Clinica Hx Exam 2018

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ΪϴϔϳΎϣΔϓΎο·ϭΪϳΪΠΘϟ΍ϭήϳϮτΘϠϟΕΎΟΎΣΎϧΪϬθϓ
ϢϜϠΟ΃ϦϣϞϤόϟ΍΍άϫϥΎϜϓ
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ϼϋϭϪϴϓΐϴϋ ϻϦϣϞΟϼϠΨϟ΍Ϊδϓ˱ΎΒϴϋΪΠΗϥ·
ϲϧϭήΘϜϟϻ΍ΪϳήΒϟ΍ϰϠϋϞλ΍ϮΘϟ΍ϮΟήϧΡ΍ήΘϗ΍ϭ΃ΔψΣϼϣϦϣϥΎϛϥ·
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ϖϴϓϮΘϟΎΑϢϜϟΎϨΗΎϴϨϤΗ
ϞϤϋϖϳήϓ
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1 Contents
General Structure of history taking and general examination
3
History and Examination of the Cardiovascular System History and Examination of the Respiratory System 14
History and Examination of the Gastrointestinal System 45
History and Examination of the Nervous System
58
History and Examination of the Genitourinary System
91
History and Examination of the Rheumatological System
99
History and Examination of the Endocrine System
112
History and Examination of the Hematological System
119
How to Report your Examination?
126
Frequently Asked Question & cranial nerves
132
29
References
Prepare for a new
Challenge..
Listen, see, be involved &
try yourself..
Confidence comes from the
continual repetition of
certain activities..
2 General Structure of H istory T aking, and General
E xamination:
™ History Taking: 1. Personal data 2. Chief complaint 3. History of the presenting illness 4. Past history 5. Medication history 6. Blood transfusion 7. Allergies 8. Menstrual history 9. Family history 10. Social history 11. Systemic review 12. summary -­‐ ™ General Examination: 1-­‐
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6-­‐
7-­‐
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General appearance vital signs The hand The head The neck Lymph nodes Lower limbs The back ™ Important Analysis Do Not Fear
Mistakes
3 ™ History taking: Important Points to Put in Your Mind: ƒ
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Say: ϪΗΎϛήΑϭௌΔϤΣέϭϢϜϴϠϋϡϼδϟ΍ Introduce yourself to the patient as a student doctor. Take the permission. Close the curtain. Sit down In order to obtain a good history, the clinician must: Establish a good relationship. Interview in a logical manner. Listen carefully. Allow the patient to tell the whole story then ask questions to fill in the gaps. Interrupt appropriately. Note non verbal clues. Correctly Interpret the information obtained. Show an interest. if the patient stops giving the story, it can be useful to provide a short summary of what has I ' already been said and encourage the patient to continue. Avoid using medical terms. 1. personal data: ƒ
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Name. Age. Nationality. gender. Residency. Marital status. Children Occupation 2. Chief complaint (CC): ƒ
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Time of admission (admitted when?): mention the date. Route of admission: through ER electively through OPC, or by referral. Complaining of no medical terms in a chronological order). If the CC is pain, mention the site. The duration (for how long'?) of each symptom alone. 4 3. History of the presenting illness (HPI): ƒ
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Chronic illness (es), Ğ͘Ő͕͘ƚŚĞƉĂƚŝĞŶƚŝƐŬŶŽǁŶƚŽďĞ͙͘͘ƐŝŶĐĞ͙͘ŽŶ;ŵĞĚŝĐĂƚŝŽŶƐͿ
͙͕͘͘ĂŶĚŵĞŶƚŝŽŶŝĨƚŚĞƌĞĂƌĞĂŶLJĐŽŵƉůŝĐĂƚŝŽŶƐ͘ Analysis of the CC(s) in a chronological order: - Onset and offset. - Duration. - Course. - Character. - Severity. - Aggravating and relieving factors. - Associated symptoms. Systemic review of the systems involved in the CC(s). Previous episodes: if yes: - How many times? - When was the and last episode? - same or more severe episodes (progression). - How did it relieve? - He Did the patient go to a doctor? - The diagnosis? - What was done (medications, investigation, or hospital admission)? Constitutional symptoms: fever, loss of appetite, and weight loss. Risk factors: hospital course: (what was done to the patient during this admissions: investigations, medications, procedures and their results) Functional history: ( how the disease affects the patient's life daily activity) e-­‐g. going to the school or work. Analysis of the chronic illnesses that related to the CC(s): - It was diagnosed on (where and when'?) by type of investigation). - Monitoring (yes or no, if yes how?). - Regular follow up in a health care center. - Medications. Always taken or missed. - Complications, and their duration. 5 4. Past History: ƒ Past Medical: - Chronic illnesses not related to the CC(s). - Childhood problems - Any other disease, e.g infection, inflammation, tumor, and for each disease'. a. When was diagnosed? By which type of investigations? b. Controlled or not. c. Drug compliance. d. Complications, and their duration. ƒ Past surgical or interjectional procedures: What? Why? When? Complications? ƒ Hospital admissions: When? why What was done? ICU admission? ƒ Past accidents and their consequences, e.g. fractures, trauma. ƒ History of physiotherapy or rehabilitation. 5. Medication history: drug For (the disease) route dose frequency duration ƒ Any complication (adverse effects) of the medications ƒ Use of herbal medications (especially in liver diseases, or jaundice). 6. Blood transfusion: ƒ
when Why? How many units? Complications? 7. Allergies: ƒ Against what, egg. food, drugs, contrast. ƒ What is the kind of the allergic reaction (symptoms)? ƒ How does it relief. -­‐ lf negative, say: " No known allergy (NKA) " 8. Family history: ƒ
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family members and their health. Causes of death. Similar illness (or presentation) in the family: duration, their ages when the disease presents. 6 ƒ
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Any inherited disease; diabetes, hypertension, cancer, or any inherited disease that is illness related. Congenital abnormalities or diseases. 9. Menstrual history: ƒ
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Age of menarche. Age of menopause. LMP (last menstrual period). Regularity (note if there is dysmenorrhea or amenorrhea). Duration. Amount. . Pregnancies (number, any problem with pregnancy?). Deliveries (number, normal/c-­‐section). Abortions (number, cause). OCP (oral contraceptive pills) and HRT ('hormonal replacement therapy): if yes, for how long and which type. Any gynecological problems), e.g. bleeding, tumor. 10.Social history: ƒ
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Place of birth, and residency. Marital status and number of children. Who is taking care of the patient (to assess if he/she can do his/her daily activity or needs help). Level of education. Socioeconomic status Occupation. Habits: smoking, drinking alcohol, drug abuse. Any activities or exercise. History of traveling to an endemic area (where'?) or contact with infectious people (when?). History of close contact with animal. Immunization. 11.Systemic review: CVS, Respiratory, GIT, GUT, CNS, Endocrine, rheumatological, Hematological, Skin. 7 12.Summary: ƒ
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Age. Gender. chronic illnesses. CC(s) and the duration. Important negatives. the patient was admitted for further evaluation and management. ™ Examination: 1. Pre-­‐exam Checklist : WIPE ƒ
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Wash your hands. Introduce yourself to the patient. Positioning of the patient and his/her Privacy. Exposure. ** Remember: ƒ Always examine from the right side of the patient (and tell the examiner if you are left handed). ƒ Ask the patient if there is any tenderness before touching him/her. 2. General appearance (ABCDE): ƒ
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Appearance: young, middle aged, or old, and looks generally ill or well. Body built: normal, thin, or obese Connections: such as nasal canula (mention the medications), nasogastric tube, oxygen mask, canals or nebulizer, Holter monitor, I.V. line or canula (mention the medications). Color: jaundiced, pale, or cyanosed. Distress: in pain, respiratory (using accessory muscles), or neurological (abnormal movements) distress. Else: mental functions: consciousness, alertness, and orientation. 3. Vital signs: ƒ
Pulse rate: - Rate: counting over 30 seconds, normally 60-­‐100. - Rhythm: regular or irregular. 8 -
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synchronization by comparing with the other side (radioradial or radiofemoral delay). - Character and volume: determined from the carotid. Blood pressure (BP) : Normal BP defined as a systolic reading less the 140, and diastolic reading less than 90. Temperature: Normal body temperature ranges from 36.6-­‐37.20C. Respiratory rate: - It is traditional to count it while taking the pulse. - The normal rate at rest should not exceed 25 beat per minute (range 16-­‐25). 4. The hand: ƒ
dorsum: - Muscle wasting. - Pigmentations. - Skin lesion (including scars). - Tendon xanthomata (hyperlipidemia). ƒ Palm: - Signs of infective endocarditis such as Osler's nodes and Janeway lesions. - Palmar xanthomata hyperlipidemia. - Sings of a respiratory disease, or nicotine staining. - Palmar erythema: liver cirrhosis, polychromia, pregnancy. - Pigmentation of palmar breves: Addison's diseases but may be normal in Asians and black. - Pallor of palmar creases anemia becomes clearer with hyperextend fingers. - Dupuytren's contracture: alcoholism. - Raynaud' phenomenon. ƒ Nail - Clubbing. - Signs of infective endocarditis like splinter hemorrhage. - Leukonychia: hypoalbuminemia, liver disease, or nephritic syndrome. - Koilonychias: iron deficiency anemia. ƒ Flapping tremor (due to accumulation of toxins): - CO2 retention. - Hepatic encephalopathy. - Renal failure. 9 5. The head: ƒ
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Scalp: hair deficiency or excess. Eye: - jaundice: (in the sclera liver disease, hemolytic anemia. - Pallor (in the conjunctiva): anemia. - Xanthelasma (in the periorbital regions: hyperlipidemia , primary biliary cirrhosis. Mouth: - Central cyanosis. - Oral hygiene. - Dryness of the mouth: dehydration. - Any lesion, e.g. ulcer, bleeding. special smell: - Sweet smell "fetor hepaticus'': liver disease. - Ammoniacal fish breathe" uremic fetor" renal failure. - Cigarette smell in smokers. 6. The neck: ƒ
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Lymph nodes. Salivary glands. Thyroid. lf there is any swelling, describe it (site, size, shape, skin and surrounding tissue, consistency) 7. Lymph nodes: (see hematology examination) Epitrochlear. -­‐ Axillary. -­‐ Cervical. -­‐ Supraclavicular. -­‐ Inguinal. 8. The lower limb: ƒ
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Any change in the nails, dorsal, or the sole of the foot. Peripheral pulses: popliteal, posterior tibial, and borealis pedes pulses. Lower limb edema. 9. The back: Sacral edema. 10 ™ Important Analyses: 1. Pain: ƒ
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Onset. Duration. Site. Radiation. Character. Severity. Continuous or intermittent. Frequency, and the duration of each episode. Progressive or constant. Daily pattern. Precipitating, aggravating and relieving factors. Associated symptoms: symptoms of differential diagnosis. 2. Weight loss: ƒ
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Appetite: normal, decreased, or increased. How many kilograms? Over what time span has the weight been lost? What does the patient thinks the cause, e.g thyrotoxicosis malignancy... etc. more than 10% loss in 6 months is significant (make sure that the patient is not on diet). 3. Fever: ƒ
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Onset duration. continues, remittent, or intermittently Diurnal pattern Changes in severity. Progression over time. Measured or not if yes: route and readings. Associated symptoms: - Chill : sensation of cold - Rigors: uncontrolled shivering occurs when a patient's temperature rises rapidly. ƒ Management: what was done to lower it. 11 4. Diabetes And Hypertension: ƒ
When was diagnosed? By which type of investigations? monitoring if yes, how? ƒ Regular follow up in a health care center. ƒ Medications, Always taken or missed. ƒ Risk factor. ƒ Complications, and their duration. Diabetes Hypertension Presentation polyuria polydipsia weight loss, lethargy Visual impairment nausea, vomiting, fits, headache, symptoms of acute cardiac failure Risk factor - Family history - Family history - Obesity - Obesity - Pancreatic disease Endocrine disease: - High alcohol intake and high salt intake cushing`s acromegaly - Renal disease - Drugs: corticosteroids, thiazide diuretics - Endocrine disease: Cushing`s, acromegaly, Conn`s, pheochromocytoma - Drugs: oral contraceptive, steroids, vasopressin - Coarctation of the aorta pre-­‐eclampsia (3rd trimester of pregnancy) complication - vascular disease - Cerebrovascular disease (stroke) - eye disease (ask about previous laser - Coronary artery disease procedure) - Renal failure - Neuropathy (ask about numbness) - Peripheral vascular disease Nephropathy (ask about frothy urine) 12 5. Smoking: ƒ
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Cigarette, cigar or pipes. How many per day? How many years? Complications: - Cardiovascular disease. - Chronic lung disease, e.g COPD. - Peptic ulcer. - Cancers. - Fetus damage or abnormality (if the patient is female). If the patient stops smoking, when and why? 6. Alcohol drinking: ƒ
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Which type? How much? How often? Complications: - GIT: erosion, bleeding, pancreatitis, liver disease, cancer. - CVS: arrhythmia hypertension, cardiomyopathy. - CNS: blackout, peripheral neuropathy, cerebellar disease, dementia. 13 H istory and E xamination of the C ardiac System:
™ Major Symptoms : 1. Chest pain 2. Dyspnea 3. Ankle swelling 4. Palpitation 5. Syncope 6. Intermittent claudication 7. Fatigue ™ Other items in the History ™ Cardiovascular Examination: 1. Pericardium Examination 2. Peripheral Examination Have Pride in
Yourself..
14 ™
Major Symptoms : 1. Chest pain or heaviness: ƒ Duration. ƒ Location. ƒ Mode of onset: sudden or gradual. ƒ Pattern: Constant Or Progressive. ƒ Radiation. ƒ Character. ƒ Course: continues or intermittent ƒ Severity. ƒ Precipitating, aggravating, and relieving factor ƒ Associated symptoms. 15 2. Dyspnea (Cardiac dyspnea): ƒ Exertional, the severity is assessed by New York Heart Association Classification (NYHA) : - Class l: only on heavy exertion - Class 11: on moderate exertion (more than usual activity) - Class 111: on minimal exertion (at usual activity) - Class IV: at rest ƒ Orthopnea: Dyspnea on lying down Severity reflected by the number of pillows been used. ƒ Paroxysmal nocturnal dyspnea ( PND): Severe dyspnea that wakes up the patient from sleep gasping for air. 3. Ankle swelling (edema): ƒ Symmetrical. ƒ Unilateral or bilateral. ƒ The level: to the ankle, below the knee, the middle of the thigh, the abdomen, or the sacrum in bed ridding patients. ƒ The progression: - From foot upward: heart failure. - Ascites then lower limb edema: constrictive pericarditis. - Worsens at evening, and improves during the night. 16 4. Palpitation: ƒ Unexpected awareness of the heartbeat. ƒ The mode of onset and termination. ƒ Specific triggers: exercise, alcohol, caffeine. ƒ Frequency. ƒ Duration of attacks. ƒ Rhythm (ask patient to tap out): regular or irregular. ƒ Fast or slow. ƒ Syncopal attack or any associated symptoms. ƒ Age of onset. 5. Syncope, presyncopal attack, and dizziness: ƒ Syncope: transient loss of consciousness resulting from cerebral anoxia. ƒ Presyncopal attack: transient sensation of weakness without loss of consciousness. ƒ Dizziness: the world seems to be turning around ƒ When and why? ƒ Frequency. ƒ symptoms preceding the attack (i.e. an aural: palpitation, chest pain, or dizziness. ƒ The duration of the attack. . ƒ Any known diagnosis. ƒ Associated symptoms. 6. Intermittent claudication : Pain in one or both calves, thighs or buttocks during walking more than a certain distance (the claudication distance). ƒ
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Description of the pain. Comes with walking, exercise, or at rest. The distant needed to cause pain. The time needed to recover. Reappearance after walking the same distant. Can the patient walk through the pain or not. How long have you had the problem? -­‐ Progression: worsens or no change. Affecting lifestyle. What relieves the pain? 17 7. Fatigue: ƒ Commonly with heart failure or diseases that lead to fatigue and cardiac symptoms like anemia, i.e. causes palpation and fatigue.
