AS Cally SECRETS MEDICINE PAEDIATRICS OBSTETRICS GYNAECOLOGY SURGERY NAFIU A.—— —~— 2 PREFACE TABLE OF CONTENTS Clinicians lay emphasis on good history & physical examination as both are essential for patient assessment & care. Firm knowledge base & good DEDICATION. communication skills are necessary requirements for mastering the art of ACKNOWLEDGEMENT. clerkship, This compendium of commonly encountered cases in Medicine, PREFACE... tries, Obstetrics & Gynaecology, and Surgery is intended to serve as a HOWTOUSETHIS BOOK, effective history taking & relevant physical examination. HOWTO CONTRIBUTE. livered in compact, colourful, easy-to-read & apply format. Mnemonics & ABBREVIATIONS. ables have been used to capture potent points to aid smooth, swift recall. wine it Clinical students, in the course of erudition & eventual practice shall find an clerkship secrets amust have! ate eee ectaha Cheers, PHYSICAL EXAMINATION IN MEDICINE2 ABDULLATEEF NAFIU 2021 \ ACASE OF DIABETES MELLITUS... REBROVA‘ R DISEASE ACASE OF SYSTEMIC HYPERTENSION. HOWTO USETHIS BOOK Read the introductory part to each clinical discipline to get a patterned overview ofits history taking & physical examination format. ‘Then proceed to the cases where each sample concentrates on specific {uestions that should be asked in the history of presenting complaints & Ml Y : /ant signsto look out forin the physical examination. . ! AMIE RENAL FAILURE 010000 sesey gaan 'felevant investigations & treatments required for each disease have been 74... (eorporated within the History of Care (Hx of Investigations & is, oF corrections on the blog; erets.wordpress.com iClerkshipsecret ipsecrets@gmail.com j/y rewarding clerkship experience!ACASE OF ACUTE GOMERULONEPHRITIS (AGN)/ NEPHROTIC SYNDROME (NS) ACASE OFSICKLE CELL ANAEMIA, LEUKAEMIA ACASE OF BURKITT'S LYMPHOMA. ACASE OF NEPHROBLASTOMA (WILMS TUMOUR)...... ODSTETRIGE & GYNAECOLOGY. senses ACASEOF ROUTINE ANTENATAL VISIT6. PIYSICAL EXAMINATION IN OBSTETRICS... ‘ACASIE OF WRONG/ UNSURE OF DATE. su : ACASE OF LARGE FOR DATE.. ACASE OF SMALL FOR DATE.. ACASE OF POST DATE (INTHE 42" WEEK) ‘ACASE OF RHESUS NEGATIVE MOTHER A CASE OF BREECH/ MALPRESENTATION.. ACASE OF HYPERTENSION IN PREGNANCY. ACASE OF DIABETIC MOTHER... ‘SE OF PREM, RUPTURE OF NES (PROM) CASE OF Al ‘TUM HAEMORRHAGE evs ‘ASE OF D FET/ ITERINE FET/ TH DELIVERY O} BIRTH/ MALE TUS ACASE OF ABDOMINAL PAIN IN PREGNANCY......... ACASE OF HYPEREMESIS GRAVIDARUM. GYNAECOLOGY CLERKSHIP SCHEMA... PHYSICAL EXAMINATION IN GYNAECOLOGY. A CASE OP INFERTILITY... ACASEOF UTERINE FIBROIDS... ACASE OF UTERINE PROLAPSE, sss ‘ACASE OF VESICO VAGINAL FISTUL/ ‘ACASE OF LATE/ REDUCED/ABSENT MENSES. ACASE OF MISCARRIAGE (ABORTION). ACASE OF ECTOPIC GESTATION... vl CASE OF PELVIC INFLAI RY DI a ACASE OF VAGINAL DISCHARGE... A.CASE OF CERVICAL) ENDOMETRIAL CANCER, SURGERY. sui cu PHYSICAL EXAMII IN AGASE OF BLADDER OUTLET OBSTRUCTION ACASE OF APPENDICITIS,, ACASE OF GASTRIC OUTLET OBSTRUCTION . FI |AL OBSTRI ACASE OF OESOPHAGEAL DISEASE. saa saan i vette a2 MAMAN Nise 0..36 ACASE OF H) ti 15, ACASE OF PAEDIATRIC ACUTE ABDOMEN innit INDEX... : 111101000 328 COMMON LABORATORY VALUES... ABBREVIAI ‘AFB: Acid and Alcohol Fast Un AGN: Acute Glomervlonephvitis ‘AML: Acute Myeloid Leukaemia ANC: Antenatal Care ‘ANS: Autonomic Nervous System BMI; Body Mass Index Ca:Cancer CHO: Carbohydrate (CNS: Central nervoussystern CVD: Cerebrovascular Disease DRE: Dilatation & Evacuation D.M: Diabetes Mellitus E/U/Cr Electrolytes Urea ® Creatinine FBC: Fullalood Count FAS; Fasting Blood Sugar FFNAC: Fine needie aspiration cytology GIT: Gastrointestinal tra ‘G6PD: Glucose-6-Phosphate Dehydrogenase Hb : Haemogiobin /oxysmal Nocturnal Dyspaoea Pr Protein SCD: Sickie cel disease FH: Symphisio fundal height ORL: Venereal disease Research SLE: Systernic Lupus Erythematosus Laboratory ORS: Oral Rehydration Solution 1B UTI: Urinary tract infection vuMEDICINE vat MEDICINE ( LERKSHIP SCHEMA HISTORY tAnING Biodata Name, aye, oecijuitton, address, religion, tile Askalso about, mode of veloral whether relered fromany hospital means 5 vii casually or clinic and duration on adinivsion (an md) *Strictly speakinp, date of admimion not part of bioihita, butofiens a better delivery when the duration on admission in stated before the presenting complajiily, E.g. "He was adwitied via the Emergency Room) diye age oy account of loss of conscious: of © hours prior to presentatioii” Presenting Complaints (4) Arrange main symptonis aiid diy of each, in order/sequenes oceurrence, ig History of Presenting Complaints (H.P.C) HLP.C encapsulates the follow iy) Complaints (symptom analysis) Course (disease progression) Cause (Hx of aetiology) Complications (of disease) Care (Hx of investipations & treatment) Complaints & Course (disease progression) foreach symptom shoul Find the right questions yon don ees te Hee them TIETZE'S SYNDROME: Cosiov on CLERKSHIP SECRETS [RENTS be analysed with respect to its; duration, onset, character/course, timing, other symptoms in the affected system, related phenomena “mnemonic doctor Causes (LIX of aetiology) should he sought for & may include, (auun, hereditary, infection, mutitional, melibolic, autoimmune/allerpic ischacmia/irradiation, diye deyenerative, endocrine, feoplastic, smoking Mmemen I: ~ thin maidens Complications in the following eyeiems, Hetralegic, cardio apaein aidominal, renaly SHH PHOANTE © Mer eats Heh & iveatinenty Hospitals ciated, Blood. wine, i (ultrasound, Titiavena fe intervals + FeRpHHee sitee ws? below Salk Ha lage if the | |ahirontc illnesses; diabetes hypertension, sickle cell ‘stiima mnelliti Drug History Medications + herbal drugs (dose + effects) & Allergies Family and Social History Similar illnesses in the family Alcohol intake, smoking, Single or married; Mono or Polygamous setting, divorced, or separated? Review of Systems Neuro; headaches, blurring of vision, restlessness, convulsions Cardio respiratory; cough, chest pain, dyspnoea, ankle swelling, hemoptysis Abdomen; anorexia, vomiting, bdominal pain, jaundice, abdominal iiision, mass, change in bowel frequency, urgency, dysuria, Hone pain, joint swelling, es, Weakness fi) fash, scar, pruritus, CLERKSHIP SECRETS *Some Examiners therefore prefer review of systems immediately after the HPC. Summary Name, age, sex, P.C & duration, Positive symptoms, important negatives, treatment so far + response totherapy PHYSICALEXAMINATION General examination First, REP the patient; Rapport; introduce yourself, inform patient about the physical exam & obtain consent Expose; allow patient's attire, provide a screen & adequate lighting Position; optimize patient's comfort/supine anatomical position & stand on the right. Inspection; General state of health & consciousness, grooming, facial expressions or obvious lesions & hygiene; odours of body/breath, cannula in-situ, oxygen therapy unit, & other relevant extras around. Palpation; Hair; fluffiness, fullness, pigmentation, pluckability Eyes; facial temperature (dorsum of palm), conjunctival pallor, jaundice Mouth; dehydration, buccal pallor, cyanosis Ask patient to sit up; Peripheral lymph node enlargement; submental, submandibular, pre auricular, cervical: superior, middle, inferior, supraclavicular, posterior cervical, post auricular, occipital wiler to ask questions.....ranz Kafka Wl Mouth Arh, Tlamgiectastas Pavondenfargement Ask patient to lie supine; Check axillary lymph nodes (anterior, posterior, medial, central, lateral) trochlear, inguinal; If enlarged, note site, number, tender, mobi Systeme examinations Netirologicexam Main eonsent pose; allow patient's attire, provide screen & adequate lighting ‘oaition; don the right. ¢ mental function Ww coma score) ilition in time, place, & person ence & Judgement aes ; introduce yourself, inform patient about the physical exam & optimize patient's {ort/supine anatomical position & level of consciousness & eis (If unconscious, state ry; intermediate, short & long vo. dysphasia, dysphonia, in CLERKSHIP SECRETS ER ‘Test for meningeal irritation Neck stiffness, Brudzinski's sign, Kernig's sign cone must first ask the exact questions, Good Clinicians ask questions ypermumerary C7 rib > Pressure on brachial plexus ---> pain radiating over ‘shoulder, arm, aad forearm over C7 distribution.