AIMST UNIVERSITY

KEDAH
MALAYSIA
FACULTY OF MEDICINE
UNIT OF MEDICINE

LOG-BOOK
NAME

_______________________________________

MAT NUMBER

_______________________________________

BATCH

______________ GROUP _________________

POSTING FROM

______________ TO _____________________

YEAR

III/ IV /V

NOTE

STUDENTS MUST HAVE THE LOG BOOK WITH THEM DURING WARD ROUNDS /
CLINICAL SESSIONS.

STUDENTS MUST OBTAIN SIGNATURES FROM THEIR SUPERVISING

CONSULTANT / DOCTOR ON A DAILY BASIS

Index
Sl
No
1

Page no.

2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

DECLARATION

IMat No:,
hereby declare that this logbook is a record of all clinical cases that I
have clerked in and the clinical activities that I have been a part of , at
Hospital
during my year III / IV / V clinical posting in the unit of
....Medicine..............................
from . to..

Signature
Name:
Mat No:

CERTIFICATE

Certified that this log book is a bonafide record of all clinical activities by
Mr. /Ms., Mat No.........................................
during his/her year III / IV / V clinical posting in the unit
of ..........................................
at Hospital

Head of Unit

Head of Department

Unit of Medicine

Department of Medicine

AIMST UNIVERSITY

Hospital

Date:

Sl no

Date:

Date

Name of
consultant

Activity
3

Signature

Preface
4

This Log book will be a record of the clinical training and experience
that you shall obtain during your junior clerkship. It contains notes on
scheme for history taking and physical examination that is aimed at
sharpening your skills in performing clinical work. The junior clerkship
is an important first phase of your active clinical posting and builds on
the walk-through that you had it in the seven weeks exposure you
had it in the hospital environment during your second year. You are
urged advised to read up various recommended textbooks on clinical
methods during the course.
During the twelve week of posting this year, you are expected to
present at least six long cases jointly with one of your colleagues. All
the six cases should be recorded in this log book and be subjected to
evaluation by clinical teacher. A total number of fifteen cases during
junior clerkship and Ten cases during Senior Clerkship should be
recorded by each of you. In addition to the clinical cases record must
be made of all the P B L sessions that are conducted during the
posting.
The cases that you will be exposed to shall cover a range of general
medical problems that will provide ample opportunity to develop your
communication skill and to learn and appreciate Clinical history taking
and Physical examination.
Accurate record of the history and
examination of each case that you are involved in should be made in
this log book in as much as they will form a part of your continuous
assessment.

Introduction to Clinical Examination

The sole purpose of medical practice is to relieve suffering due to disease, which makes
diagnosis mandatory. In order to achieve this, one needs to develop a friendly and
sensitive approach to patients so as to understand them with regard to their social and
family history. It is important not only to elucidate the problems posed by disease but also
apply their clinical skills to advice patients and families how to manage these problems
which is achieved by constant practice of the skills by combination of study and
experience. Appropriate skills are needed to elicit the symptoms from the patient's
description and conversation and the signs by observation and by physical examination.
It is also important to respect patients rights For example, if a patient indicates that he or
she does not wish to discuss certain topics, or to be examined fully, this wish must be
respected. Remember always that the communication is a two way process. To arrive at a
proper diagnosis it is necessary to establish the clinical features by clinical history and
examination. This forms the clinical database, and interpretation of the database leads to
diagnosis.
It will be comfortable for the patient if the clinician himself brings into the clinic with offer of
greeting. The response of the patient to questioning will in cases reveal the clinical
condition. Another aspect is the surroundings in the office, which should be pleasant and
patient friendly. It is important that the doctor pays full attention while the patient presents
himself. It is also good to exchange pleasantries with accompanying persons. This will
provide some more information about the social background, education level, etc., of the
patient himself. After the initial informal preliminaries, the doctor can proceed to
presenting clinical problem. It is better to maintain a slight sense of formality and neutrality
in the relationship but make it clear that you want to hear what the patient has to say and
you will inspire confidence by this. It is a good to get at least some information on
personal, marital status, employment, basic family & social and medical history including
allergies etc., these details will help the doctor to discuss symptoms and problems.
Getting Started:
As conversational skills are central to proper history it is important to remain flexible and
to be prepared to change your approach if it seems that a new start is needed. Encourage
patients either to start from the beginning, or to describe the particular problem that
worries them the most. Expecting patients to be open, you must make it clear that you will
also be open with them. If you feel there is a cloud developing in your relationship with a
particular patient, try gently to find out why and clear it.
OBSERVE YOUR PATIENT
The communication process is to enable you to make assessment of patient's general
demeanour.
Personality and Presentation.
Sign of disability, physical or mental?
What clues does the gesture convey?
The general approach and psychological feelings.
Is he or she expressing all the facts or withholding certain things.
the gait.
the voice (whether normal or hoarse).
6