™ Other Items in the History: 1.Personal data: age and sex : -­‐ Male above 50: coronary artery disease (CAD). -­‐ Female above 30: rheumatic heart disease (RHD). 2. History of the presenting illness: Risk factors: ƒ Ischemic heart disease (IHD): - Type 11 diabetes mellitus (DM). - Hypertension (HTN). - Hyperlipidemia - Smoking. - Obesity and inactivity. - Family history. - Male sex and advanced age. - Raised homocysteine level. - Type A personality. ƒ
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Heart Failure: Risk factor of IHD. Congenital heart disease. Valvular heart disease. Thyrotoxicosis. Valvular heart diseases: Rheumatic fever. Congenital valvular disease. IHD Heart failure. Connective tissue disease. Myocardial infarction (MI). Drug abuse (infective endocarditis). 18 ƒ
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Arrhythmia: Risk factor of IHD. Excessive use of alcohol. Drug abuse. Stress. Certain over-­‐the-­‐counter and prescribed medications. Dietary supplements and herbal remedies. 3. Past history: ƒ Past medical: - MI - IHD. - RHD. - Resent dental work. - Transient ischemic attack (TIA). - Stroke: Loss of vision, Dysarthria , Monoplegia. - Thyroid disease. ƒ
Surgical (interventional) history: - Open heart surgery or any cardiac or valvular surgery, e.g. CABG (coronary artery bypass grafting).
4. Family history: ƒ Premature CHD in a first-­‐degree relative: a male aged less than 55, or a female aged less than 65. ƒ HTN, DM, or hyperlipidemia. ƒ Familial hypercholesterolemia. ƒ Systemic lupus erythematosus (SLE). 5. Social history:
ƒ Smoking. ƒ Alcohol. ƒ Caffeine consumption. ƒ Drug abuse. 6. Medication history. 7. Blood transfusion. 19 8. Allergies. 9. Menstrual history. 10. Systemic review. 11. Summary ™ Cardiovascular Examination: - Position: sitting.
- Exposure: full exposure of the trunk (if you could not, tell the examiner from the beginning). 1. General appearance and vital signs: ƒ Radial pulse: -­‐ Character: anacrotic plateau, bisferiens, collapsing, alternans. -­‐Desynchronization: coarctation Of the aorta. -­‐ Water-­‐hammer test: detects the collapsing pulse, which is pathognomonic for aortic regurgitation (AR). ƒ Blood pressure: Pulsus paradoxes: a change in the systolic pressure during inspiration more than 10mmHg. 2. Precordium examination:
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Inspection: a. Shape and deformities: - Pectus excavatum (funnel shaped; depressed sternum: Marfan's syndrome. - Pectus carinatum (pigeon shaped; prominent sternum). b. Scars: median sternotomy. c. Devices: - Holter monitor: an ambulatory 24 hours ECG. - Pacemaker, or intracardiac defibrillator (lCD): usually below the left or right clavicle. d. Apex beat: with the aid of torch. 20 ƒ
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Palpation: Apex beat: The most inferolateral palpable pulse. lf it is impalpable, ask the patient to turn to the left. The beat may be: Normal. Tapping: mitral stenosis (MS), tricuspid stenosis (TS). Double impulse: hypertrophy cardiomyopathy. Sustained: aortic stenosis, uncontrolled hypertension. b. Parasternal heaves: Place the heels of your hands over the right and left parasternal regions, and ask the patient to stop breathing .
-­‐ In the presence of a heave, the heel will lift off the chest wall with each systole. -­‐ Causes include: 9 Right ventricular hypertrophy. 9 Left atrial enlargement (not hypertrophy). 3. Thrill: A palpable murmur (like the feeling on an arteriovenous fistula). The site of a thrill is the same site of the valve; we detect its site by using the valve area, i.e. mitral area, tricuspid area.. etc, or by using the anatomical position, i.e. 2nd intercostal space,5th intercostal space... etc. 21 ƒ
Auscultation: -­‐ S1 and S2. -­‐ S3 after S2 heard like a gallop rhythm: - physiological in children, exercising people, and hyperdynamic circulation like thyrotoxicosis or pregnancy - Heard in the apex area with mitral regurgitation (MR) ,AR, ventricular septal defect (VSD), or left heart failure. - -­‐May be detected in the left lower sternal edge with right heart failure or constrictive -­‐ S4; after S3, and before S1 also heard like a gallop rhythm: - May be heard at the apex area in IHD, systemic HTN, MR, or AS. - Can be detected at the left lower sternal edge with pulmonary HTN or pulmonary stenosis (PS). -­‐ Murmur; a turbulent blood flow: - Occurs with valve stenosis or regurgitation. - It can be either systolic (comes with the pulse) or diastolic. - It may radiates to the axilla with MR, and to the carotids with AS. - The area of maximum intensity is the area at which the murmur is best heard. ƒ Grades: 1. Very soft. 2. Soft. 3. Moderate without thrill. 4. Moderate with thrill. 22 5 Loud. 6. Very loud, heard even without stethoscope. ƒ There are special maneuvers to increase the intensity of a murmur: a. Right sided murmurs increase with inspiration, while left sided ones become clearer with expiration. b. Valsalva maneuvre; expiration against closed epiglottis: helpful in mitral valve prolapse (MVP) and hypertrophic cardiopyopathy. c. Squatting 4-­‐5 times: helps in MR and AS. d. Hand grip; ask the patient to squeeze a sponge 20 times, this will magnify the murmur of Types of murmurs (see below). ƒ Techniques in auscultation: -
Start the auscultation in the mitral area using the bell to detect any low intensity murmur. . -­‐Switch to the diaphragm and hear the whole area while you are feeling the pulse (to know which sound is Sl). lf the sound is very low, call it (muffled) when you present your examination. 3. Peripheral examination: ƒ
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Hand: Clubbing: cyanotic congenital heart disease, infective endocarditis. Splinter hemorrhage: vasculitis, infective endocarditis, antiphospholipid syndrome, and trauma. Cyanosis (acrocyanosis) in fingers and toes. Osler nodes: infective endocarditis. Janeway lesions: infective endocarditis. Tendon xanthomata: occur in type 11 hyperlipidemia. Face: Mitral faces; rosy, flushed cheeks and dilated capillaries: long standing MS. note
Eyes: You can also look for:
Pallor, jaundice. Xanthelasmata: type II or III hyperlipidemia. Arcus Senilis (or corneal Arcus)= Half or complete Blue sclera: Marfan's syndrome. gray circle around the pupil.
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Mouth: Central cyanosis; in the floor or sides of the tongue. Diseased teeth and petechiae are risks of infective endocarditis. High arched palate; Marfan's syndrome which is associated with AR or MR. Neck: Carotid pulse: better to get the volume and character. Jugular venous pressure (JVP Stand on the right side of the patient, and focus on the site of the right jugular vein to detect its pulsation. lf you could not see it, put the patient on 35Û then on 25Ûand then on 10Û until you see it. If you did not, do the abdominojugular refluxes test. Put the patient on 45Ûand press the abdomen while you are looking to his/her neck for 10 seconds. If the pulsation of the jugular vein is still rising and does not come back, the test is positive. Kussmaul's sign: rise of JVP in inspiration. The back: Percussion and auscultation of the lung bases. Sacral edema. The abdomen: Hepatomegaly. Splenomegaly. Ascites. The lower limb: Lower limb edema. - Peripheral pulses.
24 note
How to differentiate clinically between high JVP and visible carotid pulsation?
JVP
Visible but not palpable
2 pulses per cycle Normally it decreases with inspiration If obliterated it fills from above downwards
Carotid Pulse
Palpable
One pulse per cycle
Not affected by respiration
Filling from down upwards
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Types of murmurs: 1. Pansystolic, holosystolic murmurs (common): ƒ From S1 to S2 in same intensity. ƒ In MR, check for radiation, and if there is S3. ƒ Also present in TR and VSD. 2. Ejection systolic, mid systolic, crescendo-­‐decrescendo murmurs (common): ƒ From S1 to S2 but it stops before S2. ƒ In AS, check for radiation. ƒ Also present in PS, and hypertrophic cardiomyopathy 3. Late systolic (crescendo): ƒ Starts actually before S2 ƒ Presents in MVP. 4. Early diastolic (crescendo): ƒ In AR, check for S3. ƒ Also present in PR. ƒ It is a muffled sound. 5. Mid diastolic: ƒ In MS, TS, and atrial myxoma. ƒ In severe aortic regurgitation, the early diastolic murmur will continued till the mid diastolic. The murmur that is produced in such cases is called Austin Flint murmur.
6. Continuous, mechanical, musical murmurs -­‐ Both systolic and diastolic. ƒ Arteriovenous fistula. ƒ Patent ductus arterioles (PDA). ƒ Physiological in late pregnancy (mammary souffle) 26 27 summery note
If your examiner ask you to examine the praecordium, start locally from the chest, then move peripherally if you have time..
28 History and Examination of the Respiratory System:
™ Major Symptoms: 1. cough 2. sputum 3. hemoptysis 4. dyspnea 5. wheezing 6. chest pain 7. fever 8. night sweats 9. hoarseness 10. hyperventilation ™ Other Items in the History. ™ Chronic Illnesses. ™ Respiratory Examination: 1. Local Examination: Front 2. Local Examination: back 3. Peripheral Examination Make Positive
Statements..
29 ™ Major Symptoms 1. Cough:
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Duration: - Acute; pneumonia. - Chronic; asthma, COPD. Dry cough: ACE inhibitors, interstitial lung fibrosis, gastroesophageal reflux. Productive cough: pneumonia, bronchiectasis. Started as dry then became productive: complicated by pneumonia. Awaking the patient from sleep: cardiac failure, esophageal regurgitation. Changing in character: development of a new or serious underlying problem. Diurnal variation. Worsen at night; asthma, heart failure. Immediately after eating or drinking: tracheoesophageal fistula, esophageal reflux. Aggravating and reliving factors: dust, smoking... etc. Causes of cough: Acute Chronic <3 weeks' duration >3 weeks' duration ƒ
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Upper respiratory tract infection Exacerbation of COPD Sinusitis ƒ Allergic rhinitis
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Postnasal drip Asthma Gastro-­‐esophageal reflux disease Lung airway disease: COPD, Bronchiectasis, tumor, foreign body Lung parenchymal disease: interstitial lung disease, lung abscess Drugs: ACE inhibitors 30 2. Sputum: ƒ Amount (spoon per day). ƒ Color: - Purulent: bronchiectasis, pneumonia. - Dark: abscess. - Pink frothy: pulmonary edema. ƒ Foul smell: abscess, bronchiectasis. ƒ Diurnal variation: - Increased in the morning: bronchiectasis. 3. Hemoptysis (coughing up of blood): ƒ Duration. ƒ Amount. ƒ Smell ƒ Fresh or old. ƒ Clots or streaks. ƒ With or without mucus. ƒ Frequency. 31 Causes of haemoptysis: Respiratory: ƒ Bronchitis ƒ Bronchial carcinoma ƒ Pulmonary infection ƒ Bronchiectasis ƒ Cystic fibrosis ƒ Lung abscess ƒ Pneumonia ƒ Tuberculosis ƒ Foreign body ƒ Goodpasture's syndrome: pulmonary hemorrhage, glomerulonephritis, antibody to basement membrane antigen Cardiovascular: ƒ Mitral stenosis (severe) ƒ Acute left ventricular failure Bleeding disease 4. Dyspnea (shortness of breath):
ƒ The awareness that an abnormal amount of work is required for breathing. ƒ Duration. ƒ Onset: - Acute: pneumonia. - Worsen progressively: pulmonary fibrosis. - With sharp chest pain: pneumothorax. - Varies from day to day: asthma. ƒ Progression ƒ Association with chest pain, wheezing . . . etc. ƒ Association with orthopnea and PND to exclude cardiac causes of dyspnea. ƒ Severity: NYHA classification. 32 Differential diagnosis of dyspnea: Sudden
ƒ
Acute: over hours
Upper airway obstruction: - Inherited foreign Over days/months ƒ
Asthma ƒ
Asthma ƒ
Asthma ƒ
Pneumonia ƒ
COPD ƒ
Pulmonary oedema ƒ
Pulmonary oedema ƒ
Extrinsic allergic alveolitis Cardiac tamponade ƒ
Diffuse parenchymal lung disease Heart failure body - anaphylaxis ƒ
Pneumothorax ƒ
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Pulmonary embolism ƒ
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Asthma Intermittent ƒ
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Plural effusion Cancer of the bronchus/trachea Anemia 33 5. Wheezing: ƒ Maximum during expiration.
