LEARN MEDICINE

Medicine is to be learned only by Experience; It is not an inheritence ; It cannot be revealed Learn to Hear learn to Feel learn to Smell and know that all by practice alone you can become perfect and expert. Medicine is learned by bed side and not in the class room. See and then reason and compare and control. But see first. -Sir William Osler (1849-1919) 1

CASE SHEET WRITING

In case presentation the Medical student requires the following FIVE PRINCIPLES: 1. Avoid Anxiety & Tension 2. Have sound Expression 3. Be Confident 4. Keen observation 5. Use of common sense

INTRODUCTION
For diagnosis of any case we require the following TEN STEPS of examination I. Preliminary Data II. Complaints with duration III. History
I. II. III. IV. H/O Present illness H/O Past illness & Treatment history H/O Personal history & Menstrual history H/O Family history
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Contd
IV. General Examination & Vital Data V. Systemic Examination A. C.V.S B. RESP SYST C. G.I.T D. C.N.S E. OTHER SYST
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Contd
VI. Provisional Diagnosis & Diff Diagnosis VII. Investigations VIII. Final Diagnosis IX. Management X. Prognosis

I. Preliminary Data

Name: *Age: *Sex: Occupation: Address: D/O Admission: D/O Examination: Note: Every point has got its own importance.
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II. Complaints with duration (SYMPTOMS)

A.

Presenting complaints: Important complaints according to system Duration in chronological order III. HISTORY H/O Present illness: Duration, Mode of onset Details of each symptom Other symptoms in relation to systems
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III. History
B. H/O Past illness: H/O Similar complaints H/O Any other diseases previously H/O Any Operations, Treatment history H/O HTN, D.M, T.B, any other dis.

Contd
C. Personal history:

Appetite, Digestion Bowels & Micturition Habit of Smoking, Alcohol etc Sleep disturbences Menstrual history in Females

Contd
D. Family History: H/O similar complaints in the family H/O any other disease in the family H/O Parents and their health H/o Relatives & their health H/o sons & daughters & their health

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III. GENERAL EXAMINATION

Examine Patient in detail from Head to Toe Front and Back (Observation is important) Consiousness, Behaviour, Co-operation Built & Nutrition, Posture Head in details- Hair on head Face- Fore head , Eye brows Eyes- Look for anemia, jaundice, cyanosis etc Mouth and details Thyroid swelling Cervical lymphadenitis
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Contd
Hands & Fingers-Clubbing, Koilonychia Feet & Toes-Edema feet Any swellings any where Any other abnormalities VITAL DATA: Pulse, B.P, R.R, Temp etc
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General Examination Contd

BUILT: Dwarfism: 1. Hereditary / Genetic 2. Chromosomal - Turners syndrome, Down syndrome 3. Constitutional , Nutritional 4. Delayed puberty 5. Endocrine, Skeletal disorders 6. Systemic diseases

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Gigantism:

contd

1. Primary 2. Racial 3. Endocrine 4. Genetic 5. Metabolic PALLOR: Sites where anemia is detected1. Lower palpebral conjunctiva, 2. Tongue & Soft palate, 3. Palm & Nails 4. Other mucosal areas
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JAUNDICE:

Causes:
I. Hepato cellular (Medical jaundice): A. Infections: viral hepatitis, Septicemia B. Toxic: Anesthetic agents , Anti- T.B drugs, Anti coagulents C. Cirrhosis: II. Obstructive Jaundice (Surgical jaundice) A. Extra hepatic- Bile stone, cancer B. Intra hepatic- Drugs like steroids
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Contd
III. Hemolytic (Pre-hepatic) A. Intra corpuscular: Hereditery B. Extra corpuscular- Infections, Drugs IV. Congenital Hyper Bilirubunemia: A. Unconjugated- Gilberts syndrome B. Conjugated- Dubin Jhonson syndrome

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CYANOSIS:
Causes: 3 TypesI. Central II. Peripheral III. Mixed I.Central- Congenital cyanotic heart disease like Fallots tetrad Congestive cardiac failure C.O.P.D II. Peripheral- Cold & Shock III. Mixed- Ac L.V.F M.S
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Clubbing

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Clubbing

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CLUBBING:

Causes:
Pulmonary: Bronchogenic carcinoma, Lung abscess, Bronchiectasis Cardiac: Cyanotic cong heart dis. Inf endocarditis G.I.T : Ulcerative colitis Cirrhosis, Crohns dis
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Koilonychia

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Koilonychia
Koilonychia is seen in Iron deficiency anemia Common causes are1. Nutritional deficiency 2. Bleeding peptic ulcer 3. Hookworm infestations 4. Menorrhagia 5. Malabsorption syndrome 6. Bleeding hemorrhoids
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OEDEMA:

Causes:
A.Generalised: 1. Renal failure 2. Hepatic failure 3. Nutritional failure B. Localised: 1. Lymphatic edema 2. Inflamatory edema 3. Venous edema 4. Cellulitis

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I. COMA
Causes of coma: A. Cranial causes 1. Infections like Meningitis, Encephalitis 2. C.V.A 3. Cerebral abscess 4. Cerebral tumors 5. Head injury 6. Convulsions
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Contd
B. Extra Cranial causes: 1. Severe syst infectionsSepticemia, Cerebral malaria, Typhoid 2. Metabolic causesDiabetic coma, Hypoglycemia, Uremia 3. Toxic causesPoisoning
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Communication :The art of history taking

Aim : a).Accurate elicitation of symptoms . b).Dipending upon the PTS LIFE evaluating PTS problems . CLASSICAL WAY OF WRITING A CASE SHEET . It should be done under the following headings .

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Contd.
1).Age,address,marital status ,occupation & social status and circumstances . 2).Presenting complaint . 3).History of present complaint. 4).Previous history of illness. 5).Menstruval history . 6).Treatment history. 7).Family history .

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Contd.
ONE SHOULD DEVELOP HIS OWN WAY OF TAKING HISTORY. BEFORE GOING FOR REAL SYMPTOMS THE PT SHOULD BE ENQUIRED ABOUT HIS LIFE TO SOME EXTENT . THE EXAMINATION WILL START AS THE PT ENTERING IN TO THE CONSULTING ROOM .

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Contd.
Observe :General appearance . Manarisms. Way of walking . Way he answering . SOME TIMES WHILE THE PT LEAVING FROM THE CONSULTATION ROOM YOU MAY GET NEW ASPECTS OF HISTORY OR VITAL INFORMATION .

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It is very important that the Doctor should concentrate on the PT in every aspect . While taking the history the Doctor should develop skills to trace which part of the history is important to evaluate the PT .

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EX: If the PT complains BLEEDING enquire Family history of Bleeding disorders. If cough ,sputum:Enquire OCCUPATIONAL HISTORY (Asbestosis). Anaemia :Drug history ,infestations etc. Fever :visiting endemic areas (malaria ). Social history:Relation with wife,relatives, Emploire etc.

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Certain clues: Allow the PT to talk freely . Some times leading questions may gives the important information . Try avoid leading questions. Some times PT him/her self gives the diagnosis . Some times they link with family problems Some times the whole problems may be due to her/his partner only .

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Communications with the PT.

It is two way business.Involving two people studying each other. It is the beginning of doctor patient relation ship . Depend both the value of the PTs history& his confidence on the doctor . Many PTS feel reluctant to consult the doctor as bad as a viva voce for the students .

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Developing themes
Some

of the PTs continuosly talk more than the doctor with any information. Some PTs will present a clear,concise and chronological history with slight prompting Some PTs does not show any interest to discus about their problem and spend time with talking So the doctor shoud exercise to extract information from the PT The doctor should conversate with the PT Never interrogate unless it is absolutely

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SOME TIMES PTS FEEL THAT THE DOCTOR IS THREATENING ,FORBIDABLE FIGURE . SO THE DOCTOR SHOULD GET CONFIDENCE OF THE PT AND MAKE HIM COMFORT TO TALK FREELY. DOCTOR SHOULD HAVE COURTESY TO WARDS PT. GREET THE PT BY NAME IF POSSIBLE .

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INTRODUSE YOUR SELF TO THE PT . START EXAMINATION WITH NONCOMMITAL REMARKS . ASK ABOUT HOBBIES,INTEREST OF EVENTS ,POLITICS . ALLOW HIM TO TALK FREELY . WHILE TALKING OBSRVE HIS GESTURES,LANGUAGE.