- iWelculations, atrophy, it e muscle bulk Grade 1-5 Honia, normal, hypotonia, Deep (biceps, triceps, nator, knee, ankle) & Superficial (abdominal, cremasteric, plantar) Gait (hemiplegic, festinant, waddling, laxic, high steppage) Sensory system Pain, temperature, light touch, vibration, 2-point discrimination, sensory inattention, Stereognosis, graphestesia Coordination (cerebellar function) Rapid alternating movements, point to point test; finger to nose, heel to shin, test for apraxia; dressing & constructional, tandem walk Cardiovascular exam Rapport; introduce yourself, inform lent about the physical exam & consent patient should undress to the chest & abdomen, provide % adequate lighting iii 150 position & stand on the Hilie; rate, volume, rythmn, Synchronicity, arterial wall pulses; superficial brachial, femoral, CLERKSHIP SECRETS [jy Popliteal, dorsalis pedis & posterior tibial Blood pressure (Erect & supine) Jugular venous pressure Observe & measure in relation to the sternal angle Praecordium Inspect & palpate apical impulse” Note the location, amplitude & duration of the apex beat Listen for Ist & 2nd heart sounds -+ murmurs (Listen at cach auscultatory area with the diaphragm of the stethoscope. Listen at the apex & lower sternal border with the bell), Check for hepatomegaly & ascites, and then auscultate the lung bases for crepitations Respiratory exam Rapport; introduce yourself, inform paticnt about the physical exam & obtain consent Expose; patient should undress to expose the chest & abdomen, provide -asercen & adequate lighting Position; supine position & stand on the right. Inspection Inspect the chest symmetry, chest movement, count respiratory rate (distract with the pulse) Palpation Tracheal centrality, tactile vocal fremitus, chestexpansion OM if Lonty had the right question... Albert Einstein Pechion of distal aarva = Hip, high, and calf anne Percussion: if normal, resonant notes, except for areas of cardiac & hepatic dullness : Auscultation; brenth sounds +: adventitious CLERKSHIP SECRETS [ERTS Percussion alee Shifting dullness, do fluid thrill for massive ascites Auscultation Bowel sounds; : Heard best on the right side; 2mA CASE OF DIABET HISTORY TAKING Blodata , Name, age, occupation, address, rollgion, tribe ‘ t Ask lo about; mode of referral; whether referred from any hospital Means ; via casualty or clinic and duration on admission (mr. md) PC Passage of large volumes of urine x (duration) Increased Appetite, excessive thirst * (duration) Weightloss * (duration) Tec Complaints analysis & Course Analyse each using; doctor Duration; Onset; mode of onset Course; how many times do you pass urine in’ the day (compared to remorbid state) iming; nocturia, volume of urine bitter let symptoms; passage of froth Urine, do ants gather around urine, ay hx of pruritus (t/o Chronic renal failure), any hx of drug use (s/o Hoticed increased thirst? ite increased appetite; leet, &for how long? HNDROME: Herpes Zaster infection He Ginglion => facial patsy. Zoster of ear CLERKSHIP SECRETS MELLITUS Hx of preference for cold weather (1/0 Thyrotoxicosis) Hx of anorexia, jaundice, weight loss (r/o Malignancy) : Hx of chronic cough, night sweats i. igh, night sweats (r/o ae chronic fever, diarrhoea (rio Hx of Cause (Hx of aetiology) Ask ifprior to onset of symptoms there Was any; ‘Hx of pancreatic surgery Hx of abdominal pain, steatorthoea (r/o Pancreatitis) Hx of anorexia, jaundice, weight loss (t/0 Cahead of | ‘pancreas) : Hx of vitiligo; hypopigmented patches on skin (1/0 Autoimmune) Hx of use of prolonged use of steroids, anticonvuisants e.g. phenytoin (t/o Drug induced) soa Hx of prior smoking & alcohol abuse (s/o Nutritional) Hx of Complications Hx of loss of consciousness Hx of blurring of vision Hx of such feeling as walking on foam, or pins & needles (t/o Paraesthesia) ae of recurrent skin infections, boils etc Hx of limb weakness (r/o Proximal myopathy) Hx of leg ulcers, poor wound healing of Facial Nerve (CN VIN) and Hx of recurrent chest infections; pneumonia, upper respiratory infections (1/0 Immunosuppresion) IIx of profuse sweating, air hunger, palpitations (1/0 Hypoglycaemia) Hx of change in bowel habits (r/o Gastroparesis) Hx of difficulty with sexual performance (1/o Erectile dysfunction) IIx of dizziness on standing(r/o Postural hypotension) Hx of recurrent UTI, candidiasis, vaginal discharge, reduced flow, infertility (r/o Gynaccologic effects) IIx of previous macrosomic babies, felal anomalies, intrauterine deaths, Iniscarriages, caesarean sections(/o Obstetrics effects) IIx of skin changes; acanthosis higticans, necrobiosis lipoidica (1/0 Skin eftects) Hx of Care (Hx of investigations & treatment) jive onset of symptoms, ask about ome temedies & hospitals visited. adm on; Investigations done, only what patient says; d; FBC, FBS+2hours prindial, glycosylated Hb, serum Utinalysis (glucose & proteins), Insulin or oral drugs “& dosing intervals + CLERKSHIP SECRETS [7 PHYSICALEXAMINATION General examination Note body habitus/fat distribution or weight loss, dry tongue, air hunger, eyes for xanthelasma, ear for discharge, skin/mucosal candidiasis, skin pigmentation, vitiligo Systemic Examination Neurologic exam Test higher mental function, cranial nerves, visual acuity & fundoscopy (1/o retinopathy + cataracts) Test sensations; light touch, pin prick (distal hypoaesthesia in glove- stocking distribution), vibration (using 128Hz), proprioception (on big toc) Test reflexes; ankle & plantar Cardiovascular exam; peripheral pulses, capillary refill, B.P, JVP, cardiomegaly, murmurs, Respiratory exam: dyspnoea, pleural effusion Abdomen & Genitourinary exam; abdominal mass & discharge per urethra, vaginal discharge Musculoskeletal exam; insulin injection sites; abdomen, upper arms, thighs & buttocks, lumps (lipodystrophy), sub.cut fat (ipohypertrophy), fat loss (lipoatrophy) Hand exam; limited joint mobility (cheiroarthropathy), painless stiffness in hand, wrists orshoulders. Dupuytrens contracture nodules, Carpal tunnel syndrome, Trigger finger (flexor tenosynovitis) Thenar & hypothenar wasting Leg Exam; muscle wasting, hair loss, gramuloma annulate, loss of sensation & reflexes, Check callus on weight bearing areas, clawing of (oes(neuropathy), loss of plantar woh, skin discolouration (isehi ileers Foot deformity(ChaACASE OF CEREBROVASCULAR DISEASE (CVD) HISTORY TAKING Biodata Name, age, occupation, address, toligion, tribe Ask also about; mode of referral; whether referred fiom any hospital means ; via casualty or clinic and duration on admission. (mr. md) PC Inability to move the right leg x (duration) HPC Complaints analysis & Course Analyse using; doctor Duration; In hours, days ormonths Onset; noticed on waking up Aschaemic CVD), or during physical activity (Haemorthagic CVD) Course; progression of paralysis; improving, Static, or deteriorating Hx Of preceeding. terrible headache or seizures? (Subarachnoid haemor thage) Timing; loss of consciousness as illness progressed (1/0 Cerebral oedema or extension of Infarction) Other symptoms; motor or sensory symptoms Related Phenomena; Previous attacks that resolved(r/o Transient ischaemic attack) Hx of Cause (Hx of aetiology) Ask ifprior to onset. ofsymptoms CLERKSHIP SECRETS there was any; Hx ofhead injury or epilepsy Hx of familial hypertension Hx of diabetes mellitus Hx ofsickle cell disease Hx of weight gain or obesity Hx of use of oral Contraceptive pills (high dose estrogen in women >35 yrs) x of similar Previous episodes that Tecovered completely (1/0 TIA) Fx of previous chest pain (t/o Ischaemic heart disease) Ux of fever, IV drug use (r/o Infective endocarditis) Hx of chronic fever, diarrhoea (wo HIV) Hx of chronic cough, night sweats (t/o TB) ix of anorexia, jaundice, weight loss (vo Malignancy) Hix of cramps/ muscle pain (/o Peripheral vascular disease) Hx of prior smoking & alcohol abuse (t/o Nutritional) Hx of bleeding from various orifices (t/o Blood dyscrasias) Hx of Complications Hx of loss of consciousness Hx of projectile vomiting, irregular respiration (i/o Raised intracranial pressure) Hx of blurring of vision, ipsilateral blindness Hx of slurred speech: dysphasia Hx of Hx of emotional lability, depression PKOWN SKOUARD SYNDROME: Damage (Gnjury) to half of spinal cord —-> symptoms: Lose Of pain and temperanire sensation on contralateral side of bo HORE W/ proprioception and discriminatory touche ‘ipsilateral side of body. Hx of Care (Hx of investigations & treatment) ; Since onset of symptoms, ask; first aid at home & hospitals visited, On admission; Investigations done, report only what patient says; CT: sean, ECG, full blood count, blood glucose, serum cholesterol, clotting factors urinalysis (glucose & proteins), chestx-ray, B/U/Cr Treatment; Intravenous (fluids+ mannitol) or oral drugs (only after swallowing test is done to prevent aspiration) received & dosing intervals, physiotherapy & mobilization +response, PHYSICALEXAMINATION General examination Note consciousness, posture Neck exam for stiffness & pedal cedema, obvious limb deformity Systemic Examination Nervous system Test higher mental function; speech may be affected in dominant parietal lobe lesion, cranial nerves(UMN or LMN paralysis of the 7in nerve), visual acuity & fundoscopy (r/o papilloedema) Test motor system; Upper motor heuron(UMN) signs are expected, however in the acute phase, LMN ‘igns(hypotonia, hyporeflexia) tlicited occurs due to spinal shock. Gait may be spastic 7 ‘Test sensory system; hemianaesthesia ag mea CLERKSHIP SECRETS [ESS ACASE OF SYSTEMIC HYPERTENSION HISTORY TAKING Biodata Name, age, occupation, address, religion, tribe Askalso about; mode of referral; whether referred from any hospital means; via casualty or clinic and duration on admission (mr, md) Pe Elevated blood pressure on routine check up Othersymptoms (ifany) HPC Complaints analysis & Course Analyse each (ifany) Hx of Cause (Hx of aetiology) Ask ifprior to onset of symptoms there was any; Hx of hypertension, of family history of hypertension k Hx of heavy alcohol consumption (Units/week; males<3, females <2) 3 Hx of cigarette smoking (estimate in pack years) Hx of adding extra salt directly to meals (r/o Volume dependent Hypertension) Hx of diabetes, or family history of diabetes mellitus (r/o Metabolic syndrome)Hx of prior renal disease (1/0 Chronic renal failure) Hx of sedentiry occupation without exercise (1/0 Sedentary lifestyle) Hx of use of prolonged use of steroids, OCPs, NSAIDS (1/0 Drug induced) Hx of weight gaint bloated face + Menstrual irregularity(r/o Cushing's syndrome) Ix of pre-eclampsia or eclampsia in ptevious pregnancy Hx of sudden attacks of sweating, headaches & palpitation(r/o Phaeochromocytoma) Lx of Complications Hx of loss of