6. Chest pain: ƒ Analyze it as a pain (back to cardiovascular chapter). 7. Fever. 8. Night sweat: ƒ As in TB. ƒ Drenching sweating: the patient needs to change cloths as they become wet. 9. Hoarseness. note
10. Hyperventilation. ™ Other Items in the History Respiratory causes of clubbing:
-­‐
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Lung cancer Cystic fibrosis Interstitial pulmonary fibrosis 1. Past history: ƒ
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Chronic illnesses (see below). Medical: - TB, pneumonia, chronic bronchitis, AIDS, DM. ƒ Surgical of interventional procedures: - Bronchoscopy, thoracoscopy, lung biopsy, spirometry Pneumonectomy, chest tube. 34 2. Medication history: ƒ
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Bronchodilators. Steroids treatment. Home oxygen. Physiotherapy (cystic fibrosis or bronchiectasis). Oral contraceptive pills (pulmonary embolism). Cytotoxic agent (interstitial lung disease). ACE inhibitor, ɴ blockers, NSAID. 3. Social history: ƒ Exposure to dust, animals, humidifiers, or air conditioners: - Duration. - Complications. ƒ Smoking. ƒ Alcoholism; aspiration pneumonia. ƒ Exercise tolerance. 4. Family history: ƒ Infectious diseases, e.g. TB, pneumonia. ƒ Cystic fibrosis, emphysema. ™ Chronic Illnesses:
1. Asthmatic patient: ƒ When was diagnosed? Based on what? ƒ Progressive or sustained. ƒ How many attacks per month? ƒ How many admission(s)? ƒ Dose he/she admitted ever to the ICU? -­‐ How does he/she control the attack? ƒ Dose he/she receive a corticosteroid therapy (when, why, and for how long?). ƒ Current medications ɴ agonist, home oxygen . . . etc). ƒ Any complications of either the illness or the treatment. 35 2. TB patient:
ƒ When was diagnosed? Based on which type of investigations? ƒ Did he/she have been in the isolation? If yes, for how long? ƒ Previous steroid use. ƒ What is the treatment he/she receives? ƒ Was there any improvement? ƒ Any complications of either the illness or the treatment. 3. Patient with pulmonary embolism: ƒ Prolonged bed rest or inactivity (including long trips in planes, cars, or trains). ƒ Oral contraceptive use. ƒ Surgery (especially pelvic surgery). ƒ Childbirth. ƒ Massive trauma. ƒ Burns ƒ Cancer. ƒ Stroke. ƒ Heart attack (i.e. MI) -­‐ Heart surgery. ƒ Fractures of the hips or femur. ƒ Blood disorder. 36 ™
Respiratory Examination
Position: sitting.
Exposure: full exposure of the trunk (if you couldn't, tell the examiner from the beginning).
1. Local examination; front: Inspection: ƒ Shape and symmetry :
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Barrel shaped; the AP diameter is more than transverse diameter: hyperinflation (emphysema) Pectus excavatum (funnel shape); depressed sternum: Marfan' syndrome. Pectus carinatum (pigeon shaped); prominent sternum: chronic pulmonary disease started at young age, rickets. - Harrison's sulcus; a groove (depression) in the lower edge of the chest at the insertion of the diaphragm: long-­‐term asthma, rickets.
37 ƒ
Scars, especially in the axillary area: - If Chest tube (tube thoracostomy). - Tracheostomy. - Sternotomy. ƒ Type of breathing; abdominothoracic or thoracoabdominal.
ƒ Apex beat; visible or not (on the aid of torch).
ƒ Skin erythema and thickening from chemotherapy: lung cancer, lymphoma.
ƒ Subcutaneous emphysema : diffuse swelling of the chest wall and the neck: pneumothorax. Palpation (always compare both sides):
ƒ Apex beat: can be impalpable because Of TEEDD.
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Thick chest wall. Emphysema. Effusion. - Dextrocardia.
- Death.
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Tracheal deviation: put your index and ring fingers on sternoclavicular junctions, while your middle finger is on the trachea. - Trachea will be pulled to the site of lesion in lung collapse, interstitial pulmonary fibrosis (IPF). - It will be pushed away from the site of the lesion in the presence of a tumor, pleural effusion, or tension pneumothorx - Comment (if there is no deviation); trachea is centrally located. ƒ Tracheal tug: press the trachea and ask the patient to take deep inspiration; your finger will be pulled down in severe airway obstruction
ƒ Tactile vocal Fremitus: ask the patient to say ''44'' or '99'.
ƒ Press on the ribs to detect any rib fracture .
ƒ Palpate the supraclavicular lymph nodes .
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Chest expansions (during a deep .inspiration): ideally, it is measured by meter oater three areas; upper, middle, and lower. 38 -
At the apex of the lung: observe the equal movement of your hand (or thumbs) up and down. In the middle zone, below the nipple'. see your thumbs moving apart. A space of 3-­‐5 is considered a good expansion. In the lower zone, above costal margins'. same as the middle zone. Comment (if it is normal): (normal symmetrical chest expansion) 39 Percussion (always compare both sides): ƒ
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Start in the supraclavicular area Percuss directly on the clavicles, then just below them. Percuss in the intercostals spaces. Percuss on the axillae and their middle zones. Comment: Resonant: normal people. Dull (indicates consolidations): over the liver area, tumor, fibrosis, infection. Stony dull: pleural effusion. Hyperresonant: pneumothorax emphysema. ƒ Techniques in percussion: - Separate your fingers from each other and press the middle finger. - Percuss by the middle over the middle fingers 2-­‐3 hits are more than enough. - Don't forget to cut your nails. Auscultation (always compare both sides): -
Follow the same areas of percussion. Switch to the bell of your stethoscope in the supraclavicular area because the sounds are low-­‐pitched there. 40 -
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Continue the auscultation with the diaphragm, starting from the second intercostal space. Type of breathing: Vesicular; normal breathing: inspiratory phase is longer than the expiratory one, no gap in between, heard anywhere peripherally in the chest. Bronchial: inspiratory and expiratory phases are equal, with a gap in between, heard normally over the trachea, and if there is consolidation. Asthmatic: expiratory phase is longer, with wheezes, and gap in between. Added sounds:
Wheezes are high-­‐pitched expiratory sounds, while rhonchi are low-­‐pitched inspiratory sounds. They may present with diseases like asthma, COPD, or a lung tumor. Crepitations (also called crackles or rales) are inspiratory sounds, heard very clearly at the lung I base, and can be unilateral or bilateral'. Coarse crepitation comes with consolidation. Fine crackles heard with fibrosis. Stridor is a voice that can be heard even without stethoscopes, like grasping of air, commonly heard in children. ƒ Vocal resonance:
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Ask the patient to say ''44'' or ''99''. The voice will be heard clearly with consolidation or fibrosis, and it will be very clear with COPD. ƒ Whispering Pectoriloquy test: - The most sensitive test for consolidation. - Ask the patient to whisper '' 1, 2, 3. . .etc.'', normally his/her voice will not be clear. - In case of consolidation, the voice becomes very clear. 41 2. Local examination; back:
* The golden role: remove the scapula
lnspection: ƒ Shape, symmetry, and scars. ƒ Deformities:
- Scoliosis; curved chest, or S-­‐shaped. - Kyphosis; K-­‐shaped, seen from the side. - Kyphoscoliosis both deformities together, seen in patients with poliomyelitis. Palpation (always compare both sides):
- Chest expansion. - Tactile vocal fremitus. Percussion and auscultation (always compare both sides ):
- Vocal resonant. - Whispering Pectpriloquy tests 3. Peripheral examination: ƒ Nails: -­‐ Clubbing: lung cancer, fibrosis, bronchiectasis. -­‐ Cyanosis (acrocyanosis). -­‐ Tar or nicotine staining. ƒ Hands and arms: -­‐ Muscle wasting: lung tumor, especially at the apical area. -­‐ Palmar erythema. -­‐ Flapping tremors, Due to increased CO2 retention -­‐ Prominent veins. -­‐ Hypertrophic pulmonary osteoarthropathy: swelling and tenderness over the Wrist. -­‐ Radial pulse and blood pressure. ƒ Eyes: -­‐ Pallor. -­‐Horner's syndrome: ptosis, miosis, anhidrosis, and enophthalmus.
42 ƒ Nose: -­‐ Nasal septum deviation. -­‐ Nasal polyps or discharge. ƒ Mouth: -­‐ Oral hygiene. -­‐ Central cyanosis. -­‐ Congested tonsils and pharynx. IMP
ƒ Neck : -­‐ Carotid and JVP. ƒ Others: -­‐ Sacral edema, lower limb edema, and peripheral pulses.
Trachea Percussion Consolidation central Chest Expansion Asthma Central Resonant Added sound Course crepitations Vesicular wheezing Fibrosis Same side Resonant Vesicular Fine crepitations Effusion Opposite side Same side Stony dull No No Dull No No Opposite side Resonant No No Collapse Pneumothorax Dull Breath sound Bronchial note
If your examiner ask you to examine the chest not "respiratory examination", start locally from the chest, then move peripherally if you have time..
43 Summery 44 H istory
and E xamination of the G astrointestinal System:
™ Major Symptoms: 1.vomiting 2. taste disturbance 3. dysphagia 4. heartburn 5. abdominal pain 6. abdominal distension 7. abdominal mass 8. gas and bloating 9. disturbed defecation 10. GI bleeding 11. jaundice 12. postprandial fullness or early satiety. ™ Other Items in the History. ™ Gastrointestinal Exmination: 1. General appearance 2. Local Examination: The abdomen 3. Peripheral Examination Believe You
Can..
45 ™ Major Symptoms: 1. Vomiting: ƒ
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Frequency and duration. Timing: relation to meal, diurnal pattern. Content: yellow, recently eaten food, old food, or blood (fresh or clotted). ƒ Projectile or forceful. ƒ Precedes a pain? lf yes, did it relief it? ƒ Association with nausea, fever, pain, headache, or a neural disease. 2. Taste disturbance: ƒ
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Especially in liver diseases. Duration. 3. Dysphagia: ƒ
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Difficulty in swallowing. Odynophagia: painful swallowing. Site. Duration. Onset: sudden or gradual. Persistent, intermittent, or only with the first few swallows. Constant or progressive (i.e. starts with solid, then with liquids). Difficulty in initiating swallowing. Fluid regurgitating into the nose, choking, or food sticking. Relation to change in position, e.g. increased when lying down. History of ingestion of a foreign body, e.g. coin in children, false teeth in adults. History of scleroderma. Association with neck swelling (if positive, ask about symptoms of compression) food regurgitation and cough, or recurrent chest infection. 46 4.
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Heartburn: Retrosternal burning pain or discomfort. Frequency and duration. Site, and traveling upward. Precipitating, aggravating, and relieving factors. Relation to foods (mention the type of food). Relation to change in position: bending, stooping, or lying supine. Association with bitter or sour tasting coming up to the mouth (i.e. acid regurgitation). ƒ Association with excessive salivation (i.e. water brash). 5. Abdominal pain: ƒ Analyze it as a pain. 6. Abdominal distention: ƒ Onset and duration. ƒ Constant or progressive. ƒ Association with: ƒ Peripheral edema: heart failure, cirrhosis, nephritic syndrome. Ͳ ƒ Vomiting or constipation and which one appears first. ƒ Pain, and its frequently: to differentiate between small and large bowel obstruction. ƒ Remember the ϱ F's in generalized swelling: fat, feces, flatus, fluid, and fetus. 7. Abdominal mass: ƒ A local abdominal distention. ƒ Analyze it as a lump. 8. Gas and bloating: ƒ Association with dyspepsia. Irritable bowel syndrome (lBS). ƒ Recent surgery: postoperative ileus. 9.
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Disturbed defecation: It must be related to the patient's normal bowel habit. Frequency and duration͘ Acute or chronic, depending on duration. Physical appearance: color, consistency, amount, float or greasy. Passage of blood or mucus. 47 ƒ
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Association with pain. Associated symptoms. History of thyroid disease, inflammatory bowel disease (IBD). Drug history. ƒ
Definitions: -­‐ Diarrhea: frequent stool, more than ϯ times /day or change in the consistency of the stool (loose or watery). -­‐ constipation: infrequent stool (less than ϯ times /day) or hard stool and difficult to evacuate. -­‐ Tenesmus: sensation in the rectum of incomplete emptying after defecation, or constant intense desire to defecate. 10. Gl bleeding: ƒ Frequency and duration. ƒ Amount. ƒ Fresh or clotted. ƒ Bright or dark. ƒ Association with pain. ƒ
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Hematemesis (vomiting blood), and malena (jet black stool): The presence of blood each time, or intermittent. History of gastroesophageal reflux disease (GERD) peptic ulcer, cancer, or liver disease. ƒ
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Hematochezia; the passage of a bright red blood per rectum: Associated with defecation each time. Mixing with stool, or clearly visible (i.e. in the toilet paper). History of hemorrhoid, fistula, IBD, polyps, or colon cancer. 11. Jaundice: ƒ Site of yellow discoloration. ƒ Association with dark urine, pale stool, right upper quadrant pain, pruritus (itching of the skin), lethargy, or fever. ƒ History of hemolytic anemia, gallstone, or liver disease. ƒ History of alcohol consumption, or using herbal medications. ƒ Contact with jaundiced person. 12. Postprandial fullness or early satiety. 48 ™ Past history: ƒ
Past medical: -­‐ GERD, peptic ulcer, IBD, cholecystitis, pancreatitis, liver disease, Gl cancer. ƒ
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Past surgical: GIsurgery, and its complications (if happened). Fistula: as Crohn's disease (CD) complication. Liver transplantation. ƒ
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Past investigational or interventional procedures: Endoscopy: colonoscopy, endoscopic retrograde cholangiopancreatography (ERCP), biopsy. Reason and diagnosis. ™ Medication history: ƒ
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NSAID, antibiotics (especially for TB), steroids, immunosuppressants. Drugs that cause hepatotoxicity, e.g. paracetamol (in a large dose). Herbal medications. ™ Family history: ƒ
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IBD GI cancer. Jaundice or liver disease. ™ Social history: ƒ
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History of eating from outside. Recent travel. Contact with hepatitis or jaundiced patients. Smoking. Alcohol. Drug abuse. 49 ™ G astrointestinal E xamination:
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Position: flat or lying on one pillow. Exposure: ideally, from nipples to mid thighs, but expose up to the groin and tell your examiner the ideal exposure. ƒ
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1. General appearance: Jaundice. Weight and wasting. Skin: Pigmentation. Hereditary hemorrhagic telangiectasia. Porphyria cutaneatarde. Systemic sclerosis. 2. Local examination; the abdomen: Inspection:
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Symmetry: ask the patient to take deep breaths through the mouth and watch. Scars. Abdominal distension (remember the 5 F's): ascites causes full flanks. Local swelling. prominent veins ,pulsations or peristalsis (by squatting). Skin lesion: rash, cautery marks, scratch marks (for pruritus), Sister Joseph sign (nodules near the umbilicus indicate umbilical metastasis). ƒ
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Skin discoloration: Grey Turner 's sign, purple discoloration of the flanks: severe acute pancreatitis Cullen's signs; discoloration of the paraumblilcal area: severe acute pancreatitis. General pigmentation: Addison's disease. ƒ
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Striae: Silver pale: obesity, pregnancy. Purple: Cushing's syndrome, early after pregnancy. ƒ
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Condition of umbilicus: Inverted: normal. Everted: abdominal distension, umbilical hernia. Semilunar (lunate): Para umbilical hernia. 50 Palpation:
A.