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Particular gestures analise specific pain symptoms

Asqeezing gesturecardiac pain Hand position renal colic Rubbing the sternumHeart burn Rubbing the buttock and thighsciatica Arm clenchd around abdomen Mid gut colic

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Vocabulary
Always the doctor should talk in understandable launguage Understand basic words used by the PT Clarify and interprit the terms used by the PT Dizziness-actual vertigo but just mean light headedness,going to faint as per the PT vertion

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Diarrhoea means passing loose ,liquid stools many times in the day Hence the doctor should clarify the actual meaning of terms used by the PT

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Words and phrases that need clarification

Ordinary english words 1.Diarrhoea,2.constipation,3.Wind, 4.Indigetion, 5.Beingsick, 6.Dizziness,7.Blackouts,8.Headche, 9.Double vision10.,pins & needles, 11.Rash,12.Blister

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Medical tems used by the PTs

1.Arthrits,2.sciatica,3.Migraine,4.Fits, 5.Stroke,6.Palpitation,7.Angina, 8.Heartattack, 9.piles/haemorrhoids, 10.Anaemia,11.PLEURISY,12.Eczema, 13.Urticaria,14.Warts,15.Cystitis

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SEE DIRECTLY INTO THE EYES OF THE PT. OBSERVE HIS/HER EYES WHILE ELICITING THE HISTORY. EYES MAY TELL MORE THAN WHAT THE PT ACTUALLY TELLS . CLENCHED FIST MAY SHOW THE TENSION WHEN THE WARDS SOUND EMOTIONLESS.

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PT SHOULD HAVE THE CONFIDENCE THAT THE DOCTOR S STANCE,GESTURES & EXPRESSION,ATTENSION TOWARDS HIM ONLY. DOCTOR SHOULD NOT BE SHOCKED OR ANGREED ANY THING THE PT SAYS . TOUCH THE PT OR HOLD THE HAND OF A FRIGHTENED PT IT GIVES MORE COMFORT THAN THE DOCTORS WORDS.

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PHYSICAL EXAMINATION : GENTLE TOUCH,GENTIL EXAMINATION OF ALL THE PARTS THIS WILL GAIN THE CONFIDENCE OF PT SEEING OUT SIDE THE WINDOW,WRITING CONTINUALLY WILL PUT OF THE PT .

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Though modern diagnostic techniques avilable. HISTORY- TAKING AND PHYSICAL EXAMINATION REMAIN ESSENTIAL SKILLS . NO ONE TECHNIC OF HISTORY TAKING APPLICABLE TO ALL PT,S HISTORY TAKING NEVER BE STERIOTYPED.

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SOME TIMES PTS CAN NOT TELLTHE HISTORY PSYCHOLOGICAL SYMPTOMS CAN NOT EXPRESSED BY THE PT . SOME PTS TELLS WITH EXAGERATION THOUGH SYMPTOMS ARE MINER. DEPRESSED PTS TELLS EVERY THING IS FLAT,HOPELESS,NOTHING TO LIVE FOR .

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ANXIOUS PT FEELS THAT HIS PROBLEM IS MAJOR AND NOBODY CAN NOT WITH STAND . HE/SHE MAY FEEL SYMPTOMS LIKE INDIGESTION,HEADACHE,PALPITATIONS WHICH ARE AWFUL ABOUT TO HAPPEN . HE GETS THE FEELING THAT HE IS ALMOST UNAWARE OF IT .

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SPECIALQUESTIONAIRES MAY BE USEFULL FOR SPECIAL PURPOSES. ALLOW THE PTS TO TELL THE HISTORY IN THEIR OWN WORDS AND OWN WAY .

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Bodily systems & questions relavant for taking history

Cardiorespiratory: chest pain ,intermttent claudication,palpitation ,ankle swelling,orthopnoea,nocturnal dyspnoea,shortness of breath,cough with or with out sputum. GIT: Abdominal pain,Dyspepsia/Dysphagia Nausea/vomiting,Change in appetite, weight loss/gain,Bowel pattern/any change,Rectal bleeding,Jaundice.

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Genito urinary: Haematuria,Nocturia,

Frequency,Dysuria,Menstrual irregularity (women),Urethral discharge(men)

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Locomotar:Joint pain,change in mobility. Neurological:seizures,collapse/block outs, Dizziness/loss of balance,Vison,Hearing, TIA:VISON,SPEECH,SIGHT. Parasthesias,Weakness,Wasting,spasms involuntary movements,pain in limb& back,Headache.