consciousness, convulsions, strokes (CNS effects) Hx of blurring of vision (Eye effects) Hx of palpitations, chest pain, dyspnoea (CVS effects) Hx of polyuria, nocturia, anorexia, weakness (Renal Effects) Hx of difficulty with sexual performance(t/o Erectile dysfunction) Hx of nose bleeds (r/o haematologic effects) Hx of Care (Hx of investigations & treatment) Since onset of symptoms, ask; first aid athome & hospitals visited. On admission; Investigations done; urinalysis (glucose & proteins) blood radiological (Ultrasound, X-rays), Treatment; Oral drugs received & dosing intervals+ response, li Aewleutia, Righistept disorientation CLERKSHIP SECRETS PHYSICALEXAMINATION General examination Note consciousness, posture Neck exam for stiffness & pedal oedema, obvious limb deformity Systemic Examination Cardiovascular exam ulse Radial pulse; rate, volume, rythmn, character, synchronicity, arterial wall thickness. Other peripheral pulses; superficial temporal, carotid, brachial, femoral, popliteal, dorsalis pedis & posterior tibial Blood pressure (Erect & supine) Jugular venous pulse Observe & measure in relation to the sternal angle Praecordium Inspect & palpate apical impulse Note the location, amplitude & duration of the apex beat Palpate for heave (apex, left parasternal) Listen for Is & 2na heart sounds + murmurs (Listen at each auscultatory area with the diaphragm of the stethoscope. Listen at the apex & lower sternal border with the bell). Nervous system : Test higher mental function, motor & sensory system +Cerebeilar/Autonomic dysfunctions GURSTMANN'S SYNDROME: Lesion between occipital area and angular gyrus “Symptons: Finger egnosi, ACASE OF SEIZURE DISORDER HISTORY TAKING Biodata Name, age, occupation, address, religion, tribe Ask also about; mode of referral; whether referred from any hospital means ; via casualty or clinic and duration on admission (mr. md) PC Recurrent seizures x (no of episodes) HPC Complaints analysis & Course using; doctor How many episodes? Duration ofeach Onset ofconvulsions Character (aka Nature; tonic-clonic, atonic, tonic, myoclonic, clonic) Timing Other symptoms; febrile illness Related Phenomena; Pre-Ictal: Trauma, Last meal, Aura=abdominal cramps, unusual taste or smell letal; Loss of consciousness, head luming, eyes rolling, drooling of saliva, urinary/faccal soiling of clothes Interventions cmployed/termination of convulsion. Post-lctal: Post-ictal confusion, headache, orsleep, Inquire about Is episode and chronicle «detailed account, STRAIGHT BACK SYNDROMB» Lows of wrmal ‘murmur IWhdened cantiae slouhene on xray 1k of Cause (Hx of aetiology) Hx of sudden loss of consciousness + Aura, followed by a fall, assoc, with rapid jerking + stretching, +/- incontinence (r/o Gen. tonic clonic seizures) TIx of sudden cessation of activity or halt in speech with blank stare +/- worsening grades in school (r/o Absence scizures) Hx of sudden fall to the ground & immediate recovery to resume normal activity (1/0 Atonic seizure) Hx of shock-like movement of hands & feet (#/0 Myoclonic seizures) Hx of localized twitching of face, trunk, extremities +/- head turning to same side (r/o Simple partial seizures) Hx of repetitive actions, prolonged fugue states, aimless wandering, lip smacking, tongue thrusting(t/o Complex partial seizures) Hx of continuous seizures (~30 mins) or repeated attacks of shorter duration without regaining consciousness (r/o Status epilepticus) Ifthere is fever, ask for; Hx of neck pain/ back pain (1/0 Meningitis) Hx of irrational talk + bizarre movement with normal intervals (1/0 Encephalitis) Hx of fever, anorexia, headaches + any CNS manifestation if malaria exposed/ Coma lasting >30mins post convulsion (t/o Cerebral malaria) CLERKSHIP SECRETS I aHx of headaches, projectile vomiting, foal neurologic deficits or change in personality Space occupying lesion), ‘fuken (1/0 [ypoglycaemia) tion of aleohol or poisons. _ Painily Hx of Seizure i Hy of Complication Projectile vomiting, Irregular breathing (Raised ICP)...Measure Blood pressure Facial injuries, multiple wounds & fractures **In Tetanus; ! Trismus (Inability to open the mouth igusually the first symptom) | Spasms, not convulsions, are often provoked by touch, light or noise. Which may be preceded by injury, snake bite, burns or fracture, ! There is no_loss of consciousness; Ask Hx of restlessness, photophobia, headache, irritability, body stiffness (Very typical) Dysuria & retention of urine, abnormal sweating (ANS Involvement) Hx of dog bite, dysphagia, hydrophobia + clonic seizures (r/o Rabies) Hx of Care (Hx of investigations & treatment) I aid treatments; airway & breathing, emergency room care; anticonvulsants, iv glucose, oxygen @te. Investigations since admission: Tiood, 1/U/Cr Urinalysis, EEG, CT- Sean, X-rays donc. Treatment; Intravenous infusions, blood CLERKSHIP SECRETS [LE intervals/compliance, +/- response to therapy PHYSICALEXAMINATI General examination Check for level of consciousness, febrile? pallor, jaundice, dehydration, finger clubbing, lymph nodes enlargement, pedal oedema Systemic examination Neurologic exam Test higher mental function State level of consciousness (if unconscious, state Glasgow coma scale) Orientation intime place & person Memory; immediate, short & long term memory Intelligence & Judgemmnt Speech; r/o dysphasia, dysphonia & dysarthria Test formeningeat irritation Neck stiffness; Brudzinski's & check for Cranial Nerves CNI CNXUL Motorsystem Inspection for fasciculations, atrophy, involuntary movement Palpate & measure muscle bulk Power; MRC Grade 1-5 Tone; hypertonia, normal, hypotonia, Reflexes; Deep (biceps, triceps, supinator, knee, ankle) & superficial ( abdominal, eremasteric, plantar) Gait (hemiplegic, festinant, waddling, ataxic, high steppage) Sensory system temperature, light touch, vibration, 2- point discrimination stercognosis, graphestesia, senisory inattention Coordination (cerebellar function) Rapid altemating movements, point to point test: finger tonose, heel to shin, test for apraxia: dressing & constructional, tandem walk Others; Cardio respiratory. Abdominal & Genito A CASE OF CONGESTIVE CARDIAC FAILURE (CCF) HISTORY TAKING Biodata Name, age, occupation, address, religion, tribe Askalso about; mode of referral; whether referred from any hospital means ; via casualty or clinic and duration on admission (mr. md) Difticulty with breathing x (duration) Cough x (duration) Bilateral leg swelling x (duration) nec Complaints analysis & Course Analyse dyspnoea using: doctor Duration & Onset Course; worsening progression ‘Timing ; worse at nights + distressing Other symptoms; orthopnoea, OAysmal nocturnal dyspnoea + eze lod phenomena; easy fatigability, eough using; doctor of; in elation to Ix complaint Hiya after onset of fever) tab distressing) pain (pleuritic CLERKSHIP SECRETS Analyse leg swelling using; doctor Duration; Onset; exclude trauma or insect bite Course; progressive; bilateral, not traumatic, not painful Timing; when is it worse, if present alt through theday Other symptoms; fever Related Phenomena; loss of appetite, abdominal pain orswelling Hx of Cause (Lx of aetiology) Hx of hypertension Hx of sore throat or skin infections leading to joint & chest pain (1/0 Rheumatic heart disease) Hx of weakness & dizziness (r/o Anaemic heart failure) Hx of fever, dental extraction, congenital / valvular heart disease, -: I.V drug abuse (1/0 Infeetive endocarditis) Hx of palpitation + preference for cold weather (1/0 Thyrotoxicosis) Hx of chest pain (1/0 Constrictive pericarditis, Myocardial infarction) Hx of prior asthmatic attacks (r/o Bronchial asthma) Hix of smoking, bush burning, firewood use (r/o COPD) Hx of chronic coughtmalodorous sputum, weight loss (r/o Bronchiectasis or Pulmonary abscess) Hx of chronic cough, weight loss & HIV Status (1/0 T.B) IIx. of facial swelling, oliguria or polyuria (t/o Chronic renal disease) Hx of jaundice, abdominal pain /syelling (1/0 Chronic liver disease)Hx of Complications Hx ofsyneopal attucks Hx Of cough, hemoptysis, dyspnoea, orthopnoea, PND (1/0 Left heart failure) Hix of prominent neck veins, abdominal pain, leg swelling(1/o Right heart failure) Hx of hemiplegia or gangrene of fingers of toes (1/0 Embolic occlusion of arteries) Hx of Care (Hx of investigations & treatment) Home remedies, Prior treatment/investigations from referral hospital, Investigations since admission: Blood; full blood count, blood culture, Urinalysis. Chest x-ray, ECG. Treatment; salt restriction, alcohol & smoking cessation, intravenous infusions, blood transfusion, drugs and dosing intervals 4/- response to therapy, PHYSICAL EXAMINATION General examination Note pallor, facial puffiness, respiratory distress; nasal flaring, tachypnoed, tracheal tugging, costal recessions, posture, pedal oedema, obvious limb deformity SUPERIOR VENA CAVA SYNDROME: Caused by Hema Kngorgement of the vessels of face, neck, and CLERKSHIP SECRETS. Systemic Examination Cardiovascular exam Pulse Radial pulse; rate, volume, rythmn, character, synchronicity, arterial wall thickness Other peripheral pulses; superficial temporal, carotid, brachial, femoral, popliteal, dorsalis pedis & posterior tibial Blood pressure (Erect & supine) Jugular venous pressure Observe & measure in relation to the stemalangle Praecordium Inspect & palpate apical impulse Note the location, amplitude & duration of the apex beat Palpate for heave (apex, left parasternal) Listen for Is & 2na heart sounds + murmurs (Listen at each auscultatory area with the diaphragm of the