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CLINICAL EXAMINATION
1)
2)
Physical examination
a)
b)
general assessment
systemic examination
2)
3)
4)
5)
6)
major complaints
systemic enquiry
information from a third party
please, tell me about your present trouble..., what brings you here?...
when did your trouble start ?...
what was the first thing you felt wrong?...
what happened next ?...
can you show me where you get the pain ?...
what colour is it ?...
how often ?...
Cardiovascular system:
ankle swelling, palpitations, breathlessness when lying flat (orthopnoea), attacks of nocturnal
breathlessness (paroxysmal nocturnal dyspnoea) chest pain on exertion, pain in legs on exertion
2)
Respiratory system:
shortness of breath: exercise tolerance, wheezing, cough, sputum production (colour, amount), chest
pain isolated to respiration or coughing, blood in sputum (haemoptysis)
3)
headaches, visual symptoms (e.g. double vision, lost of acuity or visual fields), fits, faints, tingling
(paresthesiae), numbness, muscle weakness, hearing symptoms (e.g. deafness, tinnitus), excessive
thirst, sleep patterns.
4)
Urogenital:
pain on passing urine (dysuria), frequency of passing urine (nocturia), abnormal colour of urine (e.g.
blood), number of sexual partners,
males: if appropriate age ask for prostatic symptoms such as difficulty in starting to pass urine, poor
stream, terminal dribbling, if appropriate ask for mental attitude to sex (libido), morning erections,
frequency of intercourse, ability to maintain erections, ejaculation, urethral discharge
female: if premenopausal, age of onset periods (menarche), regularity of periods (e.g. 28- days cycle),
length of period, blood loss (e.g. clots, flooding), note of last period, contraception if relevant, presence
of vaginal discharge, stress and/ or urge incontinence, pain during intercourse (dyspareunia), postmenopausal bleeding where relevant
5) Alimentary:
condition of mouth (infected tongue or bleeding gums), difficulty with swallowing (dysphagia),
indigestion, heartburn, abdominal pain, weight loss, change in bowel habits, colour of motion (e.g. pale,
dark, tarry black, fresh blood)
6) Locomotor:
joint pain or stiffness, muscle pain or weakness
7) Endocrine:
heat intolerance, cold intolerance, change in sweating, prominence of eyes, swelling in neck
Information from the third party
relative or friend
eye witness
a search of patients clothing and personal belongings
GP
a hospital staff (students, nurses, social workers...etc.)
information about illnesses, operations, accidents (ask for previous medical records)
residence or travel abroad
previous health: medical examination for insurance, record the blood pressure, previous radiological
examination
DRUG HISTORY
1)
2)
3)
4)
Information regarding the age and health or cause of death of patients` relatives: parents, siblings
Information about more intimate matters: alcoholism, emotional disturbances
SOCIAL HISTORY
1)
2)
3)
4)
5)
PHYSICAL EXAMINATION
1)
2)
3)
General assessment
Cardiovascular examination
Respiratory examination
Abdominal examination
Neurological examination
Locomotor examination
Laboratory tests and image techniques
General assessment
Cardiovascular system
1)
2)
3)
4)
Respiratory system
1)
2)
3)
Examination of sputum
Upper respiratory tract (nose, tonsils, pharynx)
Chest: inspection, palpation, auscultation
Abdominal examination
1)
2)
3)
4)
5)
6)
7)
8)
Nervous system
1)
2)
3)
4)
5)
6)
7)
Mental state
Speech and language
Cranial nerves
Motor system
Sensory system
Reflexes
Supplementary tests
Locomotor system
1)
2)
3)
4)
Spine
Joints and limbs
Muscles
Bones
2)
Arterial insufficiency
pain in the limb, loss of function, altered cutaneous sensation, cold (the acute form, chronic arterial
insufficiency, severe chronic arterial insufficiency)
2)
Venous insufficiency
pain of the limb, warmth, swelling, tenderness (the acute form, chronic venous insufficiency)
2)
Dyspnoea
a)
b)
c)
Oedema
a)
b)
c)
d)
e)
f)
3)
Pain
a)
b)
c)
4)
the analysis of a pain: main site, radiation, character, severity, duration, frequency and
periodicity, special times of occurrence, aggravating factors, relieving factors, associated
phenomena
angina pectoris: chest pain- the principal symptom of myocardial ischemia
other chest pains of cardiovascular origin
paroxysmal tachycardia
pericarditis
pericardial effusion
dissecting aneurysm
mitral prolapse
pericardial catch
Cough:
-frequency, severity, character (harsh, dry, paroxysmal, loose and readily productive
of sputum, short and half- suppressed by pain...)
-is dependent on: the situation and nature of lesion responsible for the cough, the
presence or absence of sputum, coexisting abnormalities (e.g. vocal cord paralysis,
impairment of ventilatory function, pleural pain)
2)
3)
4)
Sputum: amount, character (serous, mucoid, mucopurulent, purulent, rusty), vicosity, taste or odour
Haemoptysis: frequency and d duration
Chest pain:
(due to respiratory disease)
upper retrosternal pain (acute tracheitis)
retrosternal pain associated with lesions of the mediastinum
5)
6)
7)
8)
pleural pain
Breathlessness (dyspnoea) associates with:
an increase in the work of breathing
increased pulmonary ventilation
weakness of the muscles of respiration
multiple factors (pneumonia, pulmonary oedema)
a)
acute onset breathlessness (bronchial asthma, massive pulmonary embolism...)
b)
exertional breathlessness
Apnoea
breath may be voluntarily held for short periods
periods of apnoea alternate with overventilation (Cheyne- Stoke breathing)
during sleep (obstructive, central)
Wheeze
obstruction of the small airways
Stridor
obstruction of the large airways
Infections (tbc...)
Allergic disorders
Chronic bronchitis
Social problems (housing, finance, employment...)
Cigarette smoking
Obesity