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CLARIFYING DETAIL .

History taking is not only important but should clarify each symptom as much as possible .

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PAIN .
List of clarifications for a complaint of chest pain . 1.Site 2.Radiation 3.Character 4.Severity 5.Time course 6.Aggravating factors 7.Associated symptoms.8.Relief

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Site: Pointing or Spreading his hand Radiation:Localised,It moves or spreads Severity:Influence on exertion , sleepdisturbance, Timing: Appearence,When it disappears Character:Stabbing,burning,pricking gnawing,colic

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Conditions warsening,exertion . Ishaemia of the heart produces Angina Gastritis also produces some times produces Anginal like pain

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Releif : Muscular pains releived by change of position. Duodinal ulcers pain releived by eating.

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Some painfull conditions have classical sites . Myocardial infarction:Felt centre chest,radiating to left arm. Biliary/Renal colic :coliky. Subarachnoid haecmorrhage:very sudden, like a hammer on the head Peptic ulcer:pain worse when hungry better after food.

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Migraine :Head ache with flashes of light Gall stone/obstructing bile duct:Coliky RT upper quadrant pain.

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Characteristics of pain
SOCRATES: Site: Somatic pain well localised ex: sprained ankle. Viseral pain more diffuse ex: Anginapectoris. Onset: Speed of onset &assosiated symptoms
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Character: Sharp/dull,burning/tingling,boring/stabbing Crushing/tugging, allow the PT to tell his own wards Radiation: Through local extension Reffered via neuronal pathway to distant unaffeced site ex: Diaphramatic pain at the tip of shoulder via phrenic

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Associated symptoms: Visual aura accompanying migraine with aura Numbness in the leg with back pain suggesting nerve root irritation Timing(Duration,pattern,course) since on set Episodic or cotinuous if episodic,duration and frequency of attacks, if continuous,any changes in

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Exacerbating and releiving factors

Circumstances pain provoked or increased ex: food specific activities/postures/medications can suppreses the on set. Severity: Difficulty to asses Comparing with other pains ex: tooth ache Variation:day/night,week/month

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Pain associated symptoms

Nausea,sweating,faintness due to vagal and sympathetic involvement . EX:Migraine with visual disturbance, Palpitation with Angina Effects on life style:

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Attitudes to illness
Pain and fatigue are subjective BUT PTS gives history different ways. Pain threshhold & tolerence :varies in different PTS and also in the same person dipending upon the circumstances. Past experience: Personal/family experience ex:Family H/O sudden death with cardiac problem may react a

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Gains:Most illnesses gains knowledge to the PTS . Pain threshhold: Increased: Exercise ,Analgesia, Passitive mental attitude Personality Decreased:Sleep diprivation,Depression Financial/personal problems Anxiety/fear about the cause

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Drughistory
Self medication Any prescriptions of other doctors Doses of drugs Some PTS never fallows the doctors advice H/O drug allergies/reactions Penicilline allergies Allergy towards foods,animal hair,pollen, metals

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Non-prescribed drug history

What

drugs are taking? How often and how much? Duration of taking drugs? Periods of absence and why started again? What Symptoms appear if not taken? H/O injections,getting from where? H/O sharing the needles,syringes or other drug paraphernalia? Any problems using the drugs? Any change the PT wants or change the use of drugs or change of life ?

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Complications of drug misuse.

INFECTIONS Hepatitis B & C HIV Abscesses,cellulitis Necrotising fasciitis Septic pulmonary thro mboembolism or lung abscesses

Endocarditi Tetanus Wound botulism STD.

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INJURY Thrombophlebitis & deep vein thrombosis Arterial injury and occlusion OVERDOSE Respiratory failure

Skin ulceration .

Rhabdomyolysis & Renal failure

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Chaotic life style leading to

Poor nutrition Poor dental hygiene Failure to care for dependents.

Dept Prison

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Social history
Understands PTS life. Any relatives attending during illnesses. Husbands work may affect the family. Upbringing Birth injury,parentral attachement,Schooling,Acadamic achivements,Higher education,Behaviour Problems.

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Home life
Emotional,physical/sexuval abuse(asked if relavant),Experiences of deaths/illness, Interest/attitude towards parents. Occupation: Current/previous job,Exposure to hazards ex: chemicals,asbestos,foreign travel, accidents,compensation claims. Unemploiment:reason/duration Attitude to job.