stethoscope, Listen at the apex & lower sternal border with the bell). Respiratory exam ‘Tachypnoca, basal crepitations Abdomen& Genitourinary Hepatomegaly, Ascites Neurologic exam @ tumor. Obstruction af SVC > ‘arms Nonproductive Cough Dyspnea A CASE OF BRONCHIAL ASTHMA TISTORY TAKING Biodata Name, age, occupation, address, religion, tribe Ask also about; mode of referral; whether referred from any hospital means ; via casualty or clinic and duration on admission (mr. md) PC Cough x (duration) HPC . Complaints analysis & Course Analyse cough using; doctor Duration Onset (sudden r/o foreign body or aspiration) Character (dry initially, then wet) ‘Timing (worse at nights £ distressing) Other symptoms; wheeze, Dyspnoea, ‘Sputum (thick mucoid) Related Phenomena; chest tightness, ‘sociated sweating, abdominal pain (due to diaphragm use) Hx of post tussive vomiting, chest fiche, headache 1) of Cause (Ix of aetiology) of atopy/allergies (rhinitis, itis) or family hx ofasthma exposure (0 irritants; noxious Nnoke or Wet paintorcold air osure (0 allergens (pollens, animal dander, feathers, i eto) CLERKSHIP SECRETS [[ERRSRIR Hx of aspirin/NSAIDS or beta blockers intake (t/o Drugs) Hx of excessive exercise (e.g, running) Hx ofrecent emotional stressors Hx of chronic cough + weight loss (r/o TB) Hx of snoring at nights, mouth breathing (1/0 Adenoids) Hx of orthopnoea, PND, frothy sputum (t/o Pulm.edema) Hx of Complications Hx of poor response to bronchodilator (Acute severe) Hx of Inability to talk Hx of being too weak to walk Hx of disappearing wheeze (diminished breath sounds; silent chest) Hx of other co-infections; mostly viral Hix of Care (Ix of investigations & treatment) Home remedies, Prior treatment/investigations from referral hospital, Investigations since admission: Expiratory peak flow rate. Arterial blood gases, E/U/Cr. Chest x- ray. Full blood count Treatment; Emergency room care, bronchodilator therapy, oxygen therapy, Intravenous infusions, blood transfusion, drugs and dosing intervals ++/- response to therapy, PHYSICALEXAMINATION examination Note anxious, acute ill. ny distrons, pallor, jutFy stemi¢ Examination Respirat Inspection, Count rate; tichypnoea, dyspnoea at fost, audible wheeze, shape; normal or eat. ‘alpation; ‘Trachea is central, apex beat may not be palpable due to overinflated lings, compare chest movements & expansion; both bilaterally reduced, reduced vocal fremitus, Percussion; Percuss lungs for resonance, define cardiac & hepatic dullness Auscultation; Note vesicular breathing with prolonged expiration present all over the chest, vocal resonance uniformly reduced, polyphonic expiratory & inspiratory Wheezes (rhonchi) are heard over the chest, coarse crackles at both bases, no pleural rub. Norurological exam Cardiovascular exam Abdorninal exam Musculoskeletal exam CLERKSHIP SECRETS A CASE OF PULMONARY TUBERCULOSIS HISTORY TAKING Biodata Name, age, occupation, address, religion, tribe Ask also about; mode of referral; whether referred from any hospital means ; via casualty or clinic and duration on admission (mm. md) re Cough * (duration) Fever x (duration) Weight loss x (duration) HPC Complaints analysis & Course Analyse cough using'‘DOCTOR' Duration Onset; sudden r/o foreign body or aspiration Character; dry initially, then wet Timing; worse atnights distressing Other symptoms; wheeze, dyspnoea, sputum; thick mucoid, blood stained, frank haemoptysis Related phenomena; drenching night sweats, headaches + evening fever; low grade Weight loss; how was it noticed, & for how long? Hx of Cause (Hx of aetiology) Hx of where patient lives, poor ventilation, number of persons in each room (1/0 Overcrowding) MAMMANRICH SYNDROME: ttiopathic Interstitial fibrosis of the tng Hx of occupation (r/o Low socio- economic status) Hx of exposure to irritants; noxious fumes, smoke Hx ofheavy alcohol consumption Hx of chronic low grade fever, diarrhoea, multiple sex partners (r/o HIV) Hx of diabetes, or family history of diabetes mellitus Hx°of prolonged steroid use, cytotoxics (1/0 Immunosuppresion) Hx of preference for cold weather (1/0 ‘Thyrotoxicosis) Hx of Complications IIx of severe headaches, seizures, focal deficits (r/o T.B Meningitis) IIx ofneck swelling (T.B Adenitis) Hx of pleuritic chest pain(tYo T.B wticarditis) \ of nocturia, pruritus (T.B Renals); 11x of paralysis, limb weakness, bone # joint pains (@/o T.B Bone) of Care (Hx of investigations & ment) Me remedies, Prior iieni/investigations from referral Hilsl, Investigations since don AAP & culture, Mantoux il) PBCount, ESR, C- WOH Care, oxygen HOU infusions, blood CLERKSHIP SECRETS [I] PHYSICAL EXAMINATION General examination Note chronic ill-look, weight loss, phylectenular conjunctivitis, pallor, jaundice, dyspnoea, cyanosis, lymphadenopathy; cervical/axillary, digital clubbing & pedal oedema Systemic Examination Respiratory Inspection; Count rate; tachypnoca, shape & symmetry, trachea deviation, compare chest movement, distended neck veins Palpation; ‘Trachea deviation, apex beat for mediastinal shift, compare chest expansion, and compare vocal fremitus, Percussion; Percuss lungs for resonance, define cardiac & hepatic dullness Auscultation; Note character & intensity of breath sounds on both sides, added sounds; crackles, wheozes, rubs ete, Check vocal resonance as well Others; Test for meningeal irvitation (if meningitis is suspected) Musculoskeletal; spine for deformity & tendemess Abdominal; Ascites ‘Time from — Manifestations in S-$weeks 1° comptes, “ve skit test, erythema nodosum 3-8imouths Adult pol B, bronchiectasis, collapse, ality TB Within year Pueumonia,plewaleffision Within 3 years TB Bone, Iynopht noves, jos, Gastointestinal Gerntourin AMler3 yeas Post prim TB thie to ‘eactivaion ot reafeotion About H years Usioary unc diseaseA CASE OF PEPTIC ULCER DISEASE HISTORY TAKING Blodata Natie, age, occupation, address, Feligion, tribe Aak also about; mode of referral; whether referred from any hospital means ; via casualty or clinic and duration on admission (mr. md) PC Upper abdominal pain x (duration) Abdominal discomfort x (duration) HPC Complaints analysis & Course Analyse abdominal pain using; Socrates Site; central upper abdomen Onset; sudden or insidious Character & course; constant (ca Mlomach) or intermitent pain (PUD) Radiation; toback Alleviating fhietors; food, antacids ‘Timing nocturnal, seaxon Hxacerbating fhetors; hunger Severe enough to affect daily activities Analyse abdominal discomfort using; doctor Duration; shortin Cancer Onset; sudden or recurrent (PUD) Course; may have progressed ‘Timing; related to meals Other symptoms; haematemesis, vomiting, abdominal mass Related Phenomena; anorexia, dysphagia, eatly satiety, jaundice (ca stomach), afraid toeat (Gastric ulcer) fever (infection) CLERKSHIP SECRETS Hx of Cause (Hx of aetiology) Ask if prior to onset of symptoms there was any; Hx of alcohol binge units consumed, (v/oAlcoholic gastritis) Hx of smoking, prolonged fasting Hx of retching & vomiting + haematemesis (r/o Mallory weiss tear) Hx of aspirin or NSAID ingestion (r/o Drug induced) Ux of smoked fish & foods (rio Ca stomach) Hx of prior burns (1/0 Curlings ulcer) Hx of prior head injury (1/0 Cushings ulcer) Hx of familial PUD or Ca stomach Hx of blood group © (PUD), group A (Ca stomach) Hx of Complications Hx of haematemesis, melena stool (1/0 Upper GI Bleeding) Hx of casy fatigability, weakness, dizziness (r/o Anaemia) Hx of anorexia, weight loss (1/0 Malignancy) Hx of sudden pain which becomes constant (170 Perforation/peritonitis) Hx of Care (Hy of investigations & treatment) Since onset of symptoms, ask; home aids & hospitals visited, On admission; Investigations done; blood, electrolytes & urea, urinalysis radiological (endoscopy) Treatment; Blood transfusions, intravenous infusions, surgical operation done + response PNA TL CANADA SYNDROME: GL-Polyps with dive alopecia hails) and nad straphy. May sce protein-losing enteropathy and watahsorption PHYSICALEXAMINATION General examination a Pallor, jaundice, malnourished, enlarged left supraclavicular node Systemic examination Abdominal Examination First, REP patient; establish Rapport; obtain consent, Expose; from Xiphisternum to groin, Position; Patient lies supine. Inspection; Abdominal movement (still. in peritonitis) ; Assess symmetry, hernia orifices for visible cough impulse Palpation Ask for any region of pain, then proceed to light palpation for tenderness Deep palpation for liver, spleen & ballotthe kidneys. Percussion hilling dullness, do fluid thrill for HANSiVe ascites Miseultation ‘Wel sounds, renal bruits ital rectal exam CLERKSHIP SECRETS cy ACASE OF JAUNDICE (HEPATITIS, CHRONIC LIVER DISEASE) HISTORY TAKING ji ts .. ine" age, occupation, address, religion, tribe Ask also about; mode of referral; whether referred from any hospital means ; via casualty or clinic and duration on admission (mr. md) NStowness of the eyes x (duration) Abdominal pain x (duration) HPC ‘Ape ate ee Duration & Onset ‘Course; how/when was it noticed’? Timing; intermittent or deepening? Other symptoms (GIT); loss of appetite, abdominal pain, swelling, vomiting, haematemesis, change in bowel habit, weight loss Related phenomena; pruritus, dark urine, easy bleeding 5 x Analyse abdominal pain using; Socrates tiol tt Conse fails Hx of recurrent jaundice, bone pain, blood transfusions patient genotype (1/0 Sickle cell disease) Tix of familial pean jaundice in ter sibling 0 (lirubsinverita)Ask hepatic causes; Hx of preceding 3-4 weeks contact with