Blackwell Science
Blackwell Science
The patient is the most important person in the room Ensure privacy and confidentiality
Consider need for chaperone or interpreter
Tell the patient who you are and what you are going to do My name is... My name is... and I am going to...
Establish the patient's identity
Medical notes Drug chart
Temperature chart
trouble the tr 's th Wha t 's ? ? ? ? ?
Let the patient talk
Record, use and present the patient's actual words Tell me more
Go on
Great detail about each aspect of the history More detail
I ' ' m m t e el l l l i in g n y g y o ou u t h he e d i i a ag gn o n os i i s s s
Chronology of complaints
History of presenting complaints
Tell me more about...
Irrelevant information Tell me more about... Could we focus on..?
Inspect N.B.
Privacy Consent/explanation Chaperone
• • •
Penis Scrotum Inguinal area
Palpate • • • •
Testes Herniae ±Coughing Lymph nodes
Rectal examination Prostate sulcus enlarged lumps • • •
Urine
History • • •
Examination
Menstruation Bleeding Discharge
• • •
Well/unwell Anaemia Lymph nodes
Breast examination Sexual history Contraception Urinary symptoms Obstetric history • •
Abdominal examination Scars Masses Distension Striae Body hair Herniae •
•
• • •
Speculum examination
• •
Vaginal examination
Inspection Digital bimanual exmination
Inspect • • • • • •
Palpate
Size Symmetry Dimpling Skin Tethering Nipple -Retraction -Skin changes -Discharge
•
•
•
•
Pulp of index, middle and ring fingers Small circular motions gradually increasing in pressure Cover entire breast including axillary tail Examine for lymphadenopathy
History
Examination
Last menstrual period Menstrual cycle
Well/unwell Anaemia Fever Blood pressure Breast examination
Any:
Bleeding Anaemia Hypertension Diabetes Infection Vomiting
Fundus
Past obstetric history
Gravidity Parity Mode of delivery Complications
Symphysis pubis
Oedema Cardiovascular examination Respiratory examination Urinalysis Uterine swelling Measure symphysis pubis height Tenderness Fetal parts: Lie Liquor volume Presentation Enlargement Fetal heart
fundal
—
•
Past gynaecological history
• • • •
Any localizing signs
Central nervous system (CNS) • Conscious level (GCS) • Cerebellar function • Handedness • Extrapyramidal function • Higher function • Cranial nerves speech, memory, comprehension
Parietal
Frontal
Temporal Occipital
C2
Brainstem C2 C3
Upper limbs Inspect • Tone • Pyramidal drift • Power • Co-ordination • Sensation -Pinprick -Light touch -Vibration sense -Joint position sense -Hot/cold
Reflexes
Triceps C6 T1
Supinator Palm
L1
L2
Cerebellar
C3 C4
C4 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12
Biceps C5 T2
T2 C5
T1 C6
• Abdominal reflexes • Sensation
S3
Palm
L1
L2 L2 L2 S2
C8
C6
L3
C6
C8
S2
L3
L3
Knee
Lower limbs • Inspect • Tone • SLR • Power • Co-ordination • Sensation -Pinprick -Light touch -Vibration sense -Joint position sense -Hot/cold
L3
C7
C7 L4
Reflexes
L5 S1
S1
Plantars
Gait
L4 L4 L5
L5
Ankle
S1
L4
S1
S1
S1
L5
I. Smell
T H VZ T L P AE GT
XII. Tongue Wasting, fasciculation movements
Visual acuity II. Pupils + light + accommodation
XI. Sternomastoids
W R N R O Z
Visual fields
Blind spot
IX, X. Palatal movements Gag reflex
Pin Fundoscopy
VIII. Hearing Balance
Eye movements III, IV, VI
VII. Muscles of facial expression
Nystagmus Ptosis
V. Facial sensation
Facial sensation
Corneal reflex Jaw jerk
Temporomandibular joints
Inspect • • •
Shoulder
Deformity Posture Muscle wasting Wrist
Hand
Consider
•
Neck Elbow