 Make it clear to your patients that you expect them to speak freely and give
their own account of the problem. Avoid suggesting symptoms until the patient
has finished this description, when you may wish to obtain more detail or to
enquire specifically about certain symptoms not so far mentioned. If there are
points that are not fully described, or which you think are important, do not be
afraid to ask directly for more information. However, recognize that this will
interrupt the patient's flow of recall, and that you will then need to restart the
spontaneous description that you interrupted.
While making notes, try to keep eye contact with the patient. Listen to the
patients complaints; make up your mind of what is being said and record
enough to help you remember the important points. Later, you can write up a
fuller account of the history and pertinent points based on the weight placed
on various items and, most importantly, what the patient actually said. What
patients say, word for word, is often as important as any later reconstruction of
the history.
Direct but relevant questions form an essential component of history-taking. It
is rather ideal to bring up those direct questions once the patient has
completed expressing the complaints. If you are not sure of something or
noticed any abnormality, ask for more details directly. These can again be
brought in more detail while examining the patient. After a clear understanding
of the case and presentation, it is always good to start examining symptom
wise starting from the primary complaint.
Try and relate the history from the preliminary information you have obtained
as regards to the patient's occupation, past medical history and family history
to the symptoms.
Use common and colloquial words that patient can understand. Use words like
passing urine, motion etc., rather than using medical terminology.
Another important but difficult to establish, is the functional disorders which
needs careful and detailed interrogation.
Exaggeration of symptoms may pose problem while interrogating the patient
though the symptom may be true. This has to be sympathetically approached
but firm in approach so as to analyse the depth of the symptom.
It is important to establish good and reasonable relationship with the patients,
which might not be easy in some Difficult and angered patients, which might
be because of distress or disbelief. Adopt a soothing attitude and keep
reassuring the patient.
Some time during integration the patient may introduce unrelated information
without context but could be a clue to the underlying disease state.
Information obtained from a concerned and observant relative is often helpful.
ANALYSIS
The main objective of the history is to analyse the disturbance of function and structure
responsible for the patient's symptoms. Symptoms always have a physiological or
anatomical basis. Certain physiological symptoms have to be properly analysed or will
lead to erroneous diagnosis. The most common examples are thirst, passing of large
quantities of urine etc; which should be correlated with other symptoms. Even if there are
any negative data it should also be analysed.

PAIN is one of the commonest complaints which bring the patient to the doctor.
Systematic analysis of this symptom is important and a standard approach is essential for
the evaluation of the same.
Simple questions like Where is the pain? What is the nature of pain? How is the pain
relieved?, will be helpful assessing pain. The other leading questions with regard to
radiation of pain, severity, timing and duration and character, occurrence or aggravation
and relief will be useful in proper understanding of the symptom.
PAST HISTORY
It is important to go through the past history in light of the current illness. But make sure
that the patient's description of the diagnosis of an earlier illness is consistent and likely to
be correct check on the treatment he or she had and possibly try checking the information
from the earlier physician or hospital. Check on the medication including the non
prescribed and non proprietary drugs and also about alternative or herbal remedies-some
of the latter can be powerful and may produce serious unwanted effects such as renal
failure. You should also considering asking about sexual habits and drug abuse if deemed
necessary. It is equally important to know whether is patient had any allergies for drugs or
otherwise.
SPECIAL QUESTIONS FOR WOMEN
Certain information regarding the menstrual and obstetric and gynaecological history is
important and essential. Others should include intake of oral contraceptives or other
hormones etc.,
OCCUPATIONAL HISTORY
Another important aspect of history taking is regarding the patients occupation and
exposure to toxic and industrial pollutants.
GENETIC HISTORY
The genetic history has become necessary because of role of genetic factors in many
diseases. They could be inherited with dominant or recessive or sex linked. Mitochondrial
inheritance in certain brain and muscle disease is also well understood. Inherited
disorders are generally more common in populations in which first cousin marriages are
common, as happens in isolated communities, and among certain religious groups,
especially in some Muslim communities. Diabetes and Coronary Artery Disease especially
lipoproteineamias show inherited factors in their causation.
THE PHYSICAL EXAMINATION
After going through the exercise of history taking, record all the salient and important
features. After having completed the history taking, the doctor should proceed to the
physical examination: the routine combined with specific, relevant to that patient. The
examination should be thorough but without much discomfort to the patient. The depth of
examination should be decided based on the severity of the condition. Start the
examination in a manner that is relevant to the patient's symptoms but develop a
systematic approach to each functional system in order to gain information that is both
complete and relevant.

