; HISTORY TAKING AND PHYSICAL EXAMINATION (1) THE PHYSICAL EXAMINATION Date. I. General ‘Status. — Note temperature, puilse rate, heart rate, respiratory ate, height, weight, and blood pressure. Give the general body build in definite terms (large, medium, or small), and the nutritional status (obese, average, emaciated, or cachectic), Do not use such ‘hackneyed and iU-defined ‘terins as “well developed and well nourished’, Describe gauscular development, presence of subcutaneous fat, and the average thickness f the panniculus or presence of subcotaneous oedema. {TL Body Type or Habitus. — Hypersthenic, sthenic, hyposthenic, or asthenic; ndomorphic, smesomorphic, or ectomorphic. "Constitution or diathesis. — Pyknic,. arthritic, exudative, hypoplastic, atonic ¢ hypertonic. - . i Posture. — Indicate whether or not the patient appears ill or well. If the patient able to walk, mention the gait. i * Psyche or mental status. — Is the patient oriented or confused? Does he appear be of average intelligence or not? How does he react to the situation psychically upset and uncooperative, or calm and cooperative? " DLL. Skin arid Mucous Membranes. — ‘Skin. — Note colour, texture, presence of pigmentation, rath, lesions; any Evidence of allergic reactions, pallor, floridity, icterus, cyanosis, ocdema, or birth- marks, Is the skin cool and moist; hot and dry? Describe the hair of the head and the body, lariugo, distribution, hirsutism, falling out, thia, or bald. Describe nails : any curvature, noxmal, ridged, brittle, split, flaked, or chewed short. LOCAL (OBSERVATIONS IV. Head and Neck: Note. ‘ . 1. Skull, «~ Size, shape, type, depressions of foe or cars eee ‘igs, or tender spots; scalp — cleanliness, ea es Ji ack patient to wrinkle ites; cranial nerve status, function of | al ot Pe Toe 1 ee ceks: and whistle “Jasse size aind shape, resl- xehead, bare teethy close eyes, protrud ae oe : cs vision, descr! Jasses. s. Cae es a Pye Zar ee remodation; 2 ne selene ee iti catitis, cataracts in lens. aa «erates. Thotophobia, diplopia, oF nystagmus? OPH ‘osis of either Premoscopic examination — observation of lens and media. for clouding; optic cy borders and vessels, retinal haemorrhage or exudate. A c . Elicit demess over the pj 3. Ears. — Test bearing roughly with a watch. Elicit tenderne ‘the pinng or mastoid area. Note appearance of external canal. Otoscopic examination is indicated in all children and in adults. ry . . 4. Nose. — Test sense of smell; describe shape, septunt, discharge, obstrye tion, inflammation and swelling of ‘mucosa. Rhinoscopic examination is often ind}. cated. Elicit tenderness over sinuses. 5. Mouth. Lips. — Note harelip, herpes, pigmentation of the oral Mucosa, stomatitis, ulcers, or mucous patches. . ; Gums. — Note colour, bleeding, sponginess, retraction, pigment line, evidence of pyorthoea. Teeth. — Describe as clean or dirty, spacing, absence of, presence of abnormal teeth as mulberry. molars.or pegged teeth, malccclusion, cavitation. Refrain from using careless indefinite medical jargon as “Poor oral hygiene”: ‘ongue. — Note deviation when protruded, colour, atrophy; hypertrophy of papillae, coated, indented,~or inflamed. . Throat. — Test gagging reflexes; note breath; palate symmetry. Note as to Presence or absence of tonsils; inflamed, cryptic or scarred 26. Neck. — Flex neck on chest; note pain or stiffness; describe any spastic miuséles; position of trachea in midline; size and shape of thyroid gland. Avoid using inclusive terms as “‘No general glandular.enlargement”’. Neck veins — note engorgement and any palpable thrills or audible bruits. THORAX Describe shape of the chest in. general — movements with respiration, siz and symmetry, presence of tumours, scoliosis or kyphosis. Breasts and nipples. — Note size, tenderness, masses, or scars; inversion, discharge, or bleeding of nipples. ‘V. Langs. — Inspection. Note type of respirations and chest expansion. Palpation. — Palpate for symmetry and depth of breathing, tactile, vocal, 0 bronchial fremitus. Percuss out degree of resonance over all pulmonary areas, Mark heart 204 liver borders and the excursion of the diaphragm Posteriorly. Auscultation. — Describe breath sounds, rales, fiction rub, adventitious sous and voice sounds. Vi Heart: — Snapection: — 2 Note location and character of the apex impul mal pulsation or. retra , . een Palpate for any shocks and thrills or friction fremitus. Percuss out all the heart borders, Auscultation. —-Note the character of the heart sounds over each valve oy intensity, shythm, rate, and any adventitious sounds, friction rubs, or 0" os as to int the location, time, character, and intensity and tranemiscien of al Determins ours. 7? « - 5 Peripheral Vascular Syst £ geripheral arteries. Note ‘haracn Inspect, palpate . ppv IronoUs. Take the bi pact T Of the aaa isn lood pressure §, . both legs as well. Determine status of n Both VIE. Abdomen: Inspection, — Fi > fs + — Observe ti umour masses, peristaltic. wa: the shape and Palpation. — Measure the this Veins or sears, NOM . r vein and vans 2M ii eed 8 Fpmuid wave. na Auscultate or list i. fticti 'en for borboryemi, friction sounds, and murmy VIIL. Anns and-Rectum. — Inspect the perineum for aemenn lapse of the rectiia, fistulae, or abscesses. Digital erg nos Hisures, elicit tenderness, sphincter tone, or rectal masses. The prostate Gad ie i is : ize, man, onan: nodules, and Soreness, and massaged fer ett j ack and Extremities. — The spine is inspected for any abnormalities suc xy . ee 7 tie zs kyphosis or scoliosis, immobility, or tenderness. The bones and joints and pels ‘of the extremities are palpated and tested as to mobility and functions. Note any ‘abnormalities as weakness, tremors, clawed or spade-shaped hands, clubbed fingers ‘and/or toes, flat feet, bowed legs, or limitation of joint function. Look fer any evidence of lymphangitis, varicose veins, scars, or ulcers. 2 Adapted fom Methods in Medicine by George Herrmann 5 ‘WORDS TO REMEMBER a . : : . - @naciate — make thin and weak ; spent i Cache ane — characterized by cachexia; cachexia — general a subentancous Jayer of fat £ trition ally i — a layer of tissue, espect cterized by asthenia; tthenle — active, strong; asthenic ot energy, Weakness. — having a short, thick, | tit — relating to arthritis Gnflammne ie dev lc — marked by hypoplasit & mal i — lacking normal tone 0 ia (abD0! . Pertionic — characterized by hype! topia( . qyestions