Basic Clinical Skills

Outline
• History taking

• Physical examination
INTRODUCTION

• Complete medical evaluation includes

• Medical History

• Physical examination

• Appropriate laboratory or imaging studies

• Analysis of data

• Diagnosis

• Treatment plan
 Factors in establishing rapport
• Introduce yourself in a warm, friendly manner
• Maintain good eye contact
• Listen attentively
• Facilitate verbally and non-verbally
• Touch patients appropriately
• Discuss patients’ personal concerns
The “ Classic” History Taking Sequence
• Identification
• Previous Admission
• Chief Complaints
• History of Present Illness
• Past Illness
• Functional Inquiry (System Review)
• Personal History
• Family History
 1. Identification
• Full Name
• Age
• Sex
• Address
• Date
• Occupation
• Religion
• Marital status
• Ethnicity
• Hospital number
2. Previous Admission
• List of hospitalization in the order they occurred

• Include:
• Specify the date
• Name and location of the hospital
• Disease that led to admission
• Outcome as briefly as is possible

• E.g.: 1990 (EC). Menilik II Hospital, Addis Ababa. Bleeding duodenal

ulcer. Discharged symptom free after transfusion of 2 units of blood.
3. Chief Complaints

• Those signs and symptoms which prompted the patient to seek

medical advice

• Should include:
• The complaint
• Duration of the complaint

• If more than one complaint, they should be listed in the order

of occurrence.
3. Chief Complaints Cont’d…
• Examples
• Shortness of breath of 2 weeks duration

• Exacerbation of generalized body swelling of 4 days duration

• Easy fatiguability and fever of 1 month duration

4. History of the Present Illness

• The part where you have to elaborate you chief complaint

in as much detail as possible.

• Follow in chronological order as the following.

• It is often useful to start the History of the Present Illness

with the phrase “The patient was perfectly well until …”
4. History of the Present Illness Con’t…
• Details included are:
• Date of onset
• Mode of onset and progression.
• Abrupt vs gradual
• Constant vs intermittent
• Character and location
• Exacerbating and relieving factors
• Effect of Treatment
• “Negative-positive” Statements
• How they came to the hospital
4. History of the Present Illness Con’t…
• The OPQRST of pain:
• O – Onset
• P – Provocation and palliation
• Q – Quality
• R – Region and Radiation
• S – Severity
• T - Timing
5. Past Illness
• Listing of illnesses unrelated to the present illness, experienced in
the past including:
• Childhood diseases
• Serious injuries and surgery not requiring hospitalization

• Mention of each disease with an approximate date, severity,

duration, complications and sequelae (consequences) is essential
6. Functional Inquiry (Review of systems)
• Detailed account of signs and symptoms referable to each system of the body

• Advantages in obtaining and recording

• First, it gives a clear understanding of the history of the present illness

• Secondly, it is a double check on the history of the present illness

• Thirdly, it will permit the examiner to group signs and symptoms that need to be
considered with the present complaint
• Fourthly, it will guide the examiner to concentrate on specific systems during the
physical examination
HEENT =Head, Ears, Eyes, Nose, Mouth and Throat
• Head: Headache, injury
• Ears: Pain or earache, deafness, discharge, vertigo, tinnitus.
• Eyes: Disturbance of vision, pain in the eyes or orbit, eye-strain,
lacrimation, photophobia, itching.
• Nose: Frequent colds, epistaxis, discharge.
• Mouth and throat: Teeth (dental hygiene), bleeding gums, sore tongue,
tonsillectomy, sore throat
Lymphoglandular system

• Enlarged LN

• Lumps in the breasts, discharge from the nipple

• Goiter with or without heat or cold intolerance

• Undescended or swollen testicles.