a jaundiced patient in the family, or within the locality IIx ofrecenttravels TIX of eating contaminated foods Hx ofaleohol abuse Hx of 1V drug abuse, tattooing, Unprotected sexual activity Hx of fever preceding jaundice Hx ofherbal portions & medications 2- 3 weeks after use; anti TB drugs, OCPs, sulphonamides, steroids Hx of occupational exposure to hepatotoxins/ chemicals Hx of jaundice during each pregnancy (r/o Benign intrahepatic cholestatic Jaundice of pregnancy) Ask post-hepatic causes: Hx of right upper abdominal pain, fever, intermittent jaundice (CBD stones) Hx of painless deepening jaundice, pale bulky stools, dark urine, weight loss (1/0 Ca Head of pancreas) Hx of previous intestinal biliary surgery (i/o Biliary strictures) Hx of passage of worms (r/o Round worm infestation) Hx of chronic cough, drenching night sweats (1/0 T.B lymph nodes in porta hepatis) Ask forabdominal pain; Hx of dyspepsia, sudden onset epigastric pain radiating to right iliac fossa (r/o Perforated PUD) IIx of abd pain relieved by leaning forward + steatorrhoea (r/o Cholecystitis) BUDD. CHARI SYNDROME: ewes Hepyatte Wein Thrvnibints o——-> Me CLERKSHIP SECRETS Hx of anorexia, fever, vomiting, right iliac fossa pain (r/o Acute appendicitis) Hx of loin pain + high fever (t/o Pyelonephritis) Hx of colicky pain radiating from loin to groin(t/o Renal colics) Hx of Complications Hx of restlessness, asterixis, slurred speech, loss of consciousness(1/o Hepatic encephalopathy) Hx of anorexia & weight loss, easy fatigability Hx of epistaxis, haematemesis, easy bruising/bleeding Hx of polyuria, polyphagia, polydipsia (1/o Diabetes Mellitus) Hx of Care (Hx of investigations & treatment) Since onset of symptoms, ask; home aids & hospitals visited. Ask if investigations done since admission includes; Urinalysis, Blood; full blood count, blood film, liver function test, serology (HBsAg, HepC), clotting profile . Stool; occult blood, ova & parasite Ultrasound sean Treatment; Intravenous glucose infusions, blood transfusions, Intramuscular vitamin K, antibiotic drugs received & dosing intervals, urinary catheter surgery & response lassive axeites and dramatic death, Mone: Gradhea hepuiomeyets, portal hypertension. nace, voting edema, tltmately death, PHYSICALEXAMINATION General examination Note patient's nutritional status, jaundice, scratch marks Enlarged lymph nodes; Left supraclavicular (virchow's node) ob periumbilical (sister_ mary joseph's node) suggests abdominal malignancy Look for stigmata of chronic liver disease; fluffy sparse depigmented hair, parotid swelling, spider naevi, finger clubbing, palmar erythema, caput medusa, axillary & pubic hair loss. amination inal exam rf Ascites, hepato-splenomegaly; size, shape, surface, consistency, pulsatile + tenderness (ullbladder; if palpable Frominent veins or verious collaterals Hleinial sites, previous scar, rectal respiratory exam : | cilsion, pericardial effusion, re urinalysis CLERKSHIP SECRETS (7 A CASE OF HUMAN IMM ODEFICIENCY VIRUS/ AIDS i HISTORY TAKING Biodata i Name, age, occupation, address, religion, tribe Askalso about; mode of referral; whether referred from any hospital ne means ; via casualty or clinic and duration on admission (ar. md) PC Passage of loose stools x (no of episodes) Fever x (no of episodes) Weight loss (duration) HPC : Complaints analysis & Course Analyse stooling using; doctor How many episodes? Duration Onset; insidious ‘ 3 Course; Amount (estimate in mls), Colour (blood stained, mucus) Timing Other symptoms of GIT; loss of appetite, vomiting, jaundice, abdominal pain, or distension, tenesmus : Related Phenomena; Respiratory symptoms reduced urine output. Fever analysis ? Duration & Onset, (When it was noticed) , Character (low or high fever),‘Timing; present all through the day (continuo), or only during some time in the diy (intermittent) Other ial ociated with CNS) chi Is & rigor; headache, IT) low of appetite (poor suck), yomiting, abdominal pain, Passage of leaKe stools, HHAM/MSs: weakness, muscle pain, Related Phenomena; Response to Pparacetamo] Hx of Cause (Hx of aetiology) Fx of contaminated food/water, poor Sanitation/waste disposal, abdominal cramps + passage of watery/bloody stools (1/0: Gastroenteritis) IIx of blood stained or mucus (r/o Dysentery) . Hx of intake of sea foods, unwashed vegetables, contaminated #20, unpasteurized milk, uncooked meat, Hx of exposure to contacts with similarsymptoms Hx Of recent travels (r/o traveller's dinritioea) Hy of seurifivations, tattooing, sharing ‘Hx of] transfusion, dialysis, Vv. rig abuse oT Hx of unprotected, multiple sexual partners TIx of sexually transmitted infections + treatment . Hx of high risk professions: commercial sex workers, military & puramilitary, long distance drivers Hx of Complications Hx ofconvulsions (r/o Meningitis) BANTUS SYNDROME: Chronic Congestive Spenomegaly with anaemia, caused by either Portal Hypertension on Splenic Hein Thrombosis CLERKSHIP SECRETS Hx of sore throat or pain on swallowing (r/o Oesophageal candidiasis) HX of recurrent cough, fever, chest pain(1/o pneumonias) Hx of chronic cough, night sweats, weight loss (r/o T. B) Hx of unexplained parotid enlargement Hx of mouth ulcers, painful/ pruritic skin eruptions or maculopapular rash (HIV skin) Hx of polyuria, anorexia, weakness & fatigue (1/o HIV nephropathy) Hx of change in personality, behaviour, memory loss(t/o AIDS dementia) Hx of Care (Hx of Investigations &Treatment) Home remedies, prior teatment/investigations from referral hospital, Investigations since admission: Blood, Urine, Stool, chest X-ray. Treatment; Intravenous infusions, blood transfusion, drugs and dosing intervals, side effects +/- Fesponse to therapy, PHYSIC “ALEXAMINATION General examination Note chronic ill-look, weight oss, pallor, jaundice, dyspnoea, cyanosis, lymphadenopathy; cervical axillary, digital clubbing & pedal oedema Systemic Examination ‘Abdominal exam (IPPA) Inspection. Inspect the abdomen for symmetry, movement, hetnia ovifiees for visible cough impulse Palpation Ask for any region of pain then proceed to light palpation for tenderness Deep palpation for liver, spleen & ballot the kidneys Percussion 4 Shifting dullness, do fluid thrill for massive ascites Auscultation, Bowel sounds, renal bruits Digital sectal exam Respiratory Inspection; Count rate; tachypnoea, shape & symmetry, trachea deviation, compare (lest movement, distended neck veins pation; Trachea deviation, apex beat for fiediastinal shift, compare chest jlinsion, and compare vocal CLERKSHIP SECRETS ppp A CASE OF CHRONIC RENAL FAILURE HISTORY TAKING Rote tinge, “occupation addeond! religion, tribe Ask also about; “mode of referral; whether referred from any hospital “ty means ; via casualty or clinic and duration on admission (mr, md) Wcial Swelling/Gen, Body Swelling * (duration) ss Polyuria+ Nocturia HPC Gomplaints analysis & Course uration Onset “Solhn ap govitnd) Course; mode of onset Facial swelling more prominent in the morning, but regresses as the day rogresses Body swelling usu, Craniocaudal; affects abdomen then legs; bilateral, not traumatic, not painful) Timing; nocturia ! Other symptoms; any other swellings, frothy urine, + dysuria Coke coloured’ urine, scanty urine, Fever. Related Phenomena; Loss of appetite, vomiting, hiccups, abdominal swelling, easy fatigability, dyspnoeaHx of Cause (Hx of aetiology) Hx of Diabetes mellitus (170 Diabetic hephropathy) Hx of hypertension, frothy urine, haenvaturia (oH lypertensive hephroselerosis) Hx of familial simitar symptoms (r/o Polycystic kidney Dss) Hx of using mercury containing Soaps & creams (r/o Chronic glomerulonephritis) Hx of bee stings, insect bites(r/o Allergy) Hx of previous sore throat or skin infections Hx of recurrent loin pain (r/o Chronic pyelonephritis) Hx of chronic joint pain (0/0 Arthritis) Hx of chronic use of NSAIDS (r/o Analgesic nephropathy) Hx of multiple sexual partners (lo HIV nephropathy) Hx of recurrent bone pain, transfudions (r/o SCD nephropathy) Hx of prior febrile illness & jaundice (HBV Hepatorenal syndrome) Hx of malar rash before illness (r/o, LT) IIx of isolated hemoptysis (vo Goodpastures syndrome) GOODPASTURE'S 8) YNDROME: Autoani lies agains: (ute) ahem a). Oe death yo ag en MEM > Cameron CLERKSHIP SECRETS Hx of Complications Hx of dysuria, urgency, abdominal pain (r/o UTI) Fever + sudden onset abd pain(t/o Spontaneous peritonitis) -Hx of cough, frothy sputum dyspnoea, orthopnoea, PND (r/o pulmonary edema) Hx of headaches, seizures, loss of Consciousness (r/o Uraemic encephalopathy) Hx of chest pain (1/0 Uraemic pericarditis) Hx of bone pains (r/o Renal osteodystrophy) Hx of abdominal pain (r/o Uraemic gastritis) Hx of Care (Hx of investigations & treatment) Home remedies, Priory treatment/investigations from referral hospital, Investigations since admission: Blood, Urine, Stool. Treatment; Intravenous infusions, blood transfusion, drugs and dosing intervals +/- response to therapy A CASE OF CHRONIC LEG ULCER HISTORY TAKING Biodata Name, age, occupation, address, religion, tribe Askalso about; mode of referral; whether referred from any hospital means; via casualty or clinic and duration on admission (mr. md) nC Right leg uleer x (duration) nee Complaints analysis & Course Analyse lump using; doctor Diyation; how many weeks, months or ur Hiset; how did it start? liise; how/when was it noticed? iL been improving or increasing in ‘ny previous hx or recurrence ‘symptoms; bleeding, any imalodorous: Phenomena; numbness, ss of sensation, sof