, food) PHYSICAL EXAMINATION 1) General assessment 2) Cardiovascular examination Respiratory examination ‘Abdominal examination ‘Neurological examination Locomotor examination 3) Laboratory tests and image techniques General assessment Demeanour and general condition. Posture and gait Physique and nutritional status State of hydration and presence of oedema Height and weight Finger clubbing Head, face and neck (goiter...) ‘Skin and subcutaneous tissues Breasts Lymphadenopathy Cardiovascular system 1) __Afteril pulse and pressure 2) Jugular venous pulse and pressure 3) Heart: inspection, palpation, auscultation 4) Peripheral circulation: arterial, venous Respiratory system 1) Examination of sputum 2) Upper respiratory tract (nose, tonsits, pharyrx) 3) Chest: inspection, palpation, auscultation Abdominal examination 1) Inspection (distension, movement, shape) 2) Palpation 3) Percussion 4) Auscultation 5) Digital examination 8) Examination of stool 7 Urine 8) Genitalia: inspection, palpation (in special circumstances only) Nervous system 1) Mental state 2) Speech and language 3) Cranial nerves 4) Motor system 5) Sensory system 6) Reflexes 7) Supplementary tests Locomotor system1) Spine 2) Joints and limbs 3) Muscles 4) Bones Examination of the mental state 1) General appearance and behaviour 2) Thought processes 3) Mood 4) Delusions, hallucinations, obsessions 5) Intellectual functions: ‘© offentation © memory ‘= attention and concentration * general information = intetigence Inherited diseases with important cardiac components: ‘familial hypercholesterolaemia, homocistinuria, Down's syndrome, Tumer's syndrome, Noonan’s syndrome, Marfan’s syndrome, Ehlers- Danlos syndrome, Friedreich's ataxia, dystrofia myotonia, neurofibromatosis Cardiac components of multisystem diseases diabetes melitus, alcoholism, polyartertis nodosa, systemic lupus erythematosus, rheumatoidarthrits or sarcoidosis Drug and heart disease: ‘© hypertension (corticosteroids, ephedrine...) + fluid retention (coricosteroids, liquorice. ‘© sinus tachycardia (Salbutamol, Thyroxi ‘= tachyarythmias (digoxin, ciuretics..) ‘© bradyarrythmias (beta-blockers, Verapamil. History of cardiovascular system 1) Symptoms of heart disease 2) dyspnoea pain ©) oedema 0) __ other symptoms of heart disease 2) Symptoms of peripheral vascular disease 2) arterial insufficiency b) venous insufficiency ‘Symptoms of peripheral vascular disease 1) Asterial insufficiency pain in the limb, loss of function, altered cutaneous sensation, cold (the acute form, chronic arterial ineufficiency, severe chronic arterial insufficiency) 2) Venous insutciency ‘ pain of the mb, warmth, sweling, tandemess (the acute form, chronic venous insufficiency) ‘Symptoms of heart disease ea ‘2) dyspnoea on effort: first symptom of left hear failure b) _ paroxysmal nocturnal dyspnoea: characteristic symptom of left heart fallure c) _orthopnoea: breathlessness demanding the upright position 2) Oedema 2) impairment of renal blood flowb) increased venous pressure ©) the effect of aldosterone 9) antidiuretic hormone 2) lymphatic factors f) ——_oncotic pressures 3) Pain 2) the analysis of a pain: main site, radiation, character, severity, duration, frequency and periodicity, special times of occurrence, aggravating factors, relieving factors, associated phenomena b) angina pectoris: chest pain- the principal symptom of myocardial ischemia ©) _ other chest pains of cardiovascular origin paroxysmal tachycardia pericarditis + pericardial effusion + dissecting aneurysm + ital protapse * pericardial catch 4) Other symptoms of heart disease palpitation = cough + haemoptysis = syncope + tiredness + eyes ‘gastrointestinal symptoms renal function ‘Symptoms of disease of the upper respiratory tract 1) Nose and nasopharyrxc nasal obstruction, nasal discharge, epistaxis 2) Larynx: hoarseness, cough, laryngeal stridor, laryngeal pain 3) Trachea: tracheal pain, tracheal stridor History of previous illness ‘Tuberculosis, pneumonia and pleurisy, other respiratory liness, chest injuries and operations, other surgical procedures, acute abdominal conditions, allergic disorders, previous radiological examinations HISTORY OF RESPIRATORY SYSTEM 1) Symptoms of respiratory disease ‘cough, sputum, haemoptysis, chest pain, breathlessness (dyspnoea), apnoea, wheeze 2) Symptoms of disease of the upper respiratory tract, Nose and naso- pharynx, larym, trachea 3) History of previous iliness. 4) Family and social history 5) Occupational and other environmental hazards ‘Symptoms of respiratory disease 1) Cough: -frequency, severity, character (harsh, dry, paroxysmal, loose and readily productive of sputum, short and half- suppressed by pain... -is dependent on: the situation and nature of lesion responsible for the cough, the ‘presence or absence of sputum, coexisting abnormalities (e.g. vocal cord paralysis, impairment of ventilatory function, pleural pai 2) Sputum: amount, character (serous, mucoid, mucopurulent, purulent, rusty), vicosity, taste or odour 3) Haemoptysis: frequency and d duration 4) Chest pain: (due to respiratory disease) ‘© upper retrostemal pain (acute tracheitis) ‘© retrostemal pain associated with lesions of the mediastinum ‘= pleural pain5) Breathlessness (dyspnoea) associates with: ‘= an increase in the work of breathing increased pulmonary ventilation ‘weakness of the muscles of respiration ‘© muttie factors (pneumonia, pulmonary oedema) 2) —_acute onset breathlessness (bronchial asthma, massive pulmonary embolism...) ) exertional breathlessness 6) Apnoea ‘+ breath may be