Respiratory system
• Cough
• Expectoration (amount, colour, odour)
• Hemoptysis
• Chest pain
• Shortness of breath
• Wheezing or asthma
• Cyanosis.
Cardiovascular system
• Palpitation
• Dyspnea (Shortness of breath)
• Orthopnea (number of pillows required)
• Paroxysmal Nocturnal Dyspnea (PND)
• Swelling of the feet
• Chest pain (with character, location and radiation)
• Syncope
• Hypertension
Gastrointestinal system
• Appetite
• Nausea
• Vomiting
• Dysphagia
• Odynophagia
• Constipation
• Obstipation
• Heart burn
• Abdominal pain
• Jaundice
• Melena vs Hematochezia
• Hemorrhoids
Genitourinary system
• Flank pain (steady, colicky, etc.)
• Frequency of urine
• Dysuria, urgency, hesitancy, dribbling, hematuria, incontinence
• Venereal disease
• Menstrual history: Record as “menarche/interval between
periods/duration of flow/amount of flow”
e.g. 14/28/5 profuse, moderate or normal
• Menopause
 Integumentary system (skin, hair and nails)
• Dry or moist skin
• Rashes
• Ulcers
• Hair distribution
• Pigmentary changes
• Changes in fingernails
 Allergy
• Infantile eczema
• Drug sensitivity
• Urticaria
• Hay fever
• Asthma
 Locomotor system (musculo-skeletal system)
• Joint pain or swelling
• Bony deformities
• Limping
• Loss of function of limbs or joints
• Muscle weakness or wasting
• Leg-swelling like elephantiasis.
 Central nervous system (CNS)
• Poor memory
• Lack of orientation
• Seizures
• Vertigo
• Double vision
• Anesthesia
• Insomnia
Personal History

• Record the personal history as follows:

• Early development: place of birth and early homes, childhood development,
health and activities, social and economic status.
• Education: School history, achievements and failures.
• Social activities: Recreation and other activities
• Work record: Age begun, type of work, number of jobs, industrial hazards and
exposures, present work.
• Environment: living conditions.
• Habits: Dietary, alcohol, tobacco, drugs, herbs.
• Marital status: Health of wife (or husband), adjustment, number of children and
their health.
Family History

• Father and mother: Age, health, date and cause of death.

• Siblings: List with ages, health (if dead, mention cause of

death)

• Family disease: Tuberculosis, diabetes mellitus, hypertensive

disorders, migraine.
Physical Examination
• Examination of the patient looking for signs of disease

• 'Symptoms' are what the patient volunteers

• 'Signs' are what the physician detects by examination.

The four cardinal methods
• Inspection
• Palpation
• Percussion
• Auscultation
Components
• General appearance
• Vital signs
• HEENT
• Lymphoglandular
• Chest
• Cardiovascular
• Abdomen
• Genitourinary
• Musculoskeletal
• Integumentary
• Nervous system
 General appearance
• Acutely sick looking vs chronically sick looking
• Physique
• Constitution
• Nutritional state
• Emotional state
• Colour change
Vital Signs

• Include
• Pulse rate

• Respiratory rate

• Blood pressure

• Temperature

• Oxygen saturation
A. Pulse rate
• Note the rate and rhythm
• Count for a full minute
• Normal adult heart rate is between 60 and 100 beats per minute.
• A pulse greater than 100 beats/minute is defined to be tachycardia
• Pulse less than 60 beats/minute is defined to be bradycardia
B. Respiratory rate

• Note the rate and character of breathing.

• Count breaths for 1min and record as breaths per minute
• In adults, normal resting respiratory rate is between 14-20
breaths/min.
• Tachypnea vs bradypnea vs apnea.
C. Blood Pressure
• Measure the blood pressure properly (See next page for guidelines).
• The normal blood pressure is between 90/60 and 120/80.
• Hypertension vs hypotension.
C. Blood Pressure Cont’d…
C. Blood Pressure Cont’d…
D. Temperature

a. Temperature can be measured is several different ways:

• Oral

• Axillary

• Rectal

• Aural (the ear)

• Normal range between 36.5 – 37.5 ⁰c

HEENT

• Head

• Look for scars, lumps, rashes, hair loss, or other lesions

• Look for facial asymmetry, involuntary movements, or edema.

• Palpate to identify any areas of tenderness or deformity.