GENERAL APPROACH
The examination room should be well lit, warm and exclusive ambience. Make the patient
comfortable.
First inspect the physique and expression, to rule out any obvious physical disability /
skeletal disorders / obesity/ wasting / malnutrition etc., Information regarding the patient's
health can be gained looking at the face. Nephrotic Syndromes, Congestive Cardiac
Failure, Anaemia are some examples.
The next is to look at the skin for examination of pallor, colour, pigmentation, cyanosis
(Central and Peripheral) and cutaneous eruptions etc.,
The skin is dry and inelastic in dehydration - the skin can easily pinched up.
Pallor is a sign of anaemia and best observed in conjunctiva. Cyanosis is best observed
in finger nails.
The next is to observe for the presence of oedema. Oedema of face is characteristic of
early phase of acute nephritis, which is most marked when the patient rises in the
morning.
Dependent oedema, which is typically around the ankle and dorsum of foot, is present in
Congestive Cardiac Failure, and in conditions associated with a low plasma protein level
such as malnourishment etc., The other types of oedema are lymphedema, venous
obstruction etc., The lymphedema does not pit on pressure.
Pitting is demonstrated by applying sustained finger pressure on the swelling (odema)
and on release it will leave a depression.
There can be localised oedema in angioneurotic oedema and urticaria.
THE HANDS AND FEET:
The Hands and Feet of the patient should be examined next. The strength of grip, state of
the joints, the character of the nails, the presence or absence of finger clubbing
(obliteration of angle between nail bed and skin), koilonychias (soft, thin and brittle and
spoon shaped).the presence of nail bed infarcts, staining, tremors, erythemas, petichia
are to be observed.
THE NECK should be inspected and palpated next. Swellings in the neck are usually best
felt from behind. Cervical nodes and thyroid gland, submandibular salivary gland or any
masses are to be noted down.
Observe the trachea from front for any deviation.
Pulsations in the vessels must be noted. Any arterial pulsation is both seen and felt as a
distinct thrust, whereas venous pulsation can be seen but not felt as a thrust.
THE BREASTS
The examination of breast is a necessary feature of general examination of every woman
especially nulliparous women, spinsters and women with a family history of breast cancer.
Examine the symmetry, nipple, areola and the skin for ulceration, discharge, retraction of
nipple, and peau de orange (orange peel appearance). Palpate each breast with palm
in all the quadrants of breast for any mass lesion and its relation to deeper structures.
Male breast is examined for any mass, and it is likely to be fat or a palpable disc of breast
tissue beneath the areola in younger individuals or gynacomastia.

AXILLAE
Axilla is examined for any enlarged lymphnodes.
The arm is then lowered in the flexed position to rest across the examiner's arm
and palpation is continued from downwards along the chest wall using fingers.
TEMPERATURE
Before taking the temperature, the thermometer should be washed in antiseptic solution
or in cold water, and well shaken so that the mercury is brought down and after taking
temperature it should be washed well. The thermometer must be accurate and use a
thermometer (either be in the centigrade (Celsius) scale or Fahrenheit scale) which ever is
familiar. The thermometer is kept well below the tongue and held firmly with the lip in
adults and grown up children and in infants the axilla is the choice. It should be kept for a
full minute. For collapsed, comatosed and elderly patients, rectal temperature can be
recorded.
FEVER
A rise in temperature beyond the normal (37C or 98.6F) is called fever or pyrexia. The
fever could be continuous when fever does not fluctuate more than about 1'C (1.5'F)
during 24 hours, but at no time touches the normal. Fever is Remittent when the daily
fluctuations exceed 2'C, and intermittent when fever is present only for several hours
during the day. When a paroxysm of intermittent fever occurs daily, the fever is described
as quotidian; when on alternate days, it is tertian; when two days intervene between
consecutive attacks, it is quartan. These classical types are of fevers are not encountered
frequently.
PULSE
Count the pulse for a full half minute when the patient is at rest and composed. The rate in
health during the stress of a medical examination varies from about 60 to 80 beats /
minute. The common causes of a rapid pulse are recent exercise, excitement or anxiety,
shock, fever and thyrotoxicosis. A slow pulse is characteristic of severe hypothyroidism
and of complete heart block.
RESPIRATION
Count the patient's respirations for a full minute, starting when the patient's attention is
elsewhere. It is convenient to do this when the patient thinks you are still counting the
pulse. The normal rate in an adult is about 14-18 / minute. Observe the breathing and
record if it is noisy. The noisy breathing could be because of obstruction in the nasal
passages, larynx, trachea, bronchi. Also observe the pattern of breathing.
ODOURS
The odours can also give some leading information. The smell of alcohol and paraldehyde
are easily recognizable on the breath. The odour of diabetic ketosis has been described
as 'sweet and sickly'; that of uraemia as 'ammoniacal or fishy'; and that of hepatic failure
as 'mousy', but too much reliance on such delicate distinctions is unwise. Halitosis (bad
breath) is common in patients whose dental hygiene has been poor, and is associated
especially with chronic gingivitis (periodontal or gum disease).
ROUTINE PHYSICAL EXAMINATION