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Superficial palpation: -­‐ For superficial masses, guarding, rigidity, or tenderness. Guarding
Rigidity
Resistance to palpation due to -­‐ Constant contraction of the contraction of the abdominal muscles. abdominal muscles. May result from tenderness or anxiety. -­‐ Always associated with Protective reflex in sensitive patient. tenderness. Voluntary or involuntary. -­‐ Indicates peritoneal irritation. -­‐ Pathological cause. -­‐ Involuntary. B. Deep palpation:
-­‐ For deep masses, e.g. a tumor, organomegaly. -­‐
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ƒ Liver: -­‐Start at the right iliac fossa, putting your hand parallel to the right costal margin. With each expiration, the hand is moved 1 -­‐2 cm closer to the right costal margin. Mark the lower edge of the liver by a marker or ask the patient to point it. Go to the right 2ndintercostal space, at the midclavicular line, and start to percuss, liver dullness is usually at the 5th or 6th intercostal space. Measure the liver span: ''the liver is palpable... cm below the costal margin, with span ŽĨ͙Đŵ͘ 51 -­‐
lf there is hepatomegaly you must comment on: a) Edge: tenderness, consistency, regularity, and pulsation. b) Surface: smooth or nodular. c) Span: normal liver span less than 13 cm and it is more in men than women. ƒ
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Gallbladder: Hand should be perpendicular to the costal margin, palpating from medial to lateral. Murphy's sign: sharp pain and cessation of inspiration (at the top of it) during palpation, which indicates acute cholecystitis. Spleen: Start from the right iliac fossa to the left hypochondrium, i.e. move obliquely. Identify the notch of spleen. lf you can't palpate it, use bimanual maneuver; role the patient to the right side and do palpation by bimanual push at the 11th and 12thribs area. ƒ
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52 ƒ
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Kidney: Bimanual maneuver (ballottement). Not felt in normal people. Spleen -­‐Has no palpable upper border. -­‐ Has a palpable notch. -­‐ Moves inferomedially (during inspiration) -­‐ Not ballotable
-­‐The percussion note is dull over it. -­‐ A friction rub may be heard over it. -­‐ Can't get above it. Kidney -­‐ Palpable upper border. -­‐ No notch. -­‐ Moves inferiorly. -­‐ Ballotable. -­‐ Resonant on percussion. -­‐ No friction rub over it. -­‐ Can get above it. ƒ
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Techniques in abdominal palpation: Ask the patient if there is any tenderness in the abdomen, and examine that area at the end. Ask the patient to breath gently through the mouth. Watch the patient face when you palpate to detect tenderness. Don't remove your hand from the patient's abdomen. Start from right iliac fossa, moving clock-­‐wise or anticlockwise, and end at the umbilical region. Use the palmar surface of your fingers, but for edges or masses use the lateral surface of the fingers because it is the most sensitive part. All the hand's movement should occur at the metacarpophalangeal joints. lf you find any mass, describe it as a lump. 53 Percussion: ƒ
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Liver span (mentioned above). Spleen: Percuss over the lowest intercostal spaces in the left anterior axillary line. Percussion over Traube's triangle (the area where we can percuss the enlarged spleen but still under the rib cage), which has the following boundaries: a) Upper border: the sixth rib. b) Lower border: the left costal margin. c) Lateral border: anterior axillary line. d) It overlaps the last two intercostal spaces. -­‐ lf the spleen is enlarged 3 times or more, it will cross the midline. ƒ Ascites: a) Shifting dullness (for moderate ascites): -­‐ Fingers directed downward (toward the groin). -­‐ Start percussion from the midline, and move to the left flank (away from you) When you find the area of dullness, fix your hand, role the patient to your side, and wait for 30 seconds, then percuss again. -­‐ If the area becomes resonant,the test is positive. -­‐ For completion, continue your percussion towards the midline, until the percussion note becomes dull. b) Fluid thrill (for huge ascites): -­‐ Ask the patient to place one hand firmly on the centre of his/her abdomen, with the fingers pointed downward. -­‐ Flick one side of the abdominal wall. Feel the transmitted pulsations by the other hand, which you placed it on the other side of the abdominal wall. c) Dipping maneuver: -­‐ Using two hands for palpation in case of huge abdominal distension. Auscultation: ƒ
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Bowel sounds: Two/minute, best heard on the right lumbar and epigastric areas. Exaggerated sounds indicate intestinal obstruction, whereas absent sounds (for 3 minutes or more) indicate paralytic ileus. 54 note
Don`t forget to say to your examiner: I will end up the abdominal Ex by PR / PV examination..
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Friction rub: -­‐May be audible over the liver or spleen, and indicate abnormality of the peritoneum. Arterial bruit: Over the liver: hepatocellular carcinoma (HCC) . Over renal arteries on either sides of the midline 1 cm above the umbilicus: renal artery stenosis. ƒ
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Venous hum: Heard between the xiphisternum and the umbilicus: portal hypertension. 3. Peripheral examination: ƒ
Nails: -­‐
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Leukonychia; white nails due to hypoalbumonemia: liver disease. Clubbing: chronic liver disease ,IBD. ƒ
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Palms: Palmar erythema: chronic liver disease. Pallor: anemia. Dupuytren's contracture: alcoholic liver disease. Flapping tremor (asterixis): hepatic encephalopathy. ƒ
Arm and axilla: -­‐
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Bruising. Petechiae. Muscle wasting. Scratch marks Spider nevi. Acanthosisnigricans. Lymphadenopathy. 55 ƒ
Eyes: -­‐
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Pallor. Jaundice. Iritis: IBD . Xanthelasma. ƒ
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Mouth: False teeth must be removed for complete examination of the mouth. Oral hygiene. Fetor hepaticus. Mouth ulcers:aphthous ulcer, angular stomatitis. Gum hypertrophy, pigmentation, or candidiasis. The tongue: 9 Coating over the tongue, especially in smoked. 9 Lingua nigra; black tongue. 9 Geographical tongue. 9 Leukoplakia. 9 Glossitis; smooth, red, sore tongue.. 9 Macroglossia. Neck: -­‐
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Virchow's nodes: enlarged 'left supraclavicular lymph nodes. Troisier's sign presence of Virchow's nodes in gastric cancer patients. ƒ
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Chest: Spider nevi. chronic liver disease Gynecomastia. .
56 57 H istory and E xamination of the Nervous System
™ Major Symptoms: 1.
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Brain: Headache. Seizure. Fit, faint, syncope. 2. Labyrinth and vestibular nerve: ƒ Dizziness, vertigo. 3. Head and neck: ƒ Facial, neck, back pain. ƒ Neck stiffness. 4.
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Special sense: Vision. Smelling. Tasting. Hearing. 5. Speech and swallowing. 6. Sensory: ƒ Numbness, paraesthesia. ƒ Loss or altered sensation. 7. Motor: ƒ Weakness. ƒ Involuntary movement. 8.
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9.
Sphincters: Bladder. Bowel. Gait ™ Neurological examination: 1.
2.
3.
4.
5.
6.
General. Cranial nerves. Motor system. Sensory system. Gait. Cerebellar examination. Remember:
Your Greatest Asset
is Your "Brain"..
™ Chronic illnesses. 58 ™ Major Symptoms: 1.
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Headache: Onset and duration. Site: unilateral or bilateral. Radiation. Character. Severity; effect on daily activity and sleep. Continuous or intermittent. Frequency, and the duration of each episode. Progressed or constant. Daily pattern. Precipitating, aggravating and relieving factors. Associated symptoms: flashing light photophobia, aura, fever, neck stiffness, vomiting, Jaw pain, lacrimation, eye pain, rhinorrhea, or tightness. 59 2.
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Seizure: Onset, duration, and does it preceded by and aura or not. Type (ask the patient to describe it): localized or generalized. Frequency, severity, and how long it persists. Comes with loss of consciousness, tongue pitting or incontinence. How long it takes until the patient recover. Progress or constant. Daily pattern. Precipitating factors: stroke, head injury, neurosurgery, brain tumor, or drugs. Aggravating and relieving factors. Associated symptoms: headache, nausea and vomiting. 3. Fit faint, and syncope: ƒ Transient loss of consciousness (also called blackout). ƒ Onset, duration, and does it preceded by: sweating, weakness, confusion (i.e. an aura). ƒ Frequency (previous episodes? when? what was the cause? management?), and how long it persists. ƒ Precipitating factors (e.g. some types of food). ƒ Aggravating and relieving factors. ƒ Associated symptoms. ƒ Any residual weakness? 4. Dizziness, and vertigo: ƒ A sense of motion of the surrounding or the head itself. ƒ Onset, duration, and how long it persists. ƒ Frequency and how long it persists. ƒ Precipitating factors, aggravating (e.g. by movement) and relieving factors. ƒ Associated symptoms: headache, nausea and vomiting, pallor, sweating, deafness, or ringing in the ear (tinnitus). 5. Facial, neck and back pain: ƒ Site and radiation. ƒ Onset and duration. ƒ Character. ƒ Severity, continuous or intermittent. ƒ Frequency, and the duration of each episode. ƒ Progressed or constant. ƒ Daily pattern. ƒ Precipitating, aggravating and relieving factors. ƒ Associated symptoms. 60 6.
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Neck stiffness: Onset and duration. Severity, continuous or intermittent. Frequency. Progress or constant. Daily pattern. Precipitating, aggravating and relieving factors. Associated symptoms. 7.
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Visual disturbance: Onset and duration. Unilateral or bilateral. The type: blurring, double vision (diplopia), photophobia, or visual loss. Continuous or intermittent. Frequency. Progressed or constant. Precipitating, aggravating and relieving factors. Associated symptoms. 8.
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Smelling and tasting disturbance: Onset and duration. Continuous or intermittent. Frequency. Progressed or constant. Precipitating, aggravating and relieving factors. Associated symptoms. 9.
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Hearing disturbance: Onset and duration. The type: tinnitus, deafness, or others. Continuous or intermittent. Frequency. Progressed or constant. Precipitating, aggravating and relieving factors. Associated symptoms. 10. Speech disturbance: ƒ Onset and duration. ƒ The type: difficulty in expression, articulation or comprehension. ƒ Continuous or intermittent. ƒ Frequency. ƒ Progressed or constant. ƒ Precipitating, aggravating and relieving factors. ƒ Associated symptoms. 61 11. Swallowing difficulty . 12. Sensation disturbance: ƒ Onset and duration. ƒ The type: numbness ''pins and needles", pain, odd sensation, or loss or altered sensation. ƒ Continuous or intermittent. ƒ Frequency. ƒ Progressed or constant. ƒ Precipitating, aggravating and relieving factors. ƒ Associated symptoms. 13. Motor disturbance: ƒ Onset and duration. ƒ The type: weakness, involuntary movement (e.g. tremor). ƒ Continuous or intermittent. ƒ Frequency. ƒ Progressed or constant. ƒ Precipitating, aggravating and relieving factors. ƒ Associated symptoms. -­‐ If there is weakness, inquire about which group of muscles is affected, and if there is any sphincter disturbance, or loss of balance. -­‐ If it is tremor: 9 Rapid or slow. 9 Present at rest or not. 9 Worsens on deliberate movement or not. 9 History of thyroid disease. 9 Family history of tremor. 9 History of using beta-­‐blockers. 14. Sphincters disturbance: ƒ Onset and duration. ƒ The type: urine, fecal, or both. ƒ Continuous or intermittent. ƒ Frequency. ƒ Progressed or constant. ƒ Precipitating, aggravating and relieving factors. ƒ Associated symptoms. 15. Gait disturbance: ƒ Onset and duration. ƒ Progressed or constant. ƒ Precipitating, aggravating and relieving factors. ƒ Associated symptoms. 62 ™ Other Items in the History: 1.Past history:
ƒ Past medical: Meningitis, encephalitis, epilepsy, convulsion, peripheral vascular disease, CAD, atrial fibrillation, or coagulopathy. ƒ Past surgical: Head or spinal injury, previous operations. 2.Medication history:
ƒ Anticonvulsants, antidepressants, contraceptive pills, antihypertensives, steroids, anticoagulants, or antiplatelet drugs. 3.Family history:
ƒ Any neurological or mental disease. 4.Social history: ƒ Occupation. ƒ Exposure to toxins. ƒ Smoking. ƒ Alcohol. ™ Risk factors of cerebrovascular diseases: ƒ
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Hypertension. Smoking. Diabetes mellitus. Hyperlipidemia. Atrial fibrillation. Bacterial endocarditis. Myocardial infarction. Hematological disorder. Family history of stroke. 63 ™ Neurological Examination: For complete neurological examination, follow these steps:
1. General: A. Higher mental function: -­‐ Consciousness. -­‐ Orientation. -­‐ Memory. -­‐ Speech. -­‐ Handedness. B. Neck stiffness and kernig's sign. 2. Cranial nerves examination. 3. Motor examination: ƒ Inspection. ƒ Tone. ƒ Power. ƒ Reflexes. ƒ Coordination. 4. Sensory examination: ƒ Superficial sensation: light touch, pain, and temperature. ƒ Deep sensation: position (proprioception) and vibration. 5. Gait. 6. Cerebellar Examination. ƒ Remember: Always compare the other side before moving to the next step.
64 1. General: A. Higher mental function: ƒ Consciousness: Note the level of consciousness: - Conscious. - Stupor. - Confused. - Comatose. ƒ Orientation: - Test the orientation to person, place, and time by asking the patient about his/her name, present location and the date. - Disorientation may be: 9 Delirium: acute and reversible. 9 Dementia: chronic and mostly irreversible. ƒ Memory: - Immediate memory: 9 By telling the patient 3 words, then after 2-­‐5 minutes ask to recall them. - Recent memory: 9 Ask the patient about what happened during the last 24 hours. - Remote memory: 9 Ask the patient about something happened during the last years. ƒ Speech: - Ask the patient to describe the room or daily activity (in order to promote flowing speech). Then test comprehension, e.g. "touch your chin then your nose then your ear". - After that eliciting the language by yes and no questions. - Then test repetition, by telling the patient a sentence and ask him /her to repeat it. - Finally, ask the patient to name 2 objects, and to say a phrase such as " ϚϠϤϟ΍ϰϔθΘδϣ
ϲόϣΎΠϟ΍ΪϟΎΧ" - the abnormality could be: 1. Dysphasia: a dominant higher mental function disorder in the use of symbols for communication and language. It could be: a. Receptive (sensory or anterior) dysplasia: 9 Due to a lesion in Wernicke's area (posterior part of the first temporal gyrus). 9 Patient cannot understand the spoken (auditory dysphasia) or written word (alexia). 9 Fluent and disorganized speech. b. Expressive (motor or anterior) dysphasia:
9 Due to a lesion in Broca's area (posterior part of third frontal gyrus). 65 9 Patient understands, but cannot answer appropriately. 9 Non fluent speech. c. Nominal dysphasia: 9 All types of dysphasia cause difficulty in naming objects. 9 Due to lesion in the temporoparietal area. 9 Patient cannot name objects, but other aspects of speech are normal. d. Conductive dysphasia: 9 Due to a lesion in arcuate fasciculus and/or other fibers linking Wernicke's and Broca's areas. 9 Patient repeat statements and name objects poorly, but can follow commands. 2. Dysarthria: difficulty with articulation. it could be: a. Spastic dysarthria: 9 As if the patient is trying to squeeze out words from tight lips. 9 Seen in pseudobulbar palsy (upper motor neuron lesion; UMNL). b. Nasal speech: 9 Seen in bulbar palsy (lower motor neuron lesion; LMNL). c. Monotonous speech: 9 Seen in extrapyramidal diseases, as it causes bradykinesia and muscle rigidity. d. Slurred (scanning) speech: 9 Seen in alcohol intoxication, cerebellar diseases, and facial muscle weakness. 3. Dysphonia: alteration of the sound of the voice, such as huskiness of the voice with decrease volume due to laryngeal disease, recurrent laryngeal nerve palsy or other causes. B. Neck stiffness and Kernig's sign: ƒ Any Patient with an acute neurological illness or who is febrile must be assessed for signs of meningism. ƒ With the patient lying flat in the bed, the examiner slips a hand under the occiput and gently flexes the neck passively i.e. without any assistance from the patient. ƒ Kernig's sign: - It should be elicited if meningitis is suspected. - Flex each hip in turn, then attempt to straighten the knee while keeping the hip flexed. - This is greatly limited by spasm of hamstrings when there is meningism due to inflammatory exudate around the lumbar spinal roots. 66 2. Cranial nerve examination : Olfactory ƒ Test each nostril separately with essence bottles of coffee, vanilla, or peppermint. ƒ Anosmia, i.e. no smelling, itmay be uni or bilateral. Optic : ƒ Visual acuity ;ďLJƐŶĞůůĞŶ͛ƐĐŚĂƌƚͿ͗ - The patient wearing his\her glasses test each eye separately. ƒ Visual field (by confrontation method): - Remove the patient glasses. - WĂƚŝĞŶƚ͛ƐŚĞĂĚƐŚŽƵůĚďĞĂƚƚŚĞůĞǀĞůŽĨLJŽƵƌŚĞĂĚ͕ĂŶĚƚŚĞĚŝƐƚĂŶĐĞŵƵƐƚďĞ
approximately 50cm. - Examine each eye separately. - ůŽƐĞƚŚĞƉĂƚŝĞŶƚ͛ƐůĞĨƚĞLJĞ and ask him\her to look at your right eye and vice versa. - ,ŽůĚƚŚĞƉŝŶĂƚĂƌŵ͛ƐůĞŶŐƚŚ͕ŚĂůĨǁĂLJďĞƚǁĞĞŶLJŽƵĂŶĚƚŚĞƉĂƚŝĞŶƚ͕ƚŚĞŶďƌŝŶŐŝƚ
medially and check the 4 quadrants and the middle field while his\her eye is looking at your eye. ƒ Colorvision. ƒ Funduscopy. i.