t G a i
Spine
•
Cervical Thoracic Lumbar
• •
Passive movements Active movements Palpation Function
Sacro-iliac joints Hip Femoral sciatic Nerve stretch
Knee
Hemiplegic Foot drop Ataxia Waddling Parkinsonian Apraxic Hysterical Antalgic
Inspection
Ankle
Gait Arms Legs Spine
Feet
History
Examination
Sunlight Rash • • • • •
Precipitants Lump Bump Pigmentation Itch
Papules Macules Vesicles Diet
Ulcer Itchy
Par acetamo DTar bulegtss l
Consider photography to document evidence Allergens
Distribution
Infection
•
Medical conditions
• •
Symmetrical Sun exposure Contact
Inspect
Test
TH
Ptosis
V Z T L P AE GT W
R
N
R
O
Z
Visual acuity
Colour vision Blind spot
Redness
Pupils Symmetry Size, shape Reaction to light Reaction to accommodation (PERLA)
Diplopia
• •
Nystagmus
Pin
• •
Visual fields
•
Visual field defects
Examine with ophthalmoscope
Left eye
Pigmentation Unilateral blindness Bitemporal hemianopia Macula
Proliferative retinopathy
Homonomous hemianopia
Right eye
Optic nerve Optic chiasm Optic radiation
Vessels
Haemorrhages Exudates
Eye movements
Silver wiring AV nipping Papilloedema Pallor
• •
Homonomous hemianopia with macular sparing
Optic cortex
Ears
Mouth and throat Inspect
Inspect
Otoscope
• Lips
• Hearing
• Tongue
• Weber's
• Mouth
• Rinne's
• Gums
Gag reflex
• Teeth • Tonsils
Thyroid and neck Goitre, bruit? Thyroid and parathyroid glands
Nose
Peripheral signs
Carotid
• Thyrotoxicosis
• Inspect
• Myxoedema
• Sense of smell • Sinus tenderness
Neck Movements
•
JVP
•
Lymph nodes
•
Lumps
• Tenderness • Cervical spine
Dipstick ?Glucose
Smell
?Blood ?Protein Blood
?Leucocytes ?Other
Debris Colour
Centrifuge
Microscopy
Squames
Casts
Bacteria
Red cells
White cells
Why come to medical attention now?
Current problems
Precipitants
What symptoms
Physical Psychological Social
Past psychiatric history
Previous treatment
Past medical history
Personal history
Effects
Birth Early development Education Occupations Relationships Abuse
Social/family history
Substance abuse
Thoughts and perceptions •Preoccupations •Obsessions, delusions •Hallucinations
Mental status examination
Mood
Appearance and behaviour
Alcohol Smoking Drugs
Speech/ language
Insight
Cognitive status Consciousness •Concentration •Memory •Orientation •Intelligence •Executive function
Inspect
Inspect Joints
Deformity •Wasting •Fasciculation •Scars
•Straight leg raise •Sacroiliac •Hip •Knee •Ankle •Foot
Skin • All over •Nails
Neurology
+ +
•Gait •Tone •Power • Knee jerk Ankle jerk Clonus Plantars •Sensation Pinprick Light touch Vibration Hot/cold Deep pain
+ +
+ ++ +
Mouth and tongue Cyanosis Dry mucous membranes Pigmentation
Blood pressure Supine Standing
•
•
•
•
•
Radial pulse Rate Rhythm Volume Character
Neck Carotid pulse JVP Goitre Lymph nodes
•
•
•
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•
•
•
Hands Clubbing Splinters Palmar erythema •
Chest Scars Chest movements Respiratory rate Tracheal position Chest expansion Apex beat Heaves/thrills Auscultate heart Percuss/auscultate front of chest Examine breasts/axillae Sit forwards: Sacral oedema Spine Percuss/auscultate back of chest
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•
•
• •
Vital observations Pulse BP Temperature Respiratory rate
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•
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•
• •
Look! Is the patient unwell? Is there anaemia, cyanosis, jaundice? Is the patient well hydrated, nourished? Any obvious signs of endocrine disease?