10

The object of a routine examination is to check the different body systems to exclude
abnormality. In considering symptoms related to the patient's presenting complaint a more
focused and detailed examination is necessary.
EYES
The examination of the eye forms an important aspect of examination and consists
of the following:
Simple tests of visual acuity: compare one eye against the other.
Look for Exophthalmos or enophthalmos, Ptosis and oedema of the lids.
Conjunctivae: Anaemia (pallor), Jaundice (yellowish discolouration) or Inflammation
Pupils: Size, Equality, Regularity, Reaction to light, Accommodation
Eye movement: Nystagmus, Strabismus.
Ophthalmoscopic examination of the fundi and ocular chambers.
FACE
Facies, jaw movements, Facial symmetry or asymmetry, Rash, Features of endocrine
disease or hyperlipidaemia.
MOUTH AND PHARYNX
(torch and tongue depressor should be used)
Breath odours Lips: colour and eruptions Tongue: protrusion and appearance Teeth and
gums (if patient has dentures, notice whether they fit properly and reasons for wearing)
Buccal mucous membrane: colour and pigmentation.
PHARYNX
Movement of Soft Palate. State of Tonsils.
NECK
Movement, pain and range, Veins, Lymphatic glands, Thyroid, Carotid pulses and bruits.
UPPER LIMBS
General examination of arms and hands.
Fingernails: Clubbing or Koilonychias.
Pulse: Rate, Rhythm, Volume and Character.
Blood pressure
State of the arterial wall of radials and brachials
Axillae: Lymph glands.
Muscles: Muscle wasting, Fasciculation, Tests for power, tone, reflexes and coordination
Cutaneous sensation: check all modalities to exclude root or nerve lesions
Joints: movement, pain and swelling; rheumatiod nodules and xanthelasma at elbows.
THORAX
Examine Anterlorly and laterally for:
Type of chest, asymmetry if any,
Breasts and nipples,
Respiration: rate, depth and character,
Pulsations, Dilated vessels, Position of trachea.
Look for and palpate apex beat
Palpate over precardium for thrills.
Palpate respiratory movements
11

Estimate tactile vocal fremitus

Percuss the lungs.
Auscultate the heart sounds
Auscultate the breath sounds
Estimate vocal resonance.
Cervical and Axillary glands.
Examine Posteriorly (patient sitting) for:
Respiratory movement
Estimate tactile vocal fremitus
Percuss the lung resonance
Auscultate the breath sounds
Estimate vocal resonance
Movements and deformities of the spine
Palpate from behind: cervical glands and thyroid.
Look for sacral oedema.
ABDOMEN
Inspection: size, distension, symmetry.
Abdominal wall: movement, scars, dilated vessels
Visible peristalsis or pulsation
Pubic hair
Hernial orifices
Palpation: Tenderness, Rigidity, Hyperaesthesia,
splashing, masses, liver, gallbladder, spleen,
kidneys, bladder
Percussion: masses, liver, spleen, bladder
Auscultation: bowel sounds, murmurs
Impulse on coughing at hernial orifices
Inguinal glands
Male genitalia: penis, scrotum, spermatic cord;
female genitalia: examine if relevant
Abdominal reflexes
Rectal examination when ever indicated
Gynaecological examination when ever indicated.
LOWER TIMBS
General examination of legs and feet, Stance, balance and gait, Oedema of feet and
ankles, Varicose veins,
Muscles: muscle wasting, fasciculation, tests for power, tone, reflexes (including plantar
response) and coordination
Joints: movement, pain and swelling, Peripheral pulses, Temperature of feet
Formulating a Diagnosis:
On complition of the history and examination, the clinician has usually come to a working
diagnosis. This is supported by further investigations and subsequent progress of the
disease. Sometimes it is difficult to diagnose a patients problem which may be linked to
inexperience or the disease is in a stage of resolution or may be in early stages of
presentation. It is worthwhile working on the diagnosis by first indentifying the system
involved.
12

Case No
Name of the Patient:
Age:
Sex:
Occupation:
Race:
Religion
Nationality
Place:
a. Presenting Complaints with Duration
(in Chronological order)

b. History of Present illness

c. Past history (from Childhood)

13

d. Previous treatment / drug intake / Drug abuse/ drug allergy if any

e. Family History

f.