• Ears

• Inspect the auricles and move them around gently. Ask the patient if this is
painful.
• Palpate the mastoid process for tenderness or deformity.
• Insert the otoscope inspect the ear canal and middle ear structures noting
any redness, drainage, or deformity.
• Repeat for the other ear.
• Eyes

• Inspect lid lag, ptosis, exophthalmos, lacrimation, peri-orbital

edema and nystagmus
• Inspect conjunctival pallor, hemorrhage, scleral colour
• Examine the fundi by using ophthalmoscope
• Nose

• Tilt the patient's head back slightly. Ask them to hold their breath for
the next few seconds.
• Insert the otoscope into the nostril, avoiding contact with the septum.
• Inspect the visible nasal structures and note any swelling, redness,
drainage, or deformity.
• Repeat for the other side.
• Throat
• Inspect the neck for asymmetry, scars, or other lesions.
• Palpate the neck to detect areas of tenderness, deformity, or masses
• Ask the patient to open their mouth.
• Using a wooden tongue blade and a good light source, inspect the inside of
the patients mouth including the buccal folds and under the tongue
• Note any ulcers, white patches (leucoplakia), or other lesions.
• Inspect the posterior oropharynx by depressing the tongue and asking the
patient to say "Ah." Note any tonsillar enlargement, redness, or discharge.
Lymphoglandular
• Lymph Nodes
• Systematically palpate with the pads of your index and middle fingers for the various lymph node
groups.
• Preauricular - In front of the ear
• Postauricular - Behind the ear
• Occipital - At the base of the skull
• Tonsillar - At the angle of the jaw
• Submandibular - Under the jaw on the side
• Submental - Under the jaw in the midline
• Superficial (Anterior) Cervical - Over and in front of the sternomastoid muscle
• Supraclavicular - In the angle of the sternomastoid and the clavicle
• Axillary, ingunal
• Note the size and location of any palpable nodes and whether they were soft or hard, non-tender or
tender, and mobile or fixed.
Thyroid Gland
• Inspect the neck looking for the thyroid gland. Note whether it is visible and
symmetrical
• A visibly enlarged thyroid gland is called a goiter.
• Move to a position behind the patient.
• Move laterally from the midline while palpating for the lobes of the
thyroid
• The normal gland is often not palpable
• Note the size, symmetry, and position of the lobes, as well as the
presence of any nodules
Respiratory System

• General Considerations
• The patient must be properly undressed and gowned for this examination

• Ideally the patient should be sitting on the end of an exam table

• The examination room must be quiet to perform adequate percussion and

auscultation
Inspection
• General inspection
• General signs of respiratory disease (finger clubbing, cyanosis, air hunger,
head nodding, etc.).
• Chest inspection
• Breathing characteristics (rate, rhythm, depth, and effort of breathing).
• Intercostal and subcostal retractions and use of accessory muscles
(sternocleidomastoids, scalene).
• Chest asymmetry, deformity, or increased anterior-posterior (AP) diameter
Palpation

• Areas of tenderness or deformity.

• Assess expansion and symmetry of the chest by placing your hands on the
patient's back, thumbs together at the midline, and ask them to breath deeply.
• Check for tactile fremitus
Percussion
• Principles of percussion are
• Percuss from side to side and top to bottom
• Compare one side to the other looking for asymmetry
• Note the location and quality of the percussion sounds you hear
• Categorize what you hear as normal, dull, or hyperresonant.
Proper Technique
• Hyperextend the middle finger of one hand and place the distal
interphalangeal joint firmly against the patient's chest
• With the end (not the pad) of the opposite middle finger, use a
quick flick of the wrist to strike first finger
Percussion

Proper Technique
Auscultation
• Principles
• Use the diaphragm of the stethoscope to auscultate
breath sounds.
• Auscultate from side to side and top to bottom
• Compare one side to the other looking for asymmetry
• Normally breath sounds and vesicular.
• Abnormal findings include: bronchial breath sounds, wheeze,
stridor, crepitations and rhonchi
Cardiovascular Examination

• General Considerations
• The patient must be properly undressed and in a gown for this examination

• The examination room must be quiet to perform adequate auscultation

• Observe the patient for general signs of cardiovascular disease (finger clubbing, cyanosis,
edema, etc.)