ii.
67 note
*Features of Horner`s Syndrome: Miosis , Ptosis, Anhidrosis. * Causes of Pinpoint Pupil: Opioids, Pontine pathology. Figure 11.7 Visual field defects with lesions at various levels along the optic pathway, at sites indicated at Figure 11.6. 68 Oculomotor (3rd), Trochlear (4th) , and Abducens (6th): ƒ All muscles are supplied by oculomotor , except : - Superior oblique , by trochlear (SO4) - Lateral rectus, by abducens (LR6) ƒ Assessed by testing the pupil and ocular movement : - Pupil: a. Size, shape, equality, and regularity. b. Also, note if there is any ptosis, i.e. dropping of the eyelids. - Eye movement : a. Following the finger with without moving the head: teat the 6 cardinal points in (H) pattern. b. Move your finger in (X) shape to check for superior and inferior oblique muscles. c. Asses if there is failure in eye movement, diplopia, or nystagmus . ƒ Light reflex: - Afferent fibers travel with optic nerve. - Efferent fibers come with oculomotor. - There are direct ( intact) and in direct (consensual) light reflex: a. Direct: the pupil constrict in the examined eye . b. In direct : the pupil constricts in the other eye , because they share the same nucleus (EdingerWestphal nuclei) ƒ Marcus Gunn papillary sign (also called afferent papillary defect ): - Move the torch in an arc from pupil to pupil. - If there is abnormality, the affected pupil will dilate paradoxically after a short time when the torch moved from the normal eye to the abnormal one. ƒ Accommodation: - Ask the patient to look at a far object then put a pin in front of his\her eye (the distance approximately 30cm) and observe the pupil. Normally it will constrict. - Accommodation is controlled by the Oculomotor nerve. iii.
69 iv.
Trigeminal ƒ Sensory - Ophthalmic, maxillary, and mandibular division. - Examine it by using piece of cotton to asses light touch, and pinhead to assespain bilaterally. ƒ Motor: - Muscle of mastication: temporalis, masseter, and pterygoid. - Inspect for muscle wasting. - Ask the patient to clench the teeth and palpate the masseter. - Ask the patient to open the mouth (pterygoid) and hold it open while the examiner attempt to force if shut, and note any deviation (toward the lesion side). ƒ Reflexes: - Corneal reflex: a. Lightly touch the cornea with wisp of cotton brought to the eye from the side. b. The normal response is blinking of both eyes. c. Ask the patient whether he\she feels the touch or not. d. Afferent: ophthalmic division of trigeminal. e. Efferent: facial nerve innervations of orbicularis oculi. - Jaw reflex(masseter reflex): a. Ask the patient to let the mouth fall open slightly. b. Placed your index on the tip of the jaw and tapped lightly with hammer. c. Normally there will be a slight closure of the mouth or no reaction at all. v.
Facial : ƒ Inspect for facial asymmetry, as facial palsy cause unilateral drooping of the corner of the mouth and smoothing of the wrinkled forehead and nasolabialfold . ƒ Muscle power (facial expression ): 70 -
Frontalis : ask the patient to look up ( without moving the head ) to wrinkle the forehead. -
Orbicularis oculi: ask the patient to close his\her eyes strongly, and try to open them. -
Buccinator: ask the patient purse lips, and try press cheeks. -
Orbicularis oris: ask the patient to smile or show teeth. 71 vi.
Vestibulocochlear (auditory ): x Usually not performed. tĞďĞƌ͛ƐƚĞƐƚ ZŝŶŶĞ͛ƐƚĞƐƚ Technique Hold the base of a vibrating tuning fork against the vertex. Hold the base of a vibrating tuning fork against the mastoid process. Conductive deafness Sound is louder in the affected ear, since distraction from external sounds is reduced in that ear. Bone conduction is better than air conduction. Nerve deafness Sound is louder in the normal ear. Both bone and air conduction are impaired. 72 vii.
Glossopharyngeal and Vagus. x Ask the patient to open his\ŚĞƌŵŽƵƚŚƚŽŝŶƐƉĞĐƚƚŚĞƉĂůĂƚĞ͕ƚŚĞŶƐĂLJ͞,͟ƚŽ
observe the soft palate with a torch (soft palate is pulled to the normal side ). x Test for gag reflex: 9 LJĚĞƉƌĞƐƐŝŶŐƚŚĞƉĂƚŝĞŶƚ͛ƐƚŽŶŐƵĞĂŶĚƚŽƵĐŚŝŶŐŚŝƐ\her palate, pharynx or nostril. 9 Compare with other side. 9 Afferent is glossopharyngeal, while the efferent is the vagus. 73 Accessory (11th) : ƒ Sternocleidomastoid : - Ask the patient to rotate head against resistance. - Compare the power on each side. ƒ Trapezius: - Ask the patient to shrug shoulders and hold them in position against resistance. - Compare the power on each side. viii.
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Hypoglossal: ƒ Ask the patient to open his\her mouth , and inspect for : - Atrophy: increase folds, or wasting. - Fibrillation: small wriggling movements ƒ Ask the patient to protrude tongue, note any difficulty or deviation. ƒ The tongue is deviated toward the side of weakness. 74 3. Motor system: A. Inspection(always compare!!!): ƒ Scars, stria, swelling ,dilated vein. ƒ Abnormal position : - Hemiplegia. - DĂƐŬĨĂĐĞ͗ƉĂƌŬŝŶƐŽŶ͛Ɛ - All limbs are extended :decerebration. - Extended lower limbs, and flexed, pronated , and internally rotated upper limbs: decortications. ƒ Muscle wasting: caused by : - Denervation - Primary muscle disease. - Disuse atrophy. - It can be proximal,distal,generalized, symmetrical or asymmetrical. - Determine which muscle groups. ƒ Abnormal movement, e.g. tremor or drifting. ƒ Deformity: - Wrist or foot drop. - Claw hand. ƒ Fasciculations: - Irregular contraction of small areas of a muscle, which have no rhythmical pattern. - Can be fine or coarse. - Present only at rest. - If it was not clear, tap on the muscle (usually biceps and brachioradialis with your finger or a hummer), and wait for 30 seconds. B. Tone (always compare): ƒ The resistance felt by the examiner when moving a joint passively through its range of movement. ƒ Ask the patient to relax to allow you to move his\her joint freely ( choose the big joints) ƒ Start from the distal then proximal or vice versa. ƒ Note the group of muscle affected. ƒ Normally, there is smooth minimal passive resistance. 75 ƒ
Abnormality : - Hypertonia : UMNL. - Hypotonia : LMNL. - Lead pipe and cogwheel rigidity:Parkinsonism. - Clasp knife:UMNL. C. Power (always compare): ƒ The ability to make a resistance. ƒ dĞƐƚĞĚďLJŵĞĂƐƵƌŝŶŐ;ŐĂƵŐŝŶŐͿƚŚĞĞdžĂŵŝŶĞƌ͛ƐĂďŝůŝƚLJƚŽŽǀĞƌĐŽŵĞƚŚĞƉĂƚŝĞŶƚ͛ƐĨƵůů
voluntary muscle resistance. ƒ For every joint, you have to move it in all its directions of movement. ƒ Three normal or decreased. ƒ Decide if it symmetrical or asymmetrical, group of muscles or general , and with pain or not. ƒ Grades of power(MRC grades): - No movements (complete paralysis). - Flickering (trying to move but there is no movement). - Movement with gravity. - Movement against gravity. - Movement against gravity and resistance. - Normal movement. ƒ
ZĂŝƐĞƚŚĞƉĂƚŝĞŶƚ͛ƐŚĂŶĚƵƉĂŶĚůĞĂǀĞŝƚ͘/ĨŝƚĨĂůůƐ͕ƚŚĞƉŽǁĞƌŝƐless than 3, but if not, apply resistant on it. 76 The upper limb:
ƒ Shoulder: - Adduction(C6,7and 8) abduction(C5and 6) ƒ Elbow: - Flexion (C5&6) by the biceps, and extension (C7&8)by the triceps. ƒ Wrist: - Flexion (C6&7) and extension (C7&8). ƒ Fingers: - Flexion and extension (C7&8), and abduction and adduction (C8&T1). The lower limb:
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Hip: -
Flexion(L2&3), extension(L5,S1&2), abduction (L4,5&S1), and adduction (L2,3&4) Knee: - Flexion (L5&S1), and extension (L3&4). Ankle: - Planter flexion (S1&2) and dorsiflexion (S4&5). Tarsal joint: - Eversion and inversion (L5&S1). Quick test of lower limbs power:
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Stand on toes (S1). Stand on heels(L4 &5) Squat and stand again (L3&4). 77 78 D. Reflexes(always compare): ƒ Make sure that you exposed the target muscle, and you should know the reflex roots. ƒ If the reflex did not appear properly, apply reinforcement maneuvers: - Upper limb reflex: ask patient to close his eyes firmly. - Limb reflex: ask patient to pull one hand against the other. ƒ The patient must be relaxed and properly positioned. ƒ Grades of muscle reflex: 0 absent +1 reduced reflex
+2 normal +3 exaggerated +4 exaggerated with clonus (brisk)
The upper limb:
ƒ Biceps jerk (C5&6): - Angle of the elbow: 120ȗ. - Place your thumb on the biceps tendon and tap your thumb with hummer. - Normally : a. Brisk contraction of the biceps. b. Flexion of the forearm at the elbow, followed by prompt relaxation. ƒ Triceps jerk(C7&8): - Angle of the elbow 90ȗ. - Triceps jerk with one arm flexed. - Support the elbow with one hand and tap over the triceps tendon (do not place your finger). - This reflex may cause pain if you are tapping on the ulnar nerve. - Normally there will be triceps contraction results in forearm extension. ƒ Brachioradialis (supinator )jerk (C5&6): - Strike the lower end of the radius just above the wrist. - Normally there will be contraction of brachioradialis , and flexion of the elbow . ƒ Finger jerk(C5): - WƵƚƚŚĞƉĂƚŝĞŶƚ͛ƐŚĂŶĚƵƉǁĂƌĚ͕ĂŶĚĨůĞdžƚŚĞĨŝŶŐĞƌƐƐůŝŐŚƚůLJ͘ - Put your haŶĚŽǀĞƌƚŚĞƉĂƚŝĞŶƚ͛ƐŚĂŶĚĂŶĚƐƚƌŝŬĞ͘ - Normally the fingers will slightly flex. 79 The lower limb:
ƒ Knee reflex(patellar reflex L3&4) - Hold the knee by your forearm. - Tap on the patellar ligament (between patella and tibialtuberosity). - Normally the quadriceps will contract, resulting in knee extension. - Do reinforcement maneuvers if the reflex is poor. ƒ Ankle reflex (S1&2): - Both the knee and ankle are flexed 90ȗ. - Tap on the Achilles tendon. - Normally there will be contraction of gastrocnemius muscle casing planter flexion. - If absent, do reinforcement maneuver. ƒ Planter reflex (S1&2 orL5,S1&2) - Tell the patient what will do. - Stroke up the lateral side of the sole with a sharp instrument such as a key. - Curve in ward before reaching the toes. - Normally there will be a planter flexion of the big toe (downwards). 80 ƒ
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Babinski sign (extensor response): Dorsiflexion (extension or upward flexion) of the big toe, and fanning of other toes. Seen in UMNL lesion (pyramidal) and in infants. Bilateral up going toes occurs after generalized seizure, and with a patient in coma. Always, take the first move of the lateral toes, and if positive, never say positive, but say extensor planter reflex. ƒ
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Clonus : Seen in UMNL. Done if the patient has hypertonia (especially in ankle joint). Position: like ankle jerk. Put one hand on calf and other hand on sole and catch. Suddenly, do dorsiflexion of the ankleand sustain it for about 5-­‐10 seconds. If clonus is present, recurrent ankle planter flexion movement occurs. You have to do full extension and flexion of the joint to see clasp-­‐knife spasticity if present. The patient must be relaxed. Ankle clonus: dorsi flex the ankle and observe and feel the rapid oscillation of clonus. ƒ
Patellar clonus: clasp the patella between your thumb and fingers, briskly push the patella inferiorly. Feel for oscillation of clonus. 81 E. coordination : The upper limb :
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Finger-­‐nose test : - Ask the patient to touch his nose, then rotates his finger and touch your finger (you should move his finger from one position to another, backward and forward as well as from side to side). - Note any : a. Intention tremor: tremor which increase as the target is approached. b. Past pointing (also called dysmetria ):patient over shoots the target. c. Both. ƒ
Rapid alternating movement : - Ask the patient to pronate and supinate his\ her hand on the dorsum of the other hand as rapid as possible. - Inability to perform this movement smoothly is called dysdiadochokinesis(slow and clumsy movement) seen in cerebellar disease. - May be affected in : a. Extrapyramidal disease e.g. Parkinsonism. b. Internal capsule infarction (pyramidal disease). c. Myasthenia gravis. ƒ Rebound phenomenon: - Ask the patient to flex the armat the elbow joint against your resistance. - When you suddenly let go, violent flexion may occur and, unless prevented the patient may strike him\herself in the face. - Hypotonia due to cerebellar disease cause delay in stopping the arm. 82 The lower limb:
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Heel ʹshin test - Heel: the posterior lower part of the sole, and shin: the anterior border of the tibia. - Ask the patient to run the heel of one foot up and down the opposite shin at moderatepace and as accurately as possible, then repeat it with closed eye. - Inability to perform this is a sign of cerebellar disease, or posterior column loss. ƒ
Toe-­‐finger test: - It is not practical way to assessing. - Ask the patient to lift the foot and touch your finger by his\her big toe. ƒ Foot-­‐tapping test : - Usually not done. - It tests rapid alternating movement of lower limb. - Ask the patient to tape the sole of foot quickly on your hand or tap the heel on opposite shin. - Look for loss of rhythmicity. 83 4. Sensory system : A. Spinothalamic pathway (pain and temperature): ƒ Pain : - Using a new pen or a sterile needle. - Demonstrate the patient that this induces a relatively sharp sensation by touching lightly a normal area, such as the anterior chest wall. - Then ask the patient to say whether the pinprick sharp or dull. ƒ Temperature : - This test performed only in special circumstances, e.g. syringomyelia . - Can be done by using test tubes filled with hot and cold water. - Ask the patient to close his\her eye .touch the patient with it and ask if it feels cold of hot. B. posterior column (vibration and proprioception): ƒ Vibration : - Using tuning fork. - Ask the patient to close the eyes, and place the vibrating tuning fork on bony prominence. - The patient should be able to describe a feeling of vibration. - Deaden the tuning fork; the patient should be able to say exactly when this occurs. - Golden base: do not go to proximal sites unless distal site are abnormal. C. Proprioception ( joint sensation ): - Use the distal interphalangeal joint of the little finger or the big toe of the patient. - When the patient opens his\her, grasp the big toe from side and move it up and down to demonstrate these positions. - Ask the patient to close the eyes and identify the direction of and movement. D. Both (spinothalamic and posterior column pathway ): - Light touch: Use a wisp oĨĐŽƚƚŽŶĂŶĚƚŽƵĐŚůŝŐŚƚůLJǁŚŝůĞƚŚĞƉĂƚŝĞŶƚ͛ƐĞLJĞƐĂƌĞ
closed, and let him\her tell you when he\she feels the touch. 84 85 5. Gait : -
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A. DĂŬĞƐƵƌĞƚŚĂƚƚŚĞƉĂƚŝĞŶƚ͛ƐůĞŐƐĂƌĞĐůĞĂƌůLJǀŝƐŝďůĞ͘ B. Ask the patient to walk normally a few meters, then turn around quickly and walk back. C. Then ask patient to walk heel to toe, to exclude midline cerebellar lesion. D. Some abnormal gaits: Hemiplegic:the foot is on planter flexion, and the leg swings in a lateral arc. WĂƌŬŝŶƐŽŶ͛Ɛ͗ƐŚƵĨĨůŝŶŐŐĂŝƚ͘ Cerebella disease: drunken, wide based gait. Foot drop: high stepping gait. E. Romberg test: Ask the patient stand erect with feet together and eyes open. Once the patient is stable, ask him\her to close the eyes. Note if there is unsteadiness, which indicate cerebellar or vestibular dysfunction. The test is positive in sensory ataxia (loss of proprioception) 86 -
87 6. Cerebellar examination : ƒ
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This is not separate part from the previous examination, but some doctors ask examine the cerebellum alone. Abnormalities in cerebellar palsy indicate : - Nystagmus. - Dysarthia. - Pendullar knee reflex. - Loss of coordination. - Abnormal gait (drunken ). note
Full Cerebellar Ex: (it is important as an OSCE station)
1. General inspection: 9 Inspect the head for tremor 9 Speak with the patient to assess Dysarthria 9 Inspect for nystagmus 2. Upper limbs: 9 Inspect for obvious tremor 9 Finger-­‐nose test 9 Rapid alternating movement As explained before..