aetiology) tofsymptoms there CLERKSHIP SECRETS | aupapapemee Hx of cold extremities, hair falling off, skin changes, parasthesia, intermittent claudication (r/o Arterial ulcer) Hx of associated varicose veins; tortuous dilated cords (r/o Venous ulcer) Hx of previous scar on same site (t/o Marjolins ulcer) Hx of polyuria, polydipsia, polyphagia (r/o Diabetic foot) Hx of previous surgery & painful swelling of the leg after surgery/ prolonged immobility, pain at rest (1/0 Deep vein thrombosis) Hx of jaundice, recurrent transfusions, bone pain(t/o Sickle cell disease) Hx of chronic fever & diarthoca, or use of steroids (r/o HIV/Immunosuppresion) Hx of exposure to radiation Hx of chronic cough, drenching night sweats (r/o T.B skin) Hx of Complic: e Hx of anorexia & weight loss, easy fatigability Hx of inability to use limb Hx of limb gangrene Hx of Care (Hx of investigations & treatment) Since onset of symptoms, ask; home aids & hospitals visited. On admission; Investigations done; wound swab for microscopy culture & sensitivity, for AAFB, for cytology, X- ray; AP & lateral, FNAC for enlarged fegional lymph node, Blood; fasting a sugar genotype, VDRL, full leount, P/U/Cr, Urinaly,Treatment} Debridement, dressing, i Thtmavenous infusions, blood transfusions, drugs (antibiotics, Analgesics, antitetanus) received & dosing intervals + response. PHYSICAL EXAMINATION General examination First, REP patient; establish Rapport; obtain consent, Expose; he should expose ulcer, Position; Place both limbs comfortably together Doa general Examination . Ulcer exam Inspection; Inspect both limbs, then inspect ulcer; site, shape, solitary or multiple, floor, edge, margin & its surrounding skin Palpation; Palpate for; temperature, tenderness, size, base (surrounding) movement, arterial pulses (dorsalis pedis. posterior tibial), nodes, sensations Ask patient to walk (gait) Grade the Uleer WagnerMagel); Grade HT footat rink ‘Miperficial leer Grade 2) deep uloer (skin & surrounding tissues) Grade: lecp ulcer with osteomyelitis Grade 4; partial foot gangrene Grade 5; total gangrene SYNDROME: Viaseutitis > seeondaressmptoms: Ora and gitar, ChetixOpnc toy. CLERKSHIP SECRETS A CASE OF SICKLE CELL ANAEMIA/LEUKEMIA ae HISTORY TAKING : Biodata ie Name, age, occupation, address, religion, tribe Askalso about; mode of referral; from any hospital means ; via casualty or clinic and duration on admission (a ‘ whether referred PC Bone pain * (duration) Pip Yellowness of the eyes x (duration): - HPC Complaints Analysis & Course Analyse pain using: socrates Site Onset Character & Radiation Alleviating factors Timing Exaci Severity Analyse jaundice Duratio Onse Course; ting factors lious or sudden? how/when was it noticed? ‘Timing; intermittent or deepening?.” Other symptoms; abdominal pain, swelling, vomiting, haematemesis, change inbowel habit, rectal bleeding Related Phenomena; Pruritus, dark urine, fever, easy bleeding, pale hands &' fect, abdominal swelling but autosplenect by l0 years (SCD) Abnormal bleeding from brushing teeth, & orifices (Leukemia) Symptoms are usu. recurrent, ask if its thels episode, easy fatigability, difficulty with breathing Hx of Cause (Hx of aetiology) Hx of precipitating factors; febrile illness, physical/exam stress, exposure to cold, emotional disturbance IIx of recurrent hospital admissions. Hx of recurrent blood transfusions IIx to ascertain parents’ genotype IIx of sudden death in one of the siblings (r/o Sickle cell anaemia) {Ix of unremitting pain in long bones, back, abdomen or chest (Vaso- occlusive crisis) lls of deep jaundice, abdominal swelling, pallor (Hyperhemolytic firsis) Hix of sudden pallor, abdominal elling, collapse (Sequestration 1) of vague upper respiratory tions, pallor, weakness (Aplastic ) bleeding gums on brushing, | bleeding from orifices; nose lnvdy vomitus, urine & stools mia) if, pilin, petechiae (spots on \icu’ memb), pyrexia, leripheral lymph CLERKSHIP SECRETS Hx of bleeding disorder in maternal uncle(t/o Haemophilia) Hx of passing dark coloured urine (1/0 G6PD) Hx of facial swelling/ sore throat (r/o AGN) Hx of frequency, urgency, loin pain (vio UTI) Hx of Nausea, vomiting, right iliac fossa pain (1/0 Appendicitis) Hx of fever, redness & swelling of skin, bones & joints (r/o Osteomyelitis) Hx of Complications Hx of drowsiness, convulsions, visual disturbance, dysphasia or coma(r/o CVA) Hx of hemiplegia (r/o Cerebral infarotion) . Hx of fever, chest pain, prostration(r/o Chest syndrome) Hx of polyuria, nocturia, enuresis(/o Hypostenuria) Hx of sustained painful erection (r/o Priapism) Hx of leg ulcer around medial malleolus Hx of Care (Hx of investigations & treatment) Home remedies, Prior treatment/investigations {rom referral hospital, Investigations since admission: blood; pev, wbe, malaria parasite, urinalysis & m/c/s. Diagnosis; haemoglobin electrophoresis. Treatment; linfusions, blood transfusion, oxygen therapyProphylactic vaccines antimalarials; proguanil, folie acid & vitamin C, drugs and dosing intervals +/- response (o therapy PHYSICAL EXAMINATION General examination ritable, acutely ill patient in painful distress, check if febrile, assess pallor, jaundice, cyanosis, dehydration, lymph nodes Sickle cell habitus; frontal/parietal bossing, jaundice, depressed nasal bridge, gnathopathy, barrel chest, long extremities, thin fingers, abdominal swelling Acute leukaemias; note nose/mouth bleeds, pallor, pain, petechiae; spots on skin & mucus memb, pyrexia, pruritus; scratch marks, peripheral lymph nodes; generalized or localized Subcutaneous nodules; proptosis, gingival swellings from chloromatous deposits in AML Systemic examination Neurologic exam; stroke, sensorineural deafness, visual disturbance Head Eye Ear Nose & Throat exam; cataract, hyphaema, glaucoma, retinopathy Abdominal exam; autosplenectomy (by 10yrs) MENCHAUSEN SYNDROME: Malingering fabrication of clinically convincing malingerer CLERKSHIP SECRETS Genitourinary exam; haematuria, nephrotic syndrome, priapism Cardiovascular exam; cardiomegaly + heart failure Respiratory exam; silent chest Musculoskeletal’ exam; leg uleer, osteomyelitis, hip dislocation disease hy an itinerant CLERKSHIP SECRETS PAEDIATRICSPAEDIATRICS CLERKSHIP SCHEMA HISTORY TAKING Biodata Name; correct pronunciation & meaning, age; avoid approximates, Sex, class, address, religion, tribe, informant Ask also about; mode of referral; whether referred from any hospital means; via cher or clinic and duration on admission (mr, md) ** Strictly speaking, duration on admission is not part of Biodata, but offers a better delivery when the days on admission is stated before the symptom duration and P.C E.g. "He was admitted via cher (the children emergency room) 6days ago, on account of 3days history of Fever, Cough, & a day history of fast breathing” Presenting Complaints (B.C) Arrange main Symptoms and duration in order/sequence of occurrence, History of (HLP.C) H.P.C comprises; Complaints (symptom analysis) Course (disease progression) Cause (Hx ofaetiology) Complications (of disease) Care (Hx of investigations & treatment) ating Complaints Complaints & Course (disease progression) for each symptom should be analysed with eet 10 its; duration, onset, characte course, CLERKSHIP SECRETS timing, other symptoms in the affected system, related phenomena “Mnemonic = doctor Causes (Hx of aetiology) should be Sought for & may include; trauma, hereditary, infection, nutritional. metabolic, autoimmune/allergic, ischaemia/irradiation, drugs/degenerative, endocrine, neoplastic, smoking “mnemonic =¢hin maidens Complications in the following systems; neurologic, cardio respiratory, abdominal, renals, skeletal *mnemonic=neuro cars Care (Hx of investigation & treatment) First aid at home & hospitals visited, investigations done; blood, urine, stool tests + radiological (ultrasound, x-rays), treatment; Intravenous infusions, blood transfusions, drags received & dosing intervals response since admission. When taking HPC, Ask if doctor & thin maidens drove neurocars? *See sample analyses of cases below Past Medical History _ Previous Hx of similar illness Relevant Chronic illnesses; SCD, Asthma Previous hospital admissions, transfusions, surgeries + circumcision Drug History Prescribed “medications, over-the- counter drugs & doses, herbal remedies =compliance, complications & knownallergies/reaction Aiifeiatal, Natal & Postnatal History er Age & parity of Mother Gestational age at booking and where Doses of tetanus toxoid, haematinics, &, malaria chemoprophylaxis, +/- PMTCT Hx of illness during pregnancy; fever with rash, drugs, or radiation exposure. ‘ Ix of sickle cell disease, diabetes inctlitus, hypertension Was pregnancy carried to term? Labour; spontaneous, induced, or prolonged ; Birth; via forceps, or caesarean section Haby cried immediately or not, Hospiratory distress +/- resuscitation? Neonatal period; Jaundice, cyanosis, eding difficulties, congenital syth of stay before discharge MuAlvation History CLERKSHIP SECRE Nutritional History Breast feeding; exclusive ornot If formula-fed; when it started, mode of preparation and content of feed, FADU----Frequency (How many times), Adequacy (Does he finishes the servings or licks plate clean...it shows food is inadequate), Density (CHO, Protein, Fats & oi), Utilization (Gains weight or not) : Age at weaning, content of weaning feeds Present diet; family feeds Vicvnes Nature ‘acines Dew Sle reutee m i bevory hy |orrory. pein | 0 inization eard, any paucity of informaCLERKSHIP SECRETS CLERKSHIP SECRETS