Occupational history

g. Menstrual history
Age of Menarche

Menstrual history

Obstetric history

Age of menopause

Para ..

h. Daily habits/routine

14

Gravida

i.

Systemic enquiry

j.

Physical Examination (General)

15

k. Systemic examination ( Should include examination of all the relevant systems)

16

l.

Summary of the Case

17

m. Provisional Diagnosis:

n. Laboratory Investigations (Clinical lab and Imaging)

o. Definitive Diagnosis

p. Suggested Treatment

q. Follow-up.

Date:

Case No 2:
Name of the Patient:
Age:
Sex:
Occupation:
Race:
18

Religion
Nationality
Place:
a. Presenting Complaints with Duration
(in Chronological order)

b. History of Present illness

c. Past history (from Childhood)

d. Previous treatment / drug intake / Drug abuse/ drug allergy if any

e. Family History

19

f.

Occupational history

g. Menstrual history
Age of Menarche

Menstrual history

Obstetric history

Age of menopause

Para ..

Gravida

h. Daily habits/routine

i.

Systemic enquiry

j.

Physical Examination (General)

k. Systemic examination ( Should include examination of all the relevant systems)

20

l.

Summary of the Case

m. Provisional Diagnosis:

n. Laboratory Investigations (Clinical lab and Imaging)

o. Definitive Diagnosis

p. Suggested Treatment

q. Follow-up.

21

Date:

Case No 3:
Name of the Patient:
Age:
Sex:
Occupation:
Race:
Religion
Nationality
Place:
a. Presenting Complaints with Duration
(in Chronological order)
22

b. History of Present illness

c. Past history (from Childhood)

d. Previous treatment / drug intake / Drug abuse/ drug allergy if any

e. Family History

f.

Occupational history

23

g. Menstrual history
Age of Menarche

Menstrual history

Obstetric history

Age of menopause

Para ..

Gravida

h. Daily habits/routine

i.

Systemic enquiry

j.

Physical Examination (General)

k. Systemic examination ( Should include examination of all the relevant systems)

l.

Summary of the Case

24

m. Provisional Diagnosis:

n. Laboratory Investigations (Clinical lab and Imaging)

o. Definitive Diagnosis

p. Suggested Treatment

q. Follow-up.

25

Date:

Case No 4:
Name of the Patient:
Age:
Sex:
Occupation:
Race:
Religion
Nationality
Place:
a. Presenting Complaints with Duration
(in Chronological order)

26

b. History of Present illness

c. Past history (from Childhood)

d. Previous treatment / drug intake / Drug abuse/ drug allergy if any

e. Family History

f.

Occupational history

g. Menstrual history
Age of Menarche

Menstrual history
27

Obstetric history

Age of menopause

Para ..

Gravida

h. Daily habits/routine

i.

Systemic enquiry

j.

Physical Examination (General)

k. Systemic examination ( Should include examination of all the relevant systems)

l.

Summary of the Case

28

m. Provisional Diagnosis:

n. Laboratory Investigations (Clinical lab and Imaging)

o. Definitive Diagnosis

p. Suggested Treatment

q. Follow-up.

29

Date:

Case No 5:
Name of the Patient:
Age:
Sex:
Occupation:
Race:
Religion
Nationality
Place:
a. Presenting Complaints with Duration
(in Chronological order)

b. History of Present illness

30

c. Past history (from Childhood)

d. Previous treatment / drug intake / Drug abuse/ drug allergy if any

e. Family History

f.

Occupational history

g. Menstrual history
Age of Menarche

Menstrual history

Obstetric history

Age of menopause

Para ..

h. Daily habits/routine
31

Gravida

i.

Systemic enquiry

j.

Physical Examination (General)

k. Systemic examination ( Should include examination of all the relevant systems)

l.

Summary of the Case

m. Provisional Diagnosis:

n. Laboratory Investigations (Clinical lab and Imaging)

32

o. Definitive Diagnosis

p. Suggested Treatment

q. Follow-up.

Date:

33

34