9 Rebound phenomenon 3. Lower limbs 9 Heel-­‐Shin test 9 Toe-­‐finger test 9 Knee reflex 4. Gait exanimation 88 ™ Chronic illnesses : 1. stroke: ƒ
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Onset and duration (how long did it last?). Presentation: hemiplegia, loss of sensation in one half of the body, facial weakness ,hemianopia. Management. Complication. Previous episode and their management. Regular follow up in hospital. dŚĞĞĨĨĞĐƚŽĨƚŚĞĚŝƐĞĂƐĞŽŶƚŚĞƉĂƚŝĞŶƚ͛ƐůŝĨĞ͘ Risk factor: HTN , smoking , DM ,hyperlipidemia ,atrial fibrillation , valvular disease, MI , bacterial endocarditis , hematological disorder , and family history . 2. epilepsy : ƒ
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When was diagnosed? Based on which type of investigation? Type, e.g. generalized or partial. Medication and their complication. Number of attacks. Regular follow up in the hospital. Number of hospital admission due to the disease and type of management. Progression Complication and indication of surgery. dŚĞĞĨĨĞĐƚŽĨƚŚĞĚŝƐĞĂƐĞŽŶƚŚĞƉĂƚŝĞŶƚ͛ƐůŝĨĞ͘ 3. Myasthenia gravis (MG): ƒ
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When was diagnosed? Based on which type of investigation? Regular follow up in the hospital. Medication, always taken or missed. Associated with thymic hyperplasia. Complication and their duration. A patient usually presents with easy fatigability in proximal limb muscle, extraocularmuscle, and muscle of mastication, speech and facial expression. 4. multiple sclerosis (MS): ƒ
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When was diagnosed? Based on which type of investigation (mainly MRI)? Number of attacks. Course of the disease: relapsing ʹremitting,relapsing , or progressive . 89 ƒ
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ƒ Regular follow up in the hospital. ƒ Medication and their complication ƒ Number of hospital admission and type of management given. ƒ Complication. MS patient usually present with one or more of the following : Optic neuritis; blurred vision, unilateral eye pain . Brainstem and cerebellar dysfunction:diplopia ,nystagmus , vertigo , dysphagia . Cognitive abnormality: failure of memory , loss of concentration , depression . Sensory disturbance: incontinence, frequency. Leg weakness. Important points :
UMNL
Hypertonia ,hyperreflexia , no muscle wasting LMNL
Hypotonia , hyporeflaxia , fasciculation and muscle wasting Muscle disease
Wasting , hypotonia ,hyporeflaxia in a particular group of muscle
Neuromuscular junction disease
Generalized weakness, which worsen with repetition, normal tone and reflex, e.g. myasthenia gravis.
90 H istory and E xamination of the Genitourinary System
™ Major Symptoms: 1. Renal colic 2. Change in urine appearance 3. Obstructive symptoms 4. Irritative symptoms 5. Symptoms of uremia 6. Systemic symptoms ™ Genitourinary Examination: 1 . General appearance
2. Nails 3. Hand and Arm 4. Face 5. Abdomen 6. Back ™ Other Items in the History ™ History of Chronic Renal Failure Always Have
Hope..
91 ™ Major Symptoms: 1. Renal colic: ƒ
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Analyze it as a pain. Site; it is felt in: -­‐ Loin; a space between the 12th rib and the iliac crest. -­‐ Renal angle; between the 12th rib and erector spinal muscles. ƒ Severity: sometimes constant dull ache and sometimes very sever. ƒ It never disappears between attacks. 2. Change in urine appearance: ƒ
Could be hematuria, or any other causes such as beetroot, paroxysmal nocturnal hemoglobinuria, or porphyria. ƒ In hematuria (exclude menses in a female) ask about: -­‐ Duration. -­‐ Gross or microscopic. -­‐ Pain: as in stones and urinary tract infection (UTI). -­‐ Timing of pain: a. Before hematuria: stone (the patient has a history of pain for one week then he/she developed hematuria).
b. After hematuria: clot colic due to arteriovenous malformation, malignancy, or other causes. ƒ
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Time in the stream: -­‐ At the beginning: urethral causes. -­‐ Late: trigone of the bladder, or its neck. -­‐ Total: any site other than the bladder or the urethra. The severity of hematuria is known by: -­‐ The duration: the longer, the danger. -­‐ The presence of clots, try to describe its shape. -­‐ The color of urine: the darker the urine, the more severe the case. 3. Obstructive symptoms: ƒ
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Hesitancy; difficulty starting the urine stream. interruption of urine. Incomplete voiding. Poor stream. Straining. Dribbling at the end, may stay many minutes after finishing the urination. 92 4. Irritative symptoms: ƒ
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Frequency. Nocturia. Urgency, assessed by asking the patient if he/she can tolerate long distances up to the bathroom. urge incontinence. 5. Symptoms of uremia: ƒ
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Oliguria, nocturia, or polyuria. Anorexia, metallic taste, vomiting, fatigue, hiccups, and insomnia. Edema, itch, bruising, pallor, pigmentation . weakness, mental confusion, seizures, and coma. 6. Systemic symptoms: ƒ
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Fever. Sweating. Loss of appetite. Loss of weight. chills and rigors. Fatigability. 93 ™ Other Items in the History: 1. Personal data:
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Young female: always suspect UTI. Old male: always suspect benign prostatic hyperplasia (BPH) and look for obstructive symptoms. 2. Past history:
ƒ Bilharziasis. ƒ Endoscopy, catheterization, or other invasive procedures. ƒ Trauma. ƒ Stones. ƒ TB symptoms or diagnosis. ƒ Sexual transmitted disease. ƒ Blood disorder, HTN, DM. ƒ Renal transplant. 3. Medication history: ƒ
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Warfarin. Heparin. AIDS drugs. Rifampicin. 94 4. Family history: ƒ
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Similar illness. TB BPH Any congenital disease. 5. Social history: ƒ Smoking; the most important risk factor for transitional cell carcinoma (TCC). ƒ job. ƒ Marital Status. ƒ Sexual contact. ƒ Travel. ƒ Number Of relatives (for kidney donation). ™ Genitourinary Examination: 1. General appearance: ƒ
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Pale (anemic), hyperventilation. Hiccupping, uremic fetor, gray bronze skin. Muscle twitching, tetany, epileptic seizure, subcutaneous nodule (due to calcium deposition). Overhydration, dehydration. 2. Nails: ƒ
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Leukonychia: hypoalbuminemia, a sign of nephritic syndrome. Muehrcke's lines; transverse opaque bands: hypoalbuminemia. Terry's nail', half-­‐and-­‐half nail: chronic renal failure (CRF). Mees' line', a single transverse white band: acute renal failure (ARF). Beau's line; non pigmented indented transverse bands: any cause of catabolic state. 3. Hand and Arm: ƒ
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Anemia, asterixis, arteriovenous fistula in the waist or the forearm. Bruising, hyperpigmentation, scratch mark (due to calcium deposition), uremic frost. Peripheral neuropathy, myopathy, bone tenderness. 4. Face: ƒ
Eye: -­‐ Anemia. 95 -­‐
-­‐
Jaundice (rare): hemolysis by sodium. Band keratopathy: calcium deposition in the cornea. Mouth: -­‐ Uremic fetor. -­‐ Mucosal ulcers. -­‐ Oral thrush. 5. Abdomen (see abdominal examination). ƒ inspection -­‐ Nephrectomy scare. -­‐ Bulge of a transplanted kidney. -­‐ Scares for peritoneal catheters. -­‐ Ascites (nephrotic syndrome). ƒ Palpation: -­‐ Enlarged kidney tends to bulge forward while the perinephric abscesses or collections bulge backward. -­‐ A transplanted kidney is seen in the right or left iliac fossa. -­‐ Hepatomegaly or splenomegaly may be seen in polycystic kidney disease. -­‐ Feel for the bladder enlargement or aortic aneurysm. ƒ Percussion and auscultation: -­‐ Ascites. -­‐ Renal bruit. 6. Back: ƒ By using a base of fist: -­‐ Elicit tenderness over the spine: osteomalacia. -­‐ Murphy's kidney punch', elicit tenderness over the renal angle (not too much): renal infection. -­‐ sacral edema: nephrotic syndrome. ƒ
96 97 ™ History of Chronic Renal Failure: ƒ
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Duration. Etiology, e.g. DM, HTN. History of: -­‐ Hemodialysis: when? Why? How many times? Complications? -­‐ Arteriovenous fistula: when? Why? How many times? Complications? -­‐ Kidney transplanted'. when? Why? How many times? Complications? Donor relationship? -­‐ Medications'. steroids, Mathioprine (amuranTM), cyclosporine, sirolimus, and others. ƒ Symptoms and complications of CRF: -­‐ Anemia. -­‐ Bone pain. osteomalacia, osteoporosis, secondary and tertiary hyperparathyroidism. -­‐ CNS: motor and sensory neural impairment. -­‐ CVS: HTN, lipodystrophy, atherosclerosis. -­‐ Others: peptic ulcer, acute pancreatitis, hyperuricemia sexual dysfunction, and in children, failure to thrive. ƒ
Complications of transplantation: -­‐ Opportunistic infections. -­‐ Premature coronary artery disease. -­‐ Lymphomas and skin cancers. -­‐ Complications of steroid treatment. 98 H istory and E xamination of the Rheumatological System:
™ Major Symptoms: ƒ
Joints: -­‐ Pain. -­‐ Swelling. -­‐ Morning stiffness. -­‐ Loss of function. -­‐ Deformity -­‐ Weakness. -­‐ Instability. -­‐ Changes in sensation ƒ Eyes and mouth: -­‐ Dry eyes and mouth. -­‐ Red eyes. ƒ
Systemic: -­‐ Raynaud's phenomenon -­‐ Skin rashes -­‐ Fever -­‐ Fatigue -­‐ Weight loss. -­‐ Diarrhea -­‐ Mucosal ulcer Try to eliminate
negative inputs..
99 1. Joint pain: -
Arthralgia: joint pain. Arthritis: joint pain and swelling. ƒ
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Site and number of the affected joint(s); mono or poly. Onset and duration. Distribution: small or large joints. Radiation. Symmetry. Additive, migratory or intermittent (important to mention the sequence): - Additive: affects one joint then affects another one in addition to the formal one. - Intermittent: affects the same joint, but comes and goes. - Migratory: affects one joint, and then leaves it to another one. ƒ Character. ƒ Severity. ƒ Continuous or intermittent. ƒ Getting better or worse. ƒ Frequency, and the duration of each episode. ƒ Progressed or constant. ƒ Daily pattern. ƒ Precipitating, aggravating and relieving factors. ƒ Associated symptoms. 100 2. Joint swelling: ƒ
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Site. Onset and duration. Extension. Continuous or intermittent. Progressed or constant. Precipitating, aggravating and relieving factors. Associated symptoms 3. Morning stiffness: ƒ
Duration. - Less than 30 minutes in osteoarthritis (OA). - More than 1 hour in rheumatoid arthritis (RA). 4. Loss of function: ƒ
ƒ
When and why? What was done? 101 5.