• Includes examination of :
• Arterial system

• Venous system

• Precordium
Arterial Pulses

• Rate
• Rhythm
• Volume
• Character
• Condition of Vessel Wall
 Pulse Classification in Adults
Rate
Normal Bradycardia Tachycardia
less than 60
60 to 100 bpm more than 100
bpm
Rhythm
Regularly
Regular Irregularly Irregular
Irregular
Evenly spaced beats, Regular pattern Chaotic, no real pattern,
may vary slightly overall with very difficult to measure
with respiration "skipped" beats rate accurately [2]
Jugular Venous Pressure

• Position the patient supine with the head of the bed elevated 45 degrees
• Adjust the angle of bed elevation to bring out the venous pulsation
• Identify the highest point of pulsation
• Using a horizontal line from this point, measure vertically from the sternal angle
• This measurement should be less than 4 cm in a normal healthy adult
Precordium
• Inspection

• Active or quiet precordium

• Location of apical impulse
• Deformity
Palpation
• Point of maximal impulse (PMI or apical pulse).
• Normally located at the 5th intercostal space and left midclavicular
line and is less than the size of a quarter.
• Heart sounds
• Heave – parasternal vs apical
• Thrill - systolic, diastolic, both

Percussion
• Usually not done
Auscultation
• Listen with the diaphragm at the right 2nd interspace near the
sternum (aortic area)
• Listen with the diaphragm at the left 2nd interspace near the
sternum (pulmonic area)
• Listen with the diaphragm at the left 3rd, 4th, and 5th interspaces
near the sternum (tricuspid area)
• Listen with the diaphragm at the apex (PMI) (mitral area)
• Auscultate for:
• Heart sounds - S1, S2, (S3), (S4)
• Added sounds – murmur, opening snap, ejection click, pericardial friction rub
• Characterize murmurs
• Grade
• Location
• Shape
• Quality
• Timing
• Radiation
 Murmur Grades
Grade Volume Thrill
very faint, only heard with optimal
1/6 no
conditions
2/6 loud enough to be obvious no
3/6 louder than grade 2 no
4/6 louder than grade 3 yes
heard with the stethoscope partially off the
5/6 yes
chest
heard with the stethoscope completely off
6/6 yes
the chest
Gastrointestinal System
• General Considerations
• The patient should have an empty bladder.

• The patient should be lying supine on the exam table and appropriately draped.

• The examination room must be quiet to perform adequate auscultation and

percussion.

• Watch the patient's face for signs of discomfort during the examination.

• Consider the inguinal/rectal examination in males. Consider the pelvic/rectal

examination in females
 Use the appropriate terminology to locate your findings:

Right Upper Quadrant (RUQ)

Right Lower Quadrant (RLQ)
Left Upper Quadrant (LUQ)
Left Lower Quadrant (LLQ)

Midline: Epigastric,
Periumbilical, Suprapubic
Inspection
• Scars, striae, hernias, vascular changes, lesions, or rashes
• Movement of the abdomen associated with respiration, peristalsis or
pulsations.
• Note the abdominal contour - flat, scaphoid, or protuberant?
Auscultation

• Comes before palpation

• Listen for:
• Bowel sounds
• The normal frequency is 5 -34/min
• Hypoactive normoactive and hyperactive
• Arterial bruits - over the renal arteries, iliac arteries, and aorta
• Venous hums
• Friction rub
• Palpation
• General Palpation
• Superficial palpation
• Deep palpation
• Organ palpation
• Liver
• Spleen
• Bimanual palpation of the kidneys
General palpation
• Begin with light palpation
• At this point you are mostly looking for areas of tenderness
• The most sensitive indicator of tenderness is the patient's facial
expression (so watch the patient's face, not your hands)
• Proceed to deep palpation after surveying the abdomen lightly
• Try to identify abdominal masses or areas of deep tenderness
Palpation
Palpation of the Liver