• •
Abdomen Inspect Palpate Percuss Auscultate Examine for: Liver, spleen, kidneys, aorta, herniae, lymph nodes • • •
Neurology Conscious level Speech Memory Orientation Gait •
Legs Oedema Rashes Peripheral pulses •
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Limbs Eyes Cranial nerves
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History This is...
On examination Appeared well or unwell ? Name Age Sex Occupation
Vital observations
Presenting complaint(s) in patient's words
Positive findings on examination and relevant negatives
Last well (date) Associated symptoms
Summary Short summary of name, age, sex, occupation
Past medical history
Drugs
Allergies
Smoking
Alcohol
Presenting complaints Relevant past medical history and examination findings
Relevant family and social history Differential diagnosis Relevant positives and negatives on functional enquiry
History Symptoms suggesting serious cause Very sudden onset • Severe Severe pain •Collapse/syncope • Pain on exercise exercise • Fearing Fearing death
Examination Signs suggesting serious cause •Breathlessness •Vomiting •Sweating •Cyanosis •Pulmonary oedema •Pleural/pericardial rub •Hypotension • Absent Absent pulses •Anaemia •Tachycardia • Raised Raised JVP
Diagnostic approach Chest pain
Could it be due to myocardial ischaemia? e.g. Myocardia Myocardiall infarction Angina
Could it be due to other life-threatening cause of chest pain? e.g. Aortic dissection Pulmonary embolism Pancreatitis
Might other causes be responsible? e.g. Oesophageal spasm Gastro-oesphageal reflux Gall bladder disease Musculoskeletal pain
N.B. Serious diseases such as MI and PE can present without chest pain. An abnormal ECG showing ST-elevation is a dominant finding Also need: • ECG ECG • CXR CXR • Cardiac enzymes
Is the patient unwell? Are they shocked? In severe pain? In need of immediate resuscitation?
History
Examination
Where is the pain? What type? Radiation Precipitation Alleviation
Well/unwell Systemic signs fever shock • •
Acute abdomen tenderness rebound guarding absent bowel sounds
Other symptoms
• •
Medication
• •
Remember Extra-abdominal sources of pain, e.g. myocardia myocardiall infarction, metabolic disturbance
Rectal examination Hernia Aorta Gall bladder
Important clinical questions to address Is the patient unwell? Is there hypovolaemia or shock? Is there an acute abdomen? Which organ(s) are producing the pain? •
Liver Duodenum
Spleen Stomach
•
•
Pancreas
•
Colon Small bowel
Appendix
History
Examination Particularly look for: Fever Any neurological signs Papilloedema Meningism Features of: raised intracranial pressure ↑BP, ↓P
Sudden onset
•
'Thunderclap' ± Neck stiffness
• • • •
Consider: Subarachnoid haemorrhage
Recurrent ± Visual aura ± Intolerance to noise, light, smells ± Nausea, vomiting
Consider: Migraine
Increased with coughing/ straining—wakes patient in the morning
Consider: Raised intracranial pressure
Neurological signs/symptoms
Consider: Intracranial mass
Fever, neck stiffness, photophobia
Consider: Meningitis
History
Examination
What? + blood + 'coffee grounds'
Is the patient unwell? Is there significant fluid depletion? Pallor Tachycardia Hypotension Postural hypotension Dry mucous membranes •
How long?
• •
How often?
• •
Other symptoms? Pain Diarrhoea Weight loss
Is there obstruction? Abdominal distension Succussion splash High pitched bowel sounds Abdominal mass/tenderness
• •
•
•
• • •
Any evidence of serious underlying cause? Myocardial infarction Diabetic ketoacidosis Renal failure • • •
History
Examination
Stool Volume Frequency Consistency + blood + mucus/pus
Is the patient unwell?
• • •
Is there significant fluid depletion?
Virchow's node ?
Any signs? Inflammatory bowel disease Thyrotoxicosis Malabsorption • •
Other symptoms? Vomiting Abdominal pain Fever
•
•
Rectal examination
• •
Change in bowel habit • •
What? Increased/decreased frequency of motions Change in colour /consistency
Jaundice Weight loss
•
•
Abdominal mass
History
Examination
Anaemia
Signs of hypovolaemia Pulse Blood pressure Postural fall in BP?