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Deformity: When? Which joint? Type of deformity. Progression. 6. Weakness: ƒ When? ƒ Continuous or intermittent. ƒ Progression over the time. 7. Instability: ƒ This is described by the patient as giving way or coming out. ƒ It may be due to Joint dislocation or muscle weakness. 8. Changes in sensation: ƒ May be due to nerve entrapment or ischemia. So, ask about: - Numbness or paraesthesia. - The distribution. 9. Dry eyes and mouth: ƒ Characteristic of Sjogren 's Syndrome ƒ Duration. ƒ Course. ƒ Management ƒ Associated symptoms. 10. Red eyes: ƒ Duration. 11. Raynaud's phenomenon: ƒ As abnormal response of fingers and toes to cold. ƒ First turn white (ischemia), then blue (cyanosis) and finally red (revascularization, it is the most severe and painful-­‐stage ) ƒ Duration. ƒ Complication. e.g. ulcer formation. 102 ™ Past history: ƒ
Past medical: Childhood arthritis. RA, SLE, scleroderma, vasculitis. Recent infection (may be relevant to the onset of arthralgia or arthritis). Sexually transmitted disease. Non specific urethritis and gonorrhea. Tick bite. IBD (can result in arthritis). Psoriasis (psoriatic arthropathy). ƒ
Past surgical: History of joint trauma or surgery. -­‐
-­‐
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Past interventional: Arthroscopy. Any history of physiotherapy or rehabilitation. ™ Medication history: ƒ
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Antiarthritics, e.g. aspirin, NSAID, gold, methotrexate (MTX) penicillamine, chloroquine, steroids. Side effects: gastric ulcer or hemorrhage from aspirin. ™ Family history: ƒ
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RA, OA. Hemochromatosis: can result in arthritis due to calcium pyrophosphate deposition. Seronegative spondyloarthropathies. IBD. Bleeding disorders e.g. hemophilia may lead to swollen tender joints. ™ Social history: ƒ
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Domestic set up. Occupation. Need for home assistant because of disabling arthritis. 103 ™ Rheumatological E xamination:
ƒ
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Remember: Expose the joints that are above and below the target joint. Look, feel, move, measure, and special tests. Always compare with the opposite side. Joints are three dimensional structure and need to be inspected from the front, back and the sides. ƒ Look : ƒ Nails: Note any changes. ƒ Skin : - Atrophy. - Tightness. - Erythema: suggests an active disease. - Scars: indicate previous operation of the joint or its tendon. - Rashes, e.g. psoriatic rashes. - Discoloration. ƒ Muscle: - Wasting: joint disease, inflammation of the surroundings, or nerve entrapment. ƒ Joint: - Swelling. - Deformity. ƒ Bone: - Subluxation: displaced parts of the joint surfaces remain partly in contact. ƒ
Feel: ƒ Warmth. ƒ Tenderness: - Grade 1: pain. - Grade 2: pain and wince. - Grade 3: pain, wince and withdrawal. - Grade 4: patient does not allow palpation. ƒ Swelling: - Bony swelling: hard and immobile (osteophyte) as in OA. - Effusion: soft, spongy and fluctuated swelling, occurs with RA. 104 ƒ
Move: ƒ Passive movement: the patient lets the examiner move the joint. ƒ Active movement: the patient moves the joint by himself. ƒ During the active movement note any: - Limitation. - Instability: appreciated by asking the patient to move the joint gently in abnormal directions. - Joint crepitus: a grating sensation or noise from the joint, which indicates chronicity. ƒ Measure: ƒ Range of movement (look for the normal ranges in your book). ________________________________________________________________________ 1. Hand examination: ƒ
ƒ
Position: sitting, and put the patient's hands on a pillow. Exposure: above the elbow. ƒ Look: x Nails: - Pitting nails, ridging, onycholysis, hyperkeratosis: psoriasis. - Discoloration (Raynaud's phenomenon). - Digital infarction: scleroderma. - Splinter hemorrhage: SLE. x
-
Skin: Atrophy: chronicity. Tightness: scleroderma. Erythema: inflammation. Scars: a)
Rheumatoid nodule scar. b)
Fasciotomy scar in carpal tunnel syndrome. - Rashes: psoriasis. - Discoloration. 105 x
x
x
Muscle: Wasting. It results in the appearance of hollow ridges between the metacarpal bones Bone: - Subluxation. - Dislocation. Joint swelling. x Joint deformity: - Ulnar deviation. - Radial deviation. - Swan neck: hyperextension of the PIP joint and fixed flexion of the DIP joint. - Boutonniere: fixed flexion of the PIP joint and extension of the DIP joint. - Jaccoud's arthropathy: reversible flexion of the PIP joint and extension of the DIP joint, seen in SLE. - Z-­‐deformity in the thumb: hyperextension of the IP joint, fixed flexion and subluxation of the MCP joint. - Sausage shape finger due to interphalangeal arthritis and flexor tendon sheath edema. - Telescoping fingers (arthritis mutilans): shortening of the fingers. - Resolution of finger tips (tapering fingers). ƒ
-
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Feel: x Temperature. x Tenderness. x Swelling: Bony swelling: a. Heberden's nodes: at the DIP Joint. b. Bouchard's nodes: at the PIP joint. Effusion. 106 ƒ
Move: x Passive movement. x Active movement, note any: - Limitation. - Instability. - Joint crepitus. 107 ƒ
-
Functions: Grip strength: give the patient a pen and ask him/her to squeeze it strongly. Key grip: the key is held between the pulps of the thumb and forefinger. Opposition strength. Practical test: ask the patient to undo a button or write with a pen. ƒ Measure: -­‐ Range of movement. 108 Special tests: ƒ
Phalen's wrist flexion test: - lf carpal tunnel syndrome is suspected, ask the patient to flex both wrists (dorsum on the dorsaů͕ĂŶĚƚŚĞǁƌŝƐƚƐŚŽƵůĚďĞŝŶϵϬȗ) and the patient should wait for 30 second. - Paraesthesia will often be precipitated in the affected hand in the distribution of the median nerve if the carpal tunnel syndrome is present. ƒ Tinel's test: - Tapping over the flexor retinaculum which lies at the proximal part of the palm. - The test will be positive if there is paraesthesia in the tip of the patient's fingers. ƒ Examination of the hands is not complete without feeling for the subcutaneous nodules of RA near the elbow. These nodules are firm, non-­‐tender and found over the olecranon or extensor surface. 2. Knee examination: ƒ
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Position: lying down. Exposure: both knees and thighs are fully exposed. Look: ƒ
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Nails: Note any changes of the toes' nails. Skin: Atrophy and tightness. Erythema and discoloration. Scars. Rashes. ƒ
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Muscle: Wasting. Lower limb swelling due to ruptured Backer's cyst. 109 ƒ
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Joint: Swelling. Backer's cyst in the popliteal fossa, while the knee in complete extension. Deformity: a. Valgus: deviation away from the midline: RA. b. Varus: toward the midline: OA. ƒ
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Bone: Subluxation Dislocation Feel: ƒ
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Temperature. Tenderness. Swelling: Bony swelling. Effusion: a. Huge effusion: patellar tap test. b. Moderate effusion: fluctuation test. c. Mild effusion: milking sign. Move: ƒ
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-
Passive movement. Active movement, note any: Limitation. Instability. Joint crepitus. Measure: ƒ
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Range of movement. Strength of knee ligaments: Lateral and medial collateral ligaments. Anterior and posterior cruciate ligament. 110 Special tests: ƒ
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Patellar apprehension test: Done when recurrent dislocation or subluxation of patella is suspected. Push the patella firmly to the lateral side while slowly flexing the knee. Look at the patient's face for any anxious expression that may suggest impending dislocation. Apley's grinding test. Distraction test. McMurray's test. Finish your examination by asking the patient to walk and examine the gait.. 111 H istory and E xamination of the E ndocrine System:
™ Major Symptoms : 1. Body weight and appetite: 2. Bowelhabit: 3. Sweating: 4. Hair distribution: 5. Change in the skin: 6. pigmentation: 7. stature 8. Menstruation 9. Galactorrhea. 10. Polydipsia 11. Polyuria. 12. Lethargy. 13. Loss of libido, or erectile dysfunction. 14. Lump in the neck. ™ Other Items in the History ™ Chronic Illnesses ™ History and Examination of the thyroid gland. Ensure you mix
with positive
people..
112 ™ Major Sypmtoms: 1. Body weight and appetite: ƒ Increased or decreased weight (more than 10% per 6 months is significantͿ ƒ Association with increased or decreased appetite. 2. Bowelhabit: ƒ Normal, diarrhea, or constipation. 3. Sweating: ƒ Any increment. ƒ Diurnal pattern. 4. Hair distribution: ƒ Hirsutism. ƒ Alopecia. ƒ Decreased hair distribution in a male (hypogonadism). ƒ Increased hair distribution In a female (androgen excess). 5. Change in the skin: ƒ Coarse, pale, and dry (hypothyroidism). ƒ Dry and scaly (hyperparathyroidism). ƒ Soft tissue overgrowth (acromegaly). 6. Pigmentation: ƒ Increased: adrenal insufficiency, Cushing's syndrome, and acromegaly. ƒ Decreased: hypopituitarism. ƒ Localized or generalized hypo or hyperpigmentation. 7. stature: ƒ Tall: gigantism,gonadotropin deficiency,klinefelter's syndrome,Marfan's syndrome. ƒ Short: dwarfism. 8. Menstruation 9. Galactorrhea (hyperprolactinemia). 10. Polydipsia (psychogenic, hypothalamic disease...etc) 11. Polyuria (DM, Diabetes insipidus). 113 12. Lethargy. 13. Loss of libido, or erectile dysfunction. 14. Lump in the neck, i.e. a goiter. ™ Past history: ƒ
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Radioiodine treatment(hypothyroidism, hypoparathyroidism). Antithyroid drugs. Thyroid hormone replacement. Radioactive iodine. Surgery in the neck. ™ Family history: ƒ
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DM. Thyroid problem. Multiple endocrine neoplasias (MEN). Pituitary tumor. Medullary carcinoma of thyroid. Hyperparathyroidisim. Pheochromocytoma and pancreatic tumor. 114 ™ Chronic illnesses: ƒ
Acromegaly: -
Increase of growth, Soft tissue and bone overgrowth, Thick lips and separated teeth, Bitemporalhemianopia, Thyroidenlargement, hoarseness ofvoice, Gynecomastia, Congestive heart failure, Organomegaly, osteoarthritis and foot drop, Hypertension. ƒ
Cushing : - moon face, central obesity, thin extremities, pigmentation on the extensors, proximal myopathy, buffalo hump of the back, Psychosis, Purple stria, acne and hirsutism, Hypertension and DM. ƒ
Addison's disease: - Cachexia, Pigmentation, Vitiligo, Postural hypotension. ƒ
Pheochromocytoma: - hypertension, Pallor, palpitation, sweating, headache and anxiety, Constipation, Weight loss, Glucose intolerance. ƒ
Hyperparathyroidism: - Renal stone, Osteopenia, Constipation, Peptic ulcer, Pancreatitis, Confusion. ƒ
Hypoparathyroidism: - Tetany and muscle cramp, Hyperreflexia, Dry skin, Cataract, Numbness. 115 H istory and examination of the T hyroid gland:
™ Thyroid history: 1. Chief complain: - Swelling in the neck, or symptoms of hyper or hypothyroidism. 2. History of the presenting illness: ƒ Swelling. ƒ Compressing symptoms: -­‐
-­‐
-­‐
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Dyspnea. Difficulty in swallowing. Hoarseness of the voice when the recurrent laryngeal nerve is involved. Whistling of air sounds (stridor): heard when it compresses the trachea. Symptoms of hyper or hypothyroidism (see the table below). Risk factors: -­‐
-­‐
-­‐
-­‐
General CNS CVS Exposure to radiation. Family history. Iodine intake. Pervious disease. Hyperthyroidsim Heat intolerance, sweating, Wight loss, increased appetite, malaise. Nervousness, irritability, insomnia, tremor Palpitation, breathlessness GIT Vomiting, diarrhea. Muscle weakness, proximal muscle Musculoskeletal wasting Menstrual Oligomenorrhea Staring and protrusion eyes, lid lag, Eyes lid retraction, ophthalmoplegia, chemosis Loss of libido, gynecomastia, tall Others stature in children, goiter. Hypothyroidisim Cold intolerance, edema, mild obesity, weight gain. Psychosis, dementia, ataxia, carpal tunnel syndrome. HTN, heart failure, bradycardia, pericardial effusion. constipation Muscular hypertrophy, proximal myopathy, myotonia -­‐-­‐-­‐ Loss of hair at the outer third of the eyebrow. Large tongue, dry thin hair, deep voice, deafness, goiter. 116 ™ Thyroid Examination: Look at the general appearance if he (over dressed, sweaty, facialmaxiedema) ƒ
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1. Hand: Palm (moist,. sweaty, dry) , Muscle wasting, Tremor (fine or fast): Ask the patient to extend his/her arm with fingers straight and separated and see from bedside, orby placing a sheet of paper over the fingers. Feel the pulse; rate and rhythm (there may be atrial fibrillation). 2. Eyes : Lid retraction: the upper eye retracts, Exophthalmos ,Chemosis . Lid lag: when the upper lid doesn'tkeep pace with eyeball as it follows a finger moving from abovedownwards. 3. Neck : Inspection: -­‐ Look to the mass. -­‐ Ask patient to swallow and see its movement. -­‐ Describe the swelling. -­‐ Skin status. -­‐ Old scar. -­‐ Thyroid cartilage: present or not, deviated or not. -­‐ Dilated veins due to obstruction of thoracic inlet. -­‐ Ask the patient to put out the tongue: if the mass moves, it is most likely a thyroglossal cyst, but if it did not, it may be a thyroid swelling. Palpation: a. From front: -­‐
-­‐
-­‐
-­‐
Size, number of masses (if nodular), surface, and edge. Consistency. Tenderness. Position the trachea. b. From behind: -­‐
-­‐
Flex the neck slightly; put your thumbs behind the neck and the rest of your fingers in front to feel the thyroid lobes If the lobes are small, they are easier feel by pressing firmly on the opposite side of the neck). 117 -­‐
-­‐
Ask the patient to swallow during palpation (Normal thyroid gland is not palpable). Palpate the whole neck for any cervical and supraclavicular lymphadenopathy. ƒ
-­‐
-­‐
-­‐
Percussion: ( looking for mass extending) Over sternum. The clavicle. Supraclavicular fossa. Auscultation :( for systolic bruit) ask the patient to take deep breath and hold it during auscultation. ƒ
118 H istory and E xamination of the Hematological System
™ Major Symptoms 1. RBC abnormalities 2. Platelets abnormalities 3. WBC abnormalities 4.Lymph nodes abnormalities 5.constitutional symptoms ™ Hematological Examination 1. general appearance . 2. Hand 3. Pulse 4. Lymph nodes 5. Face 6. Bony tenderness 7. Abdominal examination. 8. Legs ™ Other Items in the History ™ Chronic Illnesses Do some Charitable
Work.. 119 ™ Major Symptoms: 1. RBC abnormalities: ƒ Symptoms of anemia: - Weakness. - Tiredness. - Dyspnea. - Fatigue. - Postural dizziness. - Pallor. ƒ Jaundice (due to hemolysis). ƒ Bleeding, e.g. menstrual bleeding, GI bleeding, epistaxis. 2. Platelets abnormalities: ƒ Easy bruising, purpura, thrombotic tendency. 3. WBC abnormalities: ƒ Recurrent infections. ƒ Bone pain. 4. Lymph nodes abnormalities: ƒ Lymphadenopathy. ƒ Skin rash (lymphoma). 5. Constitutional symptoms: ƒ Fever. ƒ Weight loss. ™ Symptoms analysis: ƒ
ƒ
For each symptoms above, ask about: onset duration, course (frequency, progression, continuity), offset. In epistaxis, ask about amount nature (fresh or clotted, bright or dark), from which nostril (right, left or both). 120 ™ Other Items in the History: 1. Past history: ƒ
Past medical: - Malabsorption. - Liver disease, since it may cause coagulation abnormalities. - Systemic disease (i.e. anemia of chronic illness), e.g. rheumatoid arthritis, renal failure. ƒ Past surgical: - Gastric surgery: may cause anemia due to malabsorption. - Venesection in polycythmia patients. 2. Medication history: ƒ
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iron supplement. Vitamin Bl2 or folate supplement. Anti-­‐inflammatories or anticoagulants (e.g. warfarin), can cause bleeding. Chemotherapy or radiotherapy (treatments of leukemia or lymphoma). 3. Blood transfusion . 4. Menstrual history: ƒ
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Heavy menstrual loss. Duration. Occurrence of clots. Number of sanitary towel (to assess the severity). 5. Family history: ƒ
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Anemia. Thalassemia. Sickle cell. Hemophilia. Leukemia or lymphoma. 6. Social history: ƒ
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Patient's residency: sickle cell disease common in KSA; in the East and South. Vegetarian diet: can result in vitamin B12 deficiency. 121 ™ Chronic Illnesses: 1. Sickle cell anemia: ƒ
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Medications. Number of hospital admissions. Blood transfusion. Complications: - Hemolysis, and gallstone formation - Vaso occlusion symptoms: a. Bone pain crisis: due to avascular necrosis of the bone marrow. b. Increase susceptibility to infection because of splenic atrophy. c. Fits and hemiplegia: result from cerebral infarction. d. Retinopathy and visual loss: cause by retinal ischemia. ƒ Other complications: - Renal failure. - Leg ulcers. - Acute chest syndrome: fever, cough, dyspnea, pulmonary infiltration seen in the x-­‐ray. 2. Thalassemia: ƒ
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Medications Number of hospital admissions. Blood transfusion. Complications: - Hemolysis. - Gallstone formation. - Leg ulcers. - Bone deformity. - Abdominal distention (hepatosplenomegaly). 3. Leukemias and lymphomas: ƒ
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When was diagnosed? Based on which types of investigations? What were the first symptoms? Treatment plan. Complications. 122 ™ Hematological Examination Position: lying flat.
