Obtaining an accurate history is the critical first step in determining the etiology of a patient's problem.

A large percentage of the time70%), you will actually be able make a diagnosis based on the history alone.

The sense of what constitutes important data will grow exponentially in future as you learn about the pathophysiology of disease You are already in possession of the tools that will enable you to obtain a good history. An ability to listen and ask common-sense questions that help define the nature of a particular problem. A vast and sophisticated fund of knowledge not needed to successfully interview a patient.

When you approaches your patient , there are 3 initial Objectives : * Obtain Professional Rapport with patient & gain his confidence. * Obtain all relevant information which allow assessment of his illness & provisional diagnosis * Obtain general information regarding patient( Background , Social Situation and Problems )and the assessment of the patient as a whole is of utmost importance. One should Never approach the patient with just a set series of rote questions

Look the part of a Dr and put the patient at ease , be confident & friendly . Greet the patient, shake hand State you name & explain Let the patient tell his story in his own words as much as possible by conducting a conversation rather than an interrogation , do not interrupt too much & keeping the patients train of thought as much as possible . Ovoid Pseudo medical Terms & Ovoid leading Questions Be understanding , receptive , and matter of fact without excessive over sympathy , rarely show reproach

General Approach
Introduce yourself. Note never forget patient names Create patient appropriately in a friendly relaxed way. Confidentiality and respect patient privacy. Try to see things from patient point of view. Understand patient underneath mental status, anxiety, irritation or depression. Always exhibit neutral position.

Listening Questioning: simple/clear/avoid medical terms/open, leading, interrupting, direct questions and summarizing.

.
Always record personal details:
name, age, address, sex, ethnicity, occupation, religion, marital status. Record date of examination& Admission

Chief complaint History of present illness( details of current illness ) Past medical history Systemic enquiry Family history Past Medical History :Drug history & Treatment history Social history& Personal History In Female Obstetric & Gynecologic history

The main reason push the pt. to seek for visiting a physician or for help Usually a single symptoms, occasionally more than one complaints eg: chest pain, palpitation, shortness of breath, ankle swelling etc The patient describe the problem in their own words. It should be recorded in pts own words. What brings your here? How can I help you? What seems to be the problem?

Chief Complaint (CC) Short/specific in one clear sentence communicating present/major problem/issue. Timing fever for last two weeks or since Monday Recurrent recurring episode of abdominal pain/cough Any major disease important with PC e.g. DM, asthma, HT, pregnancy, IHD: Note: CC should be put in patient language.

Chief complaint History of present illness Past medical history Systemic enquiry Family history Past Medical History Social history

Elaborate on the chief complaint in detail Ask relevant associated symptoms Have differential diagnosis in mind Lead the conversation and thoughts Decide and weight the importance of minor complaints

History of Presenting Complaint(HPC)

In details of present problem with- time of onset/ mode of evolution/ any investigation; treatment &outcome/any associated +ve or -ve symptoms.

Sequential presentation Always relay story in days before admission e.g. 1 week before the admission, the patient fell while gardening and cut his foot with a stone. Narrate in details By that evening, the foot became swollen and patient was unable to walk. Next day patient attended Merjan hospital and they gave him some oral antibiotics. He doesnt know the name. There is no effect on his condition and two days prior to admission, the foot continued to swell and started to discharge pus. There is high fever and rigors with nausea and vomiting.

In details of symptomatic presentation If patient has more than one symptom, like chest pain, swollen legs and vomiting, take each symptom individually and follow it through fully mentioning significant negatives as well. E.g. the pain was central crushing pain radiating to left jaw while mowing the lawn. It lasted for less than 5 minutes and was relieved by taking rest. No associated symptoms with pain/never had this pain before/no relation with food/he is Known smoker, diabetic & father died of heart attack at age of 45.

Avoid medical terminology and make use of a descriptive language that is familiar to them

With all symptoms obtain : * Duration * Onset : Sudden or gradual * What has happen since :Constant or periodic , Frequency , Getting worse or better * Precipitating or relieving factors * Associated symptoms

Onset of disease Position/site

Pain (OPQRST)

Quality, nature, character burning sharp, stabbing, crushing; also

explain depth of pain superficial or deep.

Relationship to anything or other bodily function/position. Radiation: where moved to Relieving or aggravating factors any activities or position Severity how it affects daily work/physical activities. Wakes him up
at night, cannot sleep/do any work.

Timing mode of onset (abrupt or gradual), progression Treatment received or/and outcome.

(continuous or intermittent if intermittent ask frequency and nature.)

Are there any associated symptoms? Check

System Review (SR)

This is a guide not to miss anything

Any significant finding should be moved to HPC or PMH depending upon where you think it belongs. Do not forget to ask associated symptoms of PC with the System involved
When giving verbal reports, say no significant finding on systems review to show you did it. However when writing up patient notes, you should record the systems review so that the relieving doctors know what system you covered.