EE Anthropometric measurements ‘This is helpful, as mother may offer Occipitofrontal circumference relevant symptoms at this point which Use an inelastic tape, measure to may enhance clinical picture & aid nearest mm, the diameter round the diagnosis, forehead three (3) times & note the me Examiners therefore prefer the largest measurement, Developmental history Ake Movements (qoss+ tine motor response) Assessment Comments (visual response) Merriment (verbal response) (social response) Review of System Birth Well-fexed Posture Folk from either side to midtine Good cry Non social smite Font Mead Lag Startles to noise rk Social smite review of systems immediately after Maks coat i npc, Atbirth (term babies) = 35+2cm First year progression for each 23 monits | Neck controt; no | Foliows i m a ae mae. | el Ree Makes cooing | Laughs out loud sounds Summary Age, duration of quarter; 2, 1,0.5,0.5 Palmar grasp ‘ymptoms, positive symptoms, — 2cm per month for first 3 months (Ie objects 4-5 months p——_____| as important negatives, treatment so far+ quarter) . re er hae Mare sa Mi onli Resists pull of Jesponse to therapy Icm per month for next 3 months (2 rom teto side | sounds oy quarter) SLE wAN sii 0.5cm per month fornext 3 months (3.1 6 months Bison Polysyttabic. | rafera moter PITYSICALEXAMINATION quarter) jarels sounds | Chews solids ‘Goneral examination 0.5em per month for next 3 months (4: Ser 7 Observe the overall demeanour & quarter) 1-8 months rawls + Uncovers toy Follows one-ste apo ip oF i Pincer's grasp | (attersecingit | on ae ep. | Rem oe te sure; does the child appear well or hidden) gesture I}, acute (respiratory/painful distress, — Qui& 3ryears; 2cm increase/year Whurgy) or chronic (muscle wasting, ing Smyears; 1.5em inerease/yei intent facial bones, skin folds), Gd 7nyears; Lem increase / year of nourishment, any obvious By the 7th year, adult size is reached at uuilities; syndromic features etc, 56 2cm ‘priate behaviour for age, note For preterm babies, the OFC equalizes 9-10 months. Stands with Points to objects support Follows onestep | Responds co command | pe without gesture | Wines bye ‘Says daday ee nam 12 months Scribbles Says about 2-4 ‘Makes postural therapeutic apparatus with term babies at 18 months sonny | porate! | Maer Boies ee dadarmama | aressing he child if febrile, check for pallor, — Weight forage aay by stil ih . or . Unto ajean | aati arn sane eOrd | Washes & dries Ii cyanosis, dehydration, Use a bassinet scale up to 2 years & aoe ‘al lymph node enlargement, — beam balance for the older child 32months Up to 3ycars Copies u eivete u i, pedal edema Atbirth (term babies) = 5-3, 5kg, 10% of body weight (body fluid) loss Knows name, | Dey at night age, sex & sings trieyeles within 1s 7 days, regains birth weight 42months G ; by 10nday f Up to 4years eed Copies x square | Names 4 colours, | Dresses fully Preterms lose 15% and regain weight ne tells story unaided by 15uday s2months Skips Habies would weigh double their birth welyhty WO months, Triple, by’ Lyeiar & Quadruple it by years Copies a triangle Heal to toe wat arene | eae Obeys rulesFormulae for weight estimation in terms of age; 0-3 mths (n«10) x30+birth weight (nage indays) 412 inthy = os (n= age in months) lO y1s= 2n+8 (n=age in years) Ins 7-L2yrs= 75° (n= age in years) Weights of preterm babies, equalizes with term babies at 24 months ! Always express weights as Percentage of expected HeighLength forage For the first 12 months, patient lies supine for length estimation, height is taken when child can stand erect, When child stands (height), the Curvature of the spine & effect of Bravity reduces the joint spaces, this accounts for about 1.25cem difference between height & length, NB length is longer Atbirth, length « 50450m Firstyear Progression for each quarter; 3.5,2, 1.5, 12 3.5em per month for 1.3 months (Isequarter) 2cm per month for next 3 months Qnaquarter) |.5cm per month fornext3 months Guquarter) 12cm permonth fornext3 months (Au quarter) " Grace under pressure is knowing what 10 ask CLERKSHIP SECRETS Above I year = 6n+77 (n= age in years) Heights of preterm babies, equalizes with term babies at 40 months Midarm circumference (MAC) First palpate the landmarks; acromium & olecranon, Measure circumference ofarm atthe midpoint between the two bony prominences Useful for nutritional status evaluation for children between 1-5 years Normal= 13cm-17em Shakir's tape (colour coded) for rapid community assessment of MAC <12.5em=red=malnourished 12.5-14em ‘yellow = borderline 14-17?em= green = wellnourished Chest circumterence Atbirth=2-4emI year=CC>OFC Systemic examination HEENT; Head Eye Ear Nose & Throatexam Head; observe head shape, size, patency of the fontanelles, anterior closes by 15-18 months, posterior: may be closed at birth or before 6 months. Eye; Look at eyebrows, eyelashes, & eyclids, assess extraocular motions, note any congenital anomaly/ asymmetry, jaundice or Purulent discharge. Check pupillary reaction to light & red reflex Ear: Assess struct & position; low: ture, symmetry, tagy set ears i Nose & Throat; Check patency of both nostrils by blocking each nostril & observe that patient breaths with the other, Check mouth & mucous membrane for cleft lip, dehydration, - oral thrush, Observe tonsilllar enlargements, check for gums & teeth Neurologic exam Any child that presents with a history Hf fever, seizures, headaches, unsteady piil or weakness, a detailed siitological evaluation is require: © Higher mental status, Test for ningeal irritation, Cranial nerves, ior system, Sensory system, & ydination wr mental status level of consciousness (If cious, state Blantyre/Glasgow ore) oi in time, place, & person 4, intermediate, short & long © dysphasia, dysphonia, CNIV downward internal rotation of eye A CNV motor (jaw clenching temporal, masseters, jaw movement_lateral pterygoids) sensory_facial sensation V1,V2, V3, corneal reflex, & jaw jerk CNVI lateral deviation of the eye CNVII motor (facial movements_raise eyebrows, shut eyes tightly, show your teeth, blow out your cheeks) sensory (taste on anterior 2/3 oftongue) : CNVIII webers, rinnes, test (hearing) dix-hallpikes (balance) CNIX — motor (pharynx) sensory (posterior 1/3 of tongue) CNX motor (palate, pharynx, larynx) sensory (pharynx & larynx; gag reflex) CNXI_ sternocleidomastoid, & upper trapezius CNXIL motor (tongue) Motor system Inspection for fasciculations, atrophy, involuntary movement Palpate & measure muscle bulk Power; MRC Grade 1-5 / Tone; hypertonia, normal, hypotonia, Reflexes; Deep (biceps, triceps, supinator, knee, ankle) & superficial (abdominal, cremasteric, plantar) Gait (hemiplegic, festinant, waddling, Ataxic, high steppage) Sensory system Pain, temperature, light touch, vibration, 2-point discrimination CLERKSHIP SECRETS [CIEECoordination (cerebellar function) Rapid alternating movements, point to POINE (est; finger to nose, heel to shin, fest for apraxia; dressing & constructional, tandem walk Neurologic exam in neonates & infints (<12months) In addition to OFC & fontanclles, assess tone, posture, movement, & primitive reflexes, Simple! Primitive reflexes; Grasp response, pull-to-sit, ventral Suspension, vestibular response, Place&step reflex, moro reflex, rooté&suck reflex, tonic neck reflex Cardiovaseularexam Do a quick general examination; cyanosis, dyspnoea, check oxygen saturation using pulse oximeter, finger clubbing, capillary refill (normal < 2secs), precordial bulge Pulse Radial pulse; rate, volume, rythmn, character, synchronicity Other peripheral pulses; superficial temporal, carotid, brachial, femoral, popliteal, dorsalis pedis & posterior tibial Blood pressure; Use appropriate sized-cuff: the breath Covers up to 2/3rds of the arm, the length should go round the arm CLERKSHIP SECRETS Praecordium z Inspect & palpate apical impulse Note the location, amplitude & duration of the apex beat Listen for Is: & 2naheart sounds, count heart rate murmurs (Listen at each auscultatory area with the diaphragm of the stethoscope. Listen at the apex & lower sternal border with the bell). Check for tender hepatomegaly & ascites, then auscultate the lung bases for crepitations Respiratory exam Doagquick general examination Pallor, cyanosis, flaring of alae nasi, digital clubbing Inspection Inspect the chest symmetry, chest Movement, count respiratory rate (distract with the pulse) Palpation Tracheal centrality, tactile vocal fremitus, chest expansion Percussion Auscultation; breath sounds, crepitations or rhonchi Do same behind Nafiu's table of normal cardiorespiratory rates inchildven | Pulse | | 60 fees ats ee | Resp | 30-40 | 25.30 | 20.25 | 15-20 | What, What do I know?...... Michael Montaigne Abdominal exam Re Do a quick general examination; Pallor, jaundice, dehydration, umbilical cord in newborns; note granulation tissue, hernias or patent urachus Inspection Inspect the abdomen for symmetry, movement with respiration Palpation Light palpation for tenderness Deep palpation for liver, spleen & ballot the kidneys Percussion oe Shifting dullness, do fluid thrill for {lal rectal exam using little finger nidicated) , determine position of ening, scrotum size & the labia majora, urethral orifice, Look for sign of iefi, labial adhesions + CLERKSHIP SECRETS Ey Musculoskeletal exam Do a quick general examination Inspection Inspect limbs, muscle & joints Palpation Palpate limb swelling, muscle or joints; temperature, tenderness, tape measure(real & apparent lengths), test joint movements (active & passive) Gait; hip assessment in newborns; Ortolani & Barlows manoeuvreCLERKSHIP SECRETS ES ACASE OF UNCOMPLICAT ED Hix of Care (Hx MALARIA of investigations & — Systemic examination treatment). “."