• Place your fingers just below the right costal margin and press firmly
• Ask the patient to take a deep breath
• You may feel the edge of the liver press against your fingers
• Or it may slide under your hand as the patient exhales
• A normal liver is not tender
Palpation of the Spleen

• Press down just below the left costal margin with your right hand
• Ask the patient to take a deep breath
• The spleen is not normally palpable on most individuals
Percussion
Percussion
• Percuss in all four quadrants using proper technique
• Percuss to look for:
• Percussion note of the abdomen (dull, tympanic or hypertympanic)
• Total liver span
• Shifting dullness
• Fluid thrill
Liver Span

• Percuss downward from the chest in the right midclavicular line until
you detect the top edge of liver dullness

• Percuss upward from the abdomen in the same line until you detect
the bottom edge of liver dullness

• Measure the liver span between these two points

• This measurement should be 6-12 cm in a normal adult

Splenic Dullness
• Percuss the lowest costal interspace in the left anterior axillary line
• This area is normally tympanic
• Ask the patient to take a deep breath and percuss this area again
• Dullness in this area is a sign of splenic enlargement
Genitourinary System
• Urinary system
• Costo-vertebral angle (CVA) and suprapubic tenderness
• Genital organs
• In male : scrotum, and urethral orifice
Testes-- >size, tumors, descent

• In female : vaginal discharge

Labia majoria and minora-- >
choncroid,condylomata,etc
Integumentary System
• Skin
• Texture, dry, moist and temperature

• Purpura, rashes, ulcers, urticaria hypo- or hyper-pigmentation

• Hair
• Sparse, baldness, alopecia and texture

• Nails
• Colour, shape, capillary pulse and splinter hemorrhages
Musculoskeletal System

• Look for scars, rashes, or other lesions

• Look for asymmetry, deformity, or atrophy

• Always compare with the other side

• Spine Scoliosis, Kyphosis, Gibbus

Nervous System
• General Considerations
• Always consider left to right symmetry
• It includes:
• Mental Status
• Cranial Nerves
• Motor
• Coordination and gait
• Reflexes
• Sensory
 Mental Status

The Mini Mental Status Examination is

a useful screening tool
Orientation in person, place and time,
memory ( past ,present )
Level of consciousness Intelligence,
mood, attention speech, hallucination
and delusions
Level of education, cooperation with
the examiner
The Glasgow Coma Scale
Cranial Nerves
• I – Olfactory
• II – Optic
• III – Oculomotor
• IV – Trochlear
• V – Trigeminal
• VI – Abducent
• VII – Facial
• VIII – Vestibulocochlear
• IX – Glossopharyngeal
• X – Vagus
• XI – Accessory
• XII - Hypoglossal
Motor Examination
• Symmetry
• Bulk
• Tone
• Power
• Reflex
Differentiate between upper and lower motor
neuron lesions
Sensory examination
• Vibration
• Subjective Light Touch
• Position Sense
• Pain
• Temperature
• Light Touch
• Discrimination
• Coordination Tests
• Meningeal signs
Summary
Subjective.
• This will include those relevant points obtained from the Chief
Complaints, the History of the Present Illness, the Functional
Inquiry, Personal and Family History.
Objective.
• This will include only the positive physical findings.
Differential Diagnosis

• The different possible diagnosis should be listed in the order of

priorities, i.e. the most likely diagnosis on top of the list and the least
likely diagnosis at the end of the list

• The differential diagnosis must include only those conditions that are
relevant to the presenting problem(s)
Discussion of Differential Diagnosis

• A logical approach to the discussion of a given list of possible diagnoses will require
a careful analysis of the history, the physical findings, and the appropriate
investigation relevant to the presenting problem(s) before arriving at a plausible final
diagnosis
• Discussion of the differential diagnosis must start from the bottom of the list
• This will permit a step by step exclusion of the least likely conditions
• The diagnosis must be confirmed by laboratory and other diagnostic tests and
procedure
Thank you!!