1. General appearance: ƒ Looks well or ill. ƒ Cachectic, normal, or obese. ƒ In pain and dyspneic or not. ƒ Cold and clammy. ƒ Cyanosis. ƒ Pigmentation. ƒ Plethora. ƒ Racial origin: thalassemia. ƒ Pallor: anemia. ƒ Bruising: petechiae, ecchymoses. ƒ Jaundice: hemolytic. ƒ Scratch marks: lymphoma and myeloproliferative disorders. 2. Hand: ƒ Koilonychias: sever iron deficiency anemia. ƒ Digital infarction: abnormal globulins. ƒ Pallor of palmar creases: hemoglobin level is less than 8.1 g/dl. ƒ Gouty tophi. ƒ Arthopathy: hemophilia. 3. Pulse: Tachycardia. 4. Lymph nodes: - Epitrochlear. -­‐ Axillary. -­‐ Cervical. -­‐ Supraclavicular. -­‐ Inguinal. 123 5. Face:
ƒ
Eye: - Jaundice, hemorrhage, injection. - Conjunctival pallor: more reliable than nail beds or palmar creases for diagnosing anemia. - Fundi examination. ƒ Mouth: - Hypertrophy of the gum: leukemic cell infiltration. - Gum bleeding - Ulceration, infection and hemorrhage of buccal and pharyngeal mucosae. - Atrophic glossitis: megaloblastic anemia iron deficiency anemia. - Waldeyer's ring enlargement: Hodgkin's lymphoma. 6. Bony tenderness: ƒ
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Spine. Sternum. Clavicles. Shoulders. Enlarging marrow due to infiltration by myeloma, lymphoma or carcinoma may the cause of tenderness. 7. Abdominal examination : ƒ
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Hepatomegaly. Splenomegaly. Paraaortic adenopathy: lymphoma, lymphatic leukemia. 8. Legs: ƒ
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Bruising. Pigmentation. Scratch Marks. Palpable pleura: Henoch-­‐schonlein purpura. Leg ulcer: hemolytic anemia. Popliteal node. Neurological abnormalities. 124 note
Anemia is important as an OSCE station! Here are some points you should ask for: -­‐
Palpitation, pallor, dizziness, SOB, fatigue -­‐
Bleeding, e.g. menstrual bleeding, GI bleeding, epistaxis. Lymphoadenopathy or weight loss. "Menstrual Hx" (Heavy menstrual loss!! ) -­‐
-­‐
-­‐
Past history: DM, HTN, IBD, malabsorption, any ŽƚŚĞƌĐŚƌŽŶŝĐĚŝƐĞĂƐĞƐ;ůŝǀĞƌ͕ŬŝĚŶĞLJƐ͕ŚĞĂƌƚ͙Ϳ -­‐
Medication: OCP, any hormonal medication, or herbal substances. -­‐
Family history : sickle cell, thalassemia, G6PD, Hemophilia, Leukemia or lymphoma. 125 How to Report Your Examination? This is just an example of reporting an examination of a normal patient. Learn it by your heart, and try to establish you own way of reporting if you know the general structure.. 1-­‐General examination 2-­‐ Pericardium examination 3-­‐Chest examination 4-­‐Abdominal examination If we did all the things we were
capable of, we would literally
astound ourselves..
Tomas Edison
126 1. General examination: ƒ
General appearance: - A young gentle man is lying comfortably on the bed and looking well, he is thin. - Conscious, alert and oriented to: time, person, and place. - Doesn't look jaundice or cyanosed or pale. - Not on pain or respiratory distress. - Connected to IV line of normal saline. ƒ Vital signs: - The blood pressure (taken from the chart or by the nurse) was.../... - The temperature (taken from the chart or by the nurse) was .... o - The respiratory rate was... per minute. - The pulse was: regular, at rate of......, No radioradial or radiofemoral delay, With good volume and character. ƒ
The hand: - On hand examination: there was no pallor, muscle wasting, clubbing or cyanosis. - No signs of infective endocarditis or chronic liver disease or anemia. ƒ The head and neck: - On eyes: there was no pallor or jaundice. - On the mouth: there was no central cyanosis - ƚŚĞ:sWǁĂƐŶŽƌŵĂů͕ĂďŽƵƚ͙͘ĐŵĂďŽǀĞƚŚĞƐƚĞƌŶĂůĂŶŐůĞ͘ - There was no palpable neck swelling. ƒ Lymph nodes: No palpable lymph nodes. ƒ Lower limbs: On examination: pulses were palpable and equal bilateral, no edema and no clubbing. 2. Pericardium examination: ƒ
Inspection: - There was no scares (if there is a scar, mention its site and size), or deformities. - Apex beat is visible and seems to be in normal position, no other pulsations. ƒ
Palpation: - The apex beat is palpable in the left fifth intercostal space medial to the midclavicular line with normal character. - No thrills or parastenal heave. ƒ Auscultation: - S1 and S2 were audible all over. They were normal, without any added sounds. - lf there are any abnormalities you have to mention it. 127 3. Chest (respiratory) examination: ƒ
Inspection: - Chest is symmetrical, no deformities and moves freely with respiration without using of the - accessory muscles, no distended veins with visible pulsations. - Mention if there is a chest tube (for drainage). ƒ Palpation: - the trachea is centrally located. - Chest is normal with bilaterally equal chest expansion and tactile fremitus is equal over all lung fields ' ƒ Percussion: - Bilaterally equal resonant percussion all over the lungs fields ƒ Auscultation: - Normal, bilaterally vesicular breath sounds, with normal intensity, and without any added sounds. - Normal, bilaterally vocal resonance over all lungs failed. 4. abdominal examination: ƒ
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Inspection: - The abdomen was symmetrical moving with respiration, umbilicus is inverted, no visible pulsations, distended veins, or scars, hair distribution is normal, without pigmentation. - Hernial orifices were intact (in front of the examiner ask the patient to cough). Palpation: - On superficial palpation, the abdomen is soft (lax) no tenderness or superficial masses. - On deep palpation, findings were the same, and kidneys were not palpable. - Liver span was. .... cm. Percussion: - Ascites was not detected. Auscultation: - Bowel sound was normal, no bruit over the liver, renal arteries, or aorta. PR and PV: Were not performed. 128 E X A MPL E:
™ An example of a medical history ƒ Personal details: Mr. Frank, age 72, retired botanist. ƒ Presenting symptoms: 3weeks of progressive exertional dyspnoea with 2 days of dyspnoea at rest. ƒ History of present illness: - Two nights of severe orthopnoea; unable to sleep except briefly while sitting in a chair. - Mild exertional shortness of breath for nearly 10 years. - He is unable to walk 50 metres on the flat. - Na associated chest tightness or pain. - No wheeze or cough. - No fever. - No recent change in medications. - No asthma or known lung disease. No other relevant positive symptoms on systems review. ƒ Cardiac history: Previous myocardial infarction 5 years ago, treated with thrombolytic drugs. no known valvular heart disease or history of rheumatic fever. moked 25 cigarettes a day until the time of his infarct. ƒ Risk factors for heart disease: Total cholesterol 6.7 mmol/l, a family history of ischaemic heart disease, his 55 year old brother had hypertension for 30 years and inadequate control. Salt intake high, drinks 3-­‐4 litres of fluid a day. Alcohol-­‐25 g a week. There is no history of diabetes mellitus. Only occasional non-­‐steroidal anti-­‐inflammatory drugs. ƒ Other symptoms: 1 0 years of nocturne three times per night. He denies other urinary tract symptoms. ƒ Current medications: Aspirin, 100 mg daily, and metoprolol (a beta-­‐blocker) 100 mg twice a day. ƒ Past history: Gastric ulceration 3 years ago-­‐successfully treated with a 14 day course of antibiotics and a proton pump inhibitor; no recurrence of symptoms. Appendectomy and tonsillectomy in his youth. He has no drug allergies that he knows of and has never required a blood transfusion. ƒ Social history: - Lives in retirement with his wife, who is well. - Interests; gardening, history of medicinal plants, no other hobbies. No pets. - No recent overseas travel or long car trips. No use of over-­‐the-­‐counter medications. 129 ƒ Family history: His father died of a myocardial infarct at age 64 years, and his mother died of colon cancer at age 84 years. Both sons (42 and 39 years) are alive and well. No other relevant family history. ™ Physical examination: Breathless and uncomfortable at rest. Respiratory rate was 24 breaths/minute. ƒ Cardiovascular: - No cyanosis, No clubbing, No splinter haemorrhages. - Pulse rate 90 beats/minute and regular. - Blood pressure 180/1 10 mmHg, lying and standing. - Temperature 37 C - JVP not elevated. - Apex beat 2 cm displaced, dyskinetic. - Heart sounds (HS): S1 (first) and S2 (second) present and normal, S3 (third) present. - Pansystolic murmur grade 3/6 maximum at the apex consistent with mitral regurgitation. ƒ Chest Trachea in the mid-­‐line. Expansion normal right and left. Normal percussion note bilaterally. Bilateral medium basal mid-­‐inspiratory crackles and occasional expiratory wheeze over the right and left lung fiends. No areas of bronchial breathing. ƒ Abdomen Well-­‐healed appendix scar present. Abdomen soft, no tenderness. Liver not palpable, no other masses (spleen, kidneys). No ascites Normal bowel sounds. Rectal examination deferred (the patient was too unwell at the time of admission). ƒ legs on calf tenderness. No peripheral edema. Peripheral pulses present and equal. No visible varicose veins. ƒ Central nervous system (CNS): alert and orientated. No neck stiffness ƒ Cranial nerves (assessed after initial treatment) - II: acuity and fields normal; fundi normal. - III, IV and VI: pupils equal, circular and concentric-­‐react normally to light and accommodation; eye movements normal; no nystagmus. - V: sensation and motor function normal. - Vll: muscles of facial expression normal - Vlll: hearing normal. - IX, X: no uvular displacement. - Xl: normal power. - Xll: no matriculation or displacement of tongue. 130 ƒ
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Upper limbs: No wasting, fasciculations, tremor. Tone normal. Power normal (shoulders, elbows, wrists, fingers). Reflexes normal and symmetrical. Coordination normal. Sensation-­‐pain, proprioception normal. Lower limbs: Gait normal. No wasting. Tone normal; no clonus. Power normal (hips, knees, ankles). Reflexes normal and symmetrical. Coordination normal. sensation-­‐pain, proprioception normal. ƒ
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Provisional diagnosis: left ventricular failure secondary to ischaemic heart disease. Differential diagnosis: angina, pulmonary embolus, chronic obstructive pulmonary disease. ƒ Investigations: - Electrocardiogram. - Chest X-­‐ray. - Full blood count Electrolytes, creatinine, liver function tests. - Echocardiogram. ™ Comment The etiology of his cardiac failure is most likely to be ischaemic heart disease (previous infarct) or hypertensive. He has signs of mitral regurgitation, which may be secondary to cardiac failure or, less likely, the cause. there is no known history of chronic lung disease, although he has been a chronic smoker. The history and examination are not very suggestive of pulmonary embolism. 131 References:
1- 424 booklet: Your Guide to History Taking and Physical Examination.
2- Nicholas talley and Simon O`Connor, Clinical Examination, 6th
edition.
3- Pocket Clinical Examination, Nicholas Talley and Simon O`Connor,
3rd edition.
4- John Axford and Chris O`Callaghan, Medicine, 2nd edition.
5- Andrew Raftery and others , Differential Diagnosis, 3rd edition.
6- Hamad Alqahtani, Clinical Surgical Skills, 1st edition.
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