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Finance: Circumstances,including debts Benifits from social security Relation ships/domestic circustances Marriage life,Quality and relation ship , problems,partners health,occupation, attitude,others in the family,any trouble with police.

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House: Type of house,own/rented/size. Details of home :stairs/toilets/heating/ cooking,facilities,neighbers. Community support: social support: Home help,meals on wheels,Attitude to needing help

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Sexuval history: Asked if relavant Do you have regular partener Any other sexuval parteners i n lost 1 year. Using cotraception Having any sexually transemitted diseases

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Leisure activities: Hobbies/pastimes pets Exercise: what,where and when?

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Travel history
MANY DISEASES OCCUR WHEN TRAVELS OTHER COUNTRIES/AREAS.SOME OF THE ACTIVITIES LIKE WATER SPORTS,SEXUAL CONTACTS MAY CAUSE CERTAIN SPECIFIC DISEASES. THE INCUBATION PERIODS VARIABLE TO EACH DISEASES Enquire about vaccination/Malarial prophylaxis

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Falciprum malaria : Incubation period: 8 to 25 days. Travel to presentation:Upto 6 weeks. Symptoms : FEVER Vivax malaria: Incubation period: 8 to 27 days. Travel to presentation:Up to 1 year Symptoms: FEVER.

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Typhoid fever: Incubation period:10 to 14 days Travel to presentation: Up to 3 weeks. Symptoms: FEVER,HEADCHE. Dengue fever: Incubation period: 3 to 15 days Trevel to presentation: Up to 3 weeks Symptoms: FEVER,HEADCHE.

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Schistosomiasis: Incubation period:2 to 63 days Travel to presentation:Up to 10 weeks Symptoms:ITCH,FEVER,HAEMATURIA, ABDOMINAL DISCOMFORT. Hepatitis A: Incubation period:28 to 42 days Travel to presentation: Up to 6 weeks Symptoms:JAUNDICE. HIV Infection: Incubation period:12 to 24 weeks

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TOBACCO
H/O Smoking,How long,Cigarettes,cigars, Pipe. How much. Calculate the PACK YEARS: Smoking 1 pack of 20 cigarrets/day for 1 year EQUALS 1PACK YEAR. PTS With COPD Usually have a consumption > 20 pack years.

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Stopping smoking before the age of 40 years improves health. If they continue beyond 40 years they loose 3 months of life expectancy for each pack year

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Calculating pack years of smoking.

20 cigarettes= 1 packet. No.of cigarettes smoked/day x No.yrs.smoking /20. EX:SMOKING 10 CIGARATTES/DAY X 15 YRS 10 X 15 ----------- = 7.5 PACK YEARS 20

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Tobacco related disorders.

Fig 20 page

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Drug history
Medicines used by the PTS Self prescribed Any priscriptions by the doctor Inhalers,skin creams,patches,sucking tabs Any herbal or complimentary medicines.

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Systematic enquiry
Rivew of forgotten symptoms. Ask is there any thing to tell? EX: Smoker with weight loss/respiratory symptoms/chest infection/ haemoptysis SUGESTS LUNG CANCER Another cause for weight loss : Altered bowel habbit due to colon cancer.

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PT with recurent mouth ulcers: Alimentary symptoms suggests CROHNS DISEASE/ COELIAC disease If associated with locomotar symptoms suggests BEHCETS disease. PT with palpitation: Endocrine diseas suggests THYROTOXICOS. Family H/O Thyroid disease.

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PTS with Alcohol smell: Ask symptoms like numbness in the feet due to alcohol neuropathy.

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Completing the history taking.

After making relavant information should Have differential diagnosis. Before going for physical examination Summerise te history told by the PT Telling back to the PT allows him to correct any thing forgotten and correcting our selfs any misunderstandings.

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Key points/Gathering information.