• • •
•
Pale Tired Breathless
• •
Anaemia Pallor Tachycardia Koilonychia
Vomit • • • •
•
Blood 'Coffee grounds' Initial vomit How much?
• •
Signs of chronic liver disease and portal hypertension
Abdominal pain •
Ulcer Cause of blood loss Abdominal mass Malignancy
Melaena •
• •
Fresh blood
N.B. Rectal examination for mass, blood, melaena, faecal occult blood
Indigestion
Dysphagia
History
Examination
History
Examination
Pain Where? •Character • Radiation • Precipitant • Alleviated
• In pain • Anaemia • Jaundice/ lymphadenopathy • Weight loss • Masses • Tenderness • Stool-(faecal occult blood)
• Liquids vs. solids • Painful • Where?
• Weight loss, anaemia
Systemic symptoms • Jaundice • Weight loss • Anorexia • Anaemia
• Weight loss • Weakness • Vomiting
• Mouth tongue • ENT examination • Aspiration? • Abdominal mass • Hepatomegaly • Weakness • Watch patient swallow
• Vomiting • Nausea • Change in bowel habit • Melaena
Document weight loss t h g i e W
Date
•
Normal or altered body image?
•
Depression?
•
Diet?
•
Signs of thyrotoxicosis?
•
Malignancy?
•
Chronic infection?
•
Malabsorption?
Fatigue
What does the patient mean?
What other symptoms are there?
Why seeking medical attention now?
What can't they do?
Anaemia, malignancy, depression, infection, heart failure
Any symptoms of:
Any signs of:
Does the patient look unwell?
Any physical abnormalities? e.g. pallor, fever, murmurs, etc.
History
Examination A irway B reathing C irculation
From: • Relatives • Friends • Witnesses • Ambulancemen • Police • Medical notes • GP
Bruises
Neck stiffness
Blood pressure
Temperature Skin, rash, bruises, colour Breath: • Ketones, alcohol Respiratory pattern General examination
ABC Glucose Oxygenation • Cyanosis • Pulse oximetry • Arterial blood gases
Scars
Episodes • Current • Past • Previous
Cranial nerves Needle marks
Drugs Alcohol Social history
Medicalert
Pupils Size • Symmetry • Reaction to light
I • Papilloedema • Haemorrhages
III, IV, VI • Eye position • Deviation • Doll's eye movements
Pulse Glucose
VIII • Caloric reflex
V, VII IX, X • Corneal reflex • Gag reflex • Response to pain • Cough reflex
Limbs Inspect Tone Power Reflexes Sensation
Posture, myoclonus, wasting Symmetry Response to pain Spontaneous Tendon, plantars, clonus, grasp Response to pain
Glasgow Coma Score (?/15) Motor Obey Localize Withdraw Flexion Extension None
6 5 4 3 2 1
Verbal Orientated Confused Inappropriate Incomprehensible None
5 4 3 2 1
Eyes Spontaneous 4 3 opening To speech To pain 2 None 1
Protect from further damage Monitor ABC and level of coma
Airway
History Monitoring ECG Pulse Blood pressure CVP Temperature
From Patients Relatives Medical notes Other professionals
•
•
• • •
•
•
•
•
•
•
•
Breathing • • •
Full examination
Endotracheal tube Tracheostomy Oral airway
Ventilator mode CPAP Oxygen by mask
Circulation •
Ventilator
• •
Infusions
•
Perfusion Pulse Blood pressure JVP
Conscious level • •
GCS Sedation
Drains Chest Wound Urinary catheter • • •
Therapies Infusions Haemofiltration • •
Lines Arterial Venous Central venous • • •
Wounds
History
Examination
Pain When? Where? Increased by movements?