* Cardio respiratory exam; mtn rise in body temp, unusual ear tugging or Home remedies; if qiinine syrup was pe ler cyan le) by 10,respitatory HISTORY TAKING Scratching (r/o Acute Otitis media) given at-home, P a 2 i E te increases by 3 Biodata Hx of sore throat or pain. on investigations/tréatment from referral Head Eye Ear Nees & Throat eran Name; correct pronunciation & swallowing (r/o Tonsillitis) hospital, : ission: blood; Neurologic exam meaning, age; avoid approximates, Hx of Cough, Nasal discharge, fast Investigations since admission: eee dominal éxcih Sex, class, address, religion & tribe; breathing (1/0 Pneumonia) malaria parasite, fbe, e/u/cr, urinalysis, of parents, informant Hx of contaminated food/water, Ask also about; Passage of Wwatery/bloody stools (r/o mode of referral; whether referred Gastroenteritis) from any hospital Hx of severe abdominal cramps, rash, means ; via cher or clinic and Poor sanitation/waste disposal (r/o tment; — Genitourinary exam chest x-rays done. Trea ‘ nee ee infusions, blood Musculoskeletalexam transfusion, drugs and dosing intervals \/- response to therapy. duration on admission (mur. md) Typhoid fever) Hx of flank pain/ crying on micturition Pc (/oUTI) Fever x (duration) Hx of hand and foot swelling (vo Haemoglobinopathies) HPC Complaints analysis & Course Analyse fever using: doctor fi ‘or severe malaria; Duration, Onset, (When it was Hx of unarousable coma; noticed) GCS<10/Blantyre<2, or Multiple cial bones, skin folds), Convulsions; >2 in 24hours, or Impaived i i nourishment, any obvious Fonsciousness (vo Cerebral Malaria) at \dromic features etc, P ies; syndromic f fast breathing, tender abdominal ity behaviour for age, note swelling; hepatomegaly (r/o Shock, Heart moe Character (low or high fever), Timing {When is it worse? if present all through the day (continuous), or only during some time in the day failure) Cintermittent)} Hx of yellowness o: Other symptoms; i.e, associated with Hy CNS: Chills C@Syrs) & rigor, brile; record body temp, i oF, jaundice, cyanosis, headache, Prostation) | periphoral lymph node GIT: loss of appetite (poor suck), Ux of passage of reduced volume of urine Mobi pons vomiting, abdominal Pain, passage of —_("/oAcuterenal failure) : loose stools, * Of passage of coke coloured urine (r/o surements : Hacmoglobinuria) HEAM/MSS: weakness, muscle Hx of difficulty with breathing, frothy pain. Sputum (i/o Pulmonary oedema) Related Phenomena; Response to Paracetamol, tepid Sponging? HX of Cause (Hx of aetiology)A CASE OF FEVER WITH CONVULSIONS HISTORY TAKING Biodata Name; correct pronunciation & meanin, Sex, ¢ Parents, informant Ask also about; mode of referral; whether referred from any hospital means ; via cher or clinic and duration onadmission (wr. md) Be; avoid approximates, PC Fever x (duration) Convulsions * (no of episodes) HPC Complaints analysis & Course using; doctor How many episodes? Duration ofeach Onset of convulsions Character (a.k.a Nature; tonic-clonic, atonic, tonic, myoctonie, clonic) Timing Other symptoms; inconsolable cry Related Phenomena; Pre-Ietal; trauma, febrile illness, meal, aura (prior abdominal ¢ unusual taste or smell) Tetal; loss of consciousness, head tuming, eyes rolling, drooling of iva, urinary/faecal soiling of clothes) Interventions employed/termination ofconvulsion HILSON SYNDROME: Congential defect in Ceruleplasmin, leading to buildup of copper Welanlatton, cirrhosis, hepatetenticular degen address, religion & tribe: of Post-Ictal; post-ictal confusion, headache, or. sleep Inquire about Inepisodeand chronicle a detailed account, Hx of Cause (Hx of aetiology) Hx of Neck pain/ back’ pain (r/o Meningitis) Hx of irrational talk+ bizarre movement with normal intervals (W/o Encephalitis) Hx of fever, anorexia, headaches +any CNS manifestation if malaria exposed/ Coma lasting >30mins post convulsion (r/o Cerebral malaria) Family Hx of seizures ina febrile child <5 years, generalized tonic-clonic convulsions of few seconds to minutes media, tonsillit : bronchopneumonia, UTI) Hx of headaches, projectile vomiting, focal neurologic deficit or change in Personality (r/o Intracranial Space Occupying lesion) Hx of recurrent afebrile seizures (t/o Epilepsy) Hx of fever Hy of Complication Increasing size of Head (r/o Hydrocephalus) Projectile vomiting, Irregular breathing (Raised ICP)...Measure. Blood pressure -> mental “In Tetanus; ! Trismus (Inability to open the mouth is usually the first symptom or poor suck in Neonates) ! Spasms, not convulsions, are often provoked by touch, light or noise. Which may be preceded by injury, snake bite, burns or fracture(older children) ear piercing, female circumeision, poor umbilical cord care (In neonates) a“ | There is no loss of consciousness; Ask Hx of restlessness, photophobia, headache, irritability, body stiffness Very typical) dysuria & retention of ine, abnormal sweating (ANS volvement) i * of dog bite, dysphagia, ophobia + clonic seizures (r/o les) Cure (Hx of investigations & ent) F ® remedies, Prior tions/treatment from referral |, Investigations since | Blood, Urine, CSF, Stool done. Treatment; us infusions, blood Nose & CLERKSHIP SECRETS 2] Terolote exam Any chil of fever, seizures, headaches, A unsteady gait or weakness, a detailed neurological evaluation is required; Higher mental status id that presents with a history State level of consciousness (If ‘unconscious, state Blantyre/glasgow coma score) Orientation in time, place, & person Memory; intermediate, short & long term ! ; Speech; 1/0 dysphasia, dysphonia, dysarthria Test for meningeal irritation " Neck stiffness, Brudzinski's sign, Kerig's sign Cranial Nerves CNI sense of smell CNII visual acuity, visual field, fundoscopy i CNIII extraocular muscles (using 'H- test’) pupillary light reflex CNIV downward internal rotation of eye CNV motor (jaw g clenching_temporal, masseters, jaw movement _lateral pterygoids) sensory_facial sensation V1,V2,V3, corneal reflex, & jaw jerk CNVI lateral deviation of the eye CNVII motor (facial movements, raise eyebrows, shut eyes tightly, show your teeth, blow out your checks) sensory (taste on anterior 2/3 of tongue)CNVIIL Webers, rinnes, test (heari dix-hallpikes (balance) aa motor (pharynx) sensory (Posterior 1/3 of tongue) a CNX motor (palate, pharynx, larynx) Sensory (pharynx & larynx; Bag reflex) CNXI_ sternocleidomastoid, & trapezius eS eS CNXH motor (tongue) Motorsystem Inspection for fasciculations, atrophy, involuntary movement Palpate & measure muscle bulk re MRC Grade 1-5 ‘one; 'ypertonia, normal, hy otonia, Reflexes; Deep (biceps, iicars, supinator, knee, ankle) & superficial( abdominal, cremasteric, plantar) Gait (hemiplegic, festinant, waddling, ataxic, high steppage) Sensory system Pain, temperature, light touch, vibration, 2-point discrimination Coordination| (cerebellar function) Rapid alternating movements, point to Point test; finger to Nose, heel to shin, test for apraxia; dressing & constructional, tandem walk Neutologic exam in “neonaies & infants (<12months) a If < 12 months old, estimate OFC, check fontanelles, assess tone’ Posture, movement, & primitive KENDU-OSLERWEDER SYNDROME: Hereditary hemorrhagic telangiectasia CLERKSHIP SECRETS Primitive reflexes; ‘asp response, pull-to-sit, ventral Suspension, vestibular Tesponse, place&step reflex, moro reflex, root&suck reflex, tonic neck reflex Cardio respiratory exam; . Note for every loc rise in body temp, pulse Tate increases by 10, Tespiratory ate increases by 3 Abdominal exam Genitourinary, exam Musculoskeletal exam A CASE OF RECURRENT SEIZURES HISTORY TAKING Biodata Name: correct pronunciation & meaning, age; avoid approximates, sex, class, address, religion & tribe; of parents, informant Ask also about; mode of referral; whether referred Irom any hospital ‘teans ; via cher or clinic and duration on admission (ar. md) BC Recurrent seizures x (no of, episodes) Omplaints analysis & Course f, tonic, myoclonic, clonic) syiptoms (unconsolable cry n) Phenomena; | Lrauma, Febrile illness, Auia (Abd. Cramps, te or smell) 6f consciousness, head rolling, drooling of Taeoal soiling of ‘ed Aermination CLERKSHIP SECRETS DESI Post-Ictal: Post-ictal confusion, headache, or sleep. Inquire about 1s:episode and chronicle a detailed account, Hx of Cause (IIx of aetiology) Hx of sudden loss of consciousness + Aura, followed by a fall, assoc. with rapid jerking + stretching, +/- incontinence (t/o Gen. Tonic Clonic) Hx of sudden cessation of activity or halt in speech with blank stare ++/- worsening grades in school (1/0 Absence Seizures) Hx of sudden fall to the ground & immediate recovery to resume normal activity (r/o Atonic seizure) Hx of shock-like movement of hands & feet(r/o myoclonic seizures) Hx of localized twitching of face, trunk, extremities +/- head turning to same side (1/o simple pattial/ Infantile spasms) Hx of repetitive actions, prolonged fugue states, aimless wandering, lip smacking, tongue thrusting(r/o complex partial seizures) Hx of continuous seizures (>30 mins) or repeated attacks of shorter duration without regaining consciousness (r/o Status epilepticus) Family Hx of Seizure Prenatal Hx of recurrent illness or fever with rash during pregnancy(t/o TORCHES complex) Skin lesions; café au lait spots, neurofibomatosis Last Meal prior to onset (r/o Hypoglycemia) Hx of Ingestion of aleohol or poisons,