Summerising the problems and reflecting back to the PT Estimating Tobbaco,Alcohol and non prescribed drugs used by the PTS PTS past experience with symptoms and attitude. Drug history get from PTS GP. Good differential diagnosis after getting the history

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Family history
Any diseases in the family: Haemopilia,Cardiac problems. Hpertension H/O Gall stones,

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Occupational history.
Occupational diseases: Asbestosis,Silicosis Baggosis, Environmental history

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Alcohol history
Alcohol prolonged usage gives many problems Regular habbit of talking alcohol Quantity Quality,brand,cheap liquer Duration

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Units of alcohol(1 unit contains 10 gms of pure alcohol)

Standard-strength beer-1 pint=2 units Very strong lagers-1 lire can =4 units Spirits(Wisky,gin)-30ml=1 unit Wine 1 standard glass=1 unit Upper weekly limit=21 units for men 14 units for women to avoid complications

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CAGE ASSESMENT FOR ALCOHOL DEPENDENCY

C =EVER FELT TO CUT DOWN ALCOHOL CONSUPTION A= FELT ANGRY AT OTHERS CRITICISING FOR THE DRINKING G=GUILTY ABOUT EXESSIVE DRINKING E=EVER DRINKING IN THE MORNINGS (EYE OPNER)? Pasitive answers to two or more questions Sugest problem drinking.

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Retrospective history
It is a fast history that PT had any previous aliments like chest pain,relation with exertsion. Any related history depending upon the symptom

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Angry PTS
PTS some times angry with circumstances like late running the clinic,longer surgery,about department,institution. Some times the angry is a part of symptom or a reaction to the treatment. This true with NON-ORGANIC diagnosis who incist that there is some thing wrongand the doctor must do some thing

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EX: Tension headache ,irritable bowel syndrome,back pain Some tuimes the PT Doctor relation ship may broken,it better to refer the PT to another doctor

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Well informed PT
Olden days the PTS examined for longer times with out telling any thing The PTS are happy taking the attitude that the doctor knows best Now this attitude changed and the PT demands the diagnosis and informed about their choices of treatments The PTS now taking information from others & internet

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Hence the doctor should have complete knowledge of the disease and should explain in and abouts and complications Some PTS HAVE FIXED AND ERRONEOUS IDEAS about their problems that the diagnosis and treatment process is impeded.

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Acompaning persons
Some PTS come alone,some may with single or somany attendents or family members Some times PTS wants this Some times PTS feel guilty of telling history properly After greeting the attendents better to send them out side the consulting room.

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Some times they are required to ask specific questions and in case of uncociousPT. While doing physical examination better to send the attendents. Some times PTS will not give proper answers ,such situations attendents are required

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Interpreters
In case of language problem interpreters,transelaters are required It takes longer time The history always limited and incomplete

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Negative Data
Some times negative data will help in the diagnosis These questions are very specific and direct often with yes/no answer. EX: A PT with exertional chest pain can immediately asked duration ,affect further exertion,releiving factors etc ;

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Retaking the history

Some times it is necessory to take. Some PTS gives double history with out any coordination.Hence it is necessory to retake the history Some times single attemt is not sufficient repeated histories at different times with different people may give extra information for the diagnosis Second tIme IF the Pt comes instead of wasting time in asking the history more

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Generally PTS come to the doctor for the reasons

Unable to bear the symptoms,some body noticing the sympom like jaundice,noticing Hypertension,spouse or relatives warried about symptoms,unable to work with symptoms,collegues/boss complaing about his work or time off,Requirement by others( insurance,emploiment benifit ,litigation)
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Duties of doctors
PT care is the first cocern Treat PT POLITELY AND Considerately Respect PT dignity and privacy Give information that the PT understand well Respect PTs rights Updating the knowledge and skills Limitations of proffessional competency

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Honesty and trustwarthy Respect proffessional secrecy Personal beliefs never come while treating the PT Avoid abusing your position as a doctor Working with collegues to better to the PTS

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Conclusion

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Symptom analysis
Thirst :Differentiated from Dryness due to oral infections or Due decreased salvation . Thirst may be due to loss of body water due to dicreased intake , vomting ,diarrhoea,increased sweating (fever or exposure to heat),increased urine out put , severe haemorrhage

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THIRST may be due to loss of body water or due to increased urine out put . Urine of low specific gravity DIABETES INSIPIDUS Urine of high specific gravity DIABETES MELLITUS (presence of glucose) Urine of 1010 specific gravity(isotonic with plasma) of RENAL FAILURE.

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Hypercalcaemia :Decreased anti diuretic hormone causes increased water loss Diuretics : Loss of salt & water(exessive coffe,tea). Thus depending upon the sympoms doctor should analyse and think of various conditions whic are common .

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