Fever? Inspect back Skin changes Deformity Tenderness
Other symptoms Disturbance of bowel or bladder function Sciatica
Examine spine
• •
•
•
• •
•
Examine for neurological signs
•
General examination Systemic symptoms Fever Weight loss •
•
•
Lumbar spine
Consider malignant disease, tuberculosis, infection
Cervical spine
Thoracic spine
Sacroiliac joints
Range of movements
Twisting Chest expansion
Tenderness
Straight leg raise
Lateral flexion
Extension
Femoral stretch
Touch toes
Is BP truly elevated ? Is there evidence of malignant/accelerated hypertension ? Is there evidence for a secondary cause ?
Causes
•
•
•
•
•
Factors affecting BP accuracy Pain Incorrect size of cuff Anxiety 'White coat hypertension' •
•
•
'Essential' Renovascular disease e.g. renal artery stenosis Renal disease e.g. glomerulonephritis Reflux nephropathy
Rarely Cushing's disease Conn's disease Phaeochromocytoma Coarctation of the aorta
•
•
•
• • •
Systolic
Effects
140
•
Pulse pressure Diastolic
• •
90
•
Heart failure (LVH) Renal failure Hypertensive retinopathy Stroke
Examine for: Radial femoral delay Cushingoid Abdominal bruits Renal size LVH/heart failure Urine protein/haematuria/casts Neurological deficits –
Fundoscopy Grades I. Silver wiring, tortuous vessels II. A-V nipping III. Flame haemorrhages and cotton wool spots IV. Papilloedema
History • • •
Examination Is JVP elevated?
Swelling? Redness? Pain?
Signs of cardiac failure? Tachycardia Gallop rhythm Crackles Pleural effusion Enlarged liver Ascites •
Symptoms of: Heart disease Liver disease Kidney disease Malabsorption
•
•
•
•
•
•
•
•
•
Any lymphadenopathy? Proteinuria? Area of swelling? Skin changes Ulceration Erythema • • •
Pitting
History Jaundice Dark urine Pale stools
Examination Liver
Haemolysis
Gall bladder
Pain
Weight loss Fever
Jaundiced? Signs of chronic liver disease? Signs of portal hypertension? Tender Liver Gallbladder Murphy's sign Masses
Courvoisier's Law
Alcohol Drugs Family history
Spleen
'In the presence of jaundice a palpable gallbladder is not due to chronic cholecystitis'
Par acetamol Dr gs Tabulets
Steatorrhoea Dark urine
History
Observations
What operation? When? Antibiotic treatment DVT prophylaxis Other symptoms Breathlessness Cough Calf pain Vomiting Abdominal pain
Respiratory rate Temperature Pulse Blood pressure
• • • •
Temperature Pulse Respiratory rate Blood pressure
• • •
Lungs
•
•
•
• •
Crackles Poor air entry Bronchial breathing
Legs •
DVT
(NB. May be asymptomatic and with no abnormal examination findings)
Wound Drains • •
Pus Blood
• •
Inflamed Pus
Look at drips, drains, catheters, etc. and consider as possible sources of infection
History • • • •
Examination
Headache Photophobia Drowsy Neck stiffness
• • •
•
Kernig's sign positive
•
! O w
Fever Papilloedema Evidence of sinusites or otitis media Stiff neck Meningococcal purpuric rash
Glasgow Coma Scale
? Immunosuppression ? Complement deficiencies ? CSF foreign bodies/ shunts/leaks
Drowsy Confused Unconscious
Differential diagnoses Bacterial Viral Meningitis Tuberculosis Cerebral abscess (? focal signs) Encephalitis (usually no meningism) Other bacterial infections, e.g. pneumonia Malignant meningitis
History
Examination
Fatigue • Breathlessness • Angina • Malaise
Pallor, jaundice
Diet Malabsorption Blood loss - Gut - Gynaecological Chronic illness - Malignancy - Renal failure - Other
Hepatosplenomegaly
Lymphadenopathy
Bruising Family history of anaemia Petechiae Microcytosis
Normocytosis
Macrocytosis
Peripheral neuropathy Iron deficiency Thalassaemia
Chronic disease Renal failure Acute blood loss Malignancy
B12 deficiency Folate deficiency Liver disease Myxoedema