voluntarily held for short periods ‘periods of apnoea alternate with overventilation (Cheyne- Stoke breathing) * during sleep (obstructive, central) 7) Wheeze ‘obstruction of the small airways 8) Stridor ‘obstruction ofthe large airways Family and social history 1) Infections (tbc...) 2) Allergic disorders 3) Chronic bronchitis 4) Social problems (housing, finance, employment...) Cigarette smoking Obesity ‘Occupational and other environmental hazards The inhalation of certain inorganic and organic dusts and chemical substances Points of special emphasis 1)A detailed clinical history is usually more helpful in making the correct diagnosis than is ‘the physical examination 2)The essential skill in history- taking isthe ability to listen to the patient's story. This ‘requires establishing a good report Any system of history- taking must be flexible and also methodical 44)The history of the presenting complaint includes events right up to the time of the interview 65)The personel history should include details of tobacco and alcohol consumption, travel ‘abroad, current medication and allergy 6)The clinician must be prepared to listen to, and as necessary discuss, personal problems without embarrassmentPHYSICAL EXAMINATION HEAD AND NECK Hair - quantity, distribution, texture Skull - size, deformities, lumps, tenderness Face - symmetry, movements, edema, masses Skin - color, pigmentation, hair distribution, texture Eyes - color of conjuctiva and sclera, position of eyes (e.g. strabismus), ~ eyebrows, eyelashes, eyelids - edema, color - visual acuity, visual field, papillary reaction to light, convergence, eye movements, - Graefe’s sign, Kocher's sign, Moebius's sign Ears - location, color, inspection of external canal - auditory acuity Nose and paranasal sinuses - inspection of anterior and inferior surfaces - asymmetry, nasal obstruction - palpation for sinus tendemess (frontal and maxillary) - Mouth and pharynx - lips, oral mucosa (color, ulcers, other lesions) - gums and teeth condition - tongue color - color of the palate, tonsils (redness of palate arch, enlargement of tonsils, spots Neck lymph nodes — enlargement, mobility, consistency - preauricular - posterior auricular = occipital - submandibular - submental - superficial cervical - posterior cervical - deep cervical chain = supraclavicular -thyroid _- swelling, nodular surface, tendemess, mobility during swallowing, bruits -vessels _- pulsation, venous distentionLUNGS and CVS Type of breathing - normal, rapid shallow, rapid deep, slow, - Cheyne-Stokes breathing, Biot’s breathing Inspection of the chest - color, symmetry, pigmentation, hair growth, vessel distensions - shape (‘barrel chest”, “pigeon chest’, “funnel chest”, scoliosis etc.) - mobility (respiratory movernents) Palpation ~tendemess, masses, sinus tracts - respiratory expansion - tactile fremitus (symmetrical or not; if not — specify) - position of heart apex Percussion resonance, dullness, tympany — specify regions - establish lung lower borders and relative heart dullness Auscultation (lungs) _- sounds: vesicular, bronchovesicular, bronchial — specify regions - intensity of sounds - added sounds — crackles, wheezes, rhonchi, friction rubs Arterial pulse - check radial, carotid, femur and dorsal pedis artery pulse - frequency, regularity, amplitude Blood pressure measurement Auscultation (heart) mitral valve, aortic valve, tricuspid valve, pulmonic valve - frequency, regularity (estimate together with peripheral pulse), splitting BREASTS AND AXILLAE - lymph nodes in axillae - shape, color, tendemess, skin lesions, discharge, consistency, massesABDOMEN Inspection - skin - scars, striae, dilated veins, rashes, lesions -contour of abdomen —_- flat, protuberant, concave etc. - symmetry - visible peristalsis (intestinal obstruction) - aortal pulsation Auscultation - 5-30 sounds per minute ~ bruits Percussion - tympany/dullness — describe area - dullness of liver and spleen - specify - dullness of any additional masses in abdomen Palpation - light palpation _- identify abdominal tendemness, muscular resistance, organs and masses - deep palpation _- establish borders of abdominal organs and masses Signs - rebound tendemess - assessing kidney tendemess - assessing gall bladder tendemess - assessing tendemess of appendix area (Rovsing's sign, etc) Test for fluid wave (peritoneal cavity fluid — ascites)CNS Level of consciousness Alertness —_- full reactions Lethargy - drowsy, but opens eyesm responds to question, falls asleep Obtundation - opens the eyes, responds slowly, confused Stupor —_- awake only after painful stimuli, usually absent verbal response Coma ~ eye closed, no response to any stimuli Cranial nerves 1 - smell " - visual acuity, field ut - papillary reactions Mil, lv, VI - extraocular movements v - comeal reflexes, facial sensation, vil ~facial movements (smile etc.) vill - hearing Ix, X - swallowing, rise of palate, gag reflex V, VIL, X, Xi - voice and speech xi - shoulder and neck movements xil - tongue symmetry and position Deep tendon reflexes —_- knee, biceps, triceps, brachoradialis, abdominal, ankle —_ (hyperactive, diminished, absent) Plantar response - Babinski sign (positive or negative) Muscle strength - flexion and extension -elbow, hip, knee Point-to-point movements - finger to the finger, finger to the nose, heel to the knee Gait - heel-to-toe, walk on the toes and on the heels Romberg test Sensory system - light ‘touch - pain and temperature - position and vibrations - discriminative sensations Sign of meningitis - stiffness of the neck