System Review
General Weakness Fatigue Anorexia Change of weight Fever FRCS Lumps Night sweats
Gastrointestinal/Alimentary Appetite (anorexia/weight change) Diet Nausea/vomiting Regurgitation/heart burn/flatulence Difficulty in swallowing Abdominal pain/distension Change of bowel habit Haematemesis, melaena, haematochagia Jaundice Cardiovascular Chest pain Paroxysmal Nocturnal Dyspnoea Orthopnoea Short Of Breath(SOB) Cough/sputum (pinkish/frank blood) Swelling of ankle(SOA) Palpitations Cyanosis Respiratory System Cough(productive/dry) Sputum (color, amount, smell) Haemoptysis Chest pain SOB/Dyspnoea Tachypnoea Hoarseness Wheezing

System Review
Urinary System Frequency Dysuria Urgency Hesitancy Terminal dribbling Nocturia Back/loin pain Incontinence Character of urine:color/ amount (polyuria) & timing Fever Genital system Pain/ discomfort/ itching Discharge Unusual bleeding Sexual history Menstrual history menarche/ LMP/ duration & amount of cycle/ Contraception Obstetric history Para/ Nervous System Visual/Smell/Taste/Hearing/Spe ech problem Head ache Fits/Faints/Black outs/loss of consciousness(LOC) Muscle weakness/numbness/paralysis Abnormal sensation Tremor Change of behaviour or psyche Musculoskeletal System Pain muscle, bone, joint Swelling Weakness/movement Deformities Gait

Start by asking the patient if they have any medical problems

IHD/Heart Attack/DM/Asthma/HT/RHD,TB/Jaundice/Fits :E.g. if diabetic- mention time of diagnosis/current medication/clinic check up Past surgical/operation history E.g. time/place/ and what type of operation. Note any blood transfusion and blood grouping. History of trauma/accidents E.g. time/place/ and what type of accident

Drug History (DH) Always use generic name or put trade name in brackets with dosage, timing and how long. Example: Ranitidine 150 mg BD PO Note: do not forget to mention OTC /Vitamins/Traditional medicine

Current treatment Allergy to drug Abuse to drug Other remedies( RT , CT , Immunotherapy & Hormonal )

bd (Bis die) - Twice daily (usually morning and night) tds (ter die sumendus)/tid (ter in die) = Three times a day mainly 8 hourly qds (quarter die sumendus)/qid (quarter in die) = four times daily mainly 6 hourly Mane/(om omni mane) = morning Nocte/(on omni nocte) = night ac (ante cibum) = before food pc (post cibum) = after food po (per orum/os) = by mouth stat statim = immediately as initial dose Rx (recipe) = treat with

Any familial disease/running in families e.g. breast cancer, IHD, DM, schizophrenia, Developmental delay, asthma, albinism AFather BMother CEach sibling DHistory of disease in which heredity or contact may play a role. Rerecord a family tree

Smoking history - amount, duration and type. A strong risk factor for IHD Drinking history - amount, duration and type. Cause cardiomyopathy, vasodilatation Occupation, social and education background, family social support and financial situation

Gyane/Obstetric history if female Immunization if small child Note: Look for the child health card. Travel and sexual history if suspected STI or infectious disease Note: If small child, obtain the history from the care giver. Make sure; talk to right care giver. If some one does not talk to your language, get an interpreter(neutral not family friend or member also familiar with both language). Ask simple & straight question but do not go for yes or no answer.

SOAP
Subjective: how patient feels/thinks about him.
How does he look. Includes PC and general appearance/condition of patient

Objective relevant points of patient

complaints/vital sings, physical examination/daily weight,fluid balance,diet/laboratory investigation and after Assessment address each active problem interpretation making a problem list. Make differential diagnosis. Plan about management, treatment, further investigation, follow up and rehabilitation

Inspection Palpation Percussion Auscultation

Stethoscope BP cuff Otoscope Ophthalmoscope

Can you think of any other tools?

Vital Signs
Pulse Ventilations (Respirations) Blood Pressure Temperature

Height Weight Spo2

General Survey Mental Status Emotional Status Vital Signs Hand Face Neck Chest

Abdomen Pelvis (as needed) Posterior Body Extremities

Vascular Musculoskeletal

Neurologic Exam

What does mental status tell you about the patient?

What should we look for?

Why? What do these things tell us?

Appearance & Behavior

Posture & Motor Activity Dress, Grooming & Personal Hygiene Facial Expression Speech & Language Mood Thoughts & Perceptions Insight & Judgment Memory & Attention

General Physical Appearance

Height, Weight & Build Sexual & Physical Development Posture, Gait & Motor Activity Hair, Nails & Skin appearance Dress, Grooming & Personal Hygiene Odors Facial Expressions & Body Language

Emotional state Agitation Apathy Lack of expression Emotional laiblelity Euphoria cheerfullens

1-Herditary/Congenital 2-Endocrine 3- connective tissue disorder

10. C. HEAD Palpates scalp: 11. Palpates thoroughly (temples, including over temporal arteries), parietal sides above ears, crown, occipital back, palpate temporomandibular joint as patient opens and closes jaw

chevosteks sign Jaw Jerk

Inspect Visual acuity Extraoccular movements, accommodation Visual fields Pupillary response, swinging flashlight Fundoscopic exam

12. D. EYES Inspects external ocular (eye) structures (lids, conjunctiva, iris cornea, pupils) 13. Gently moves eyelids up and down to obtain better view 14. Checks acuity with Snellen and from proper distance (12-14 inches and any printed material is acceptable) 15. Checks acuity both eyes separately

16. Evaluates extraocular movement (big H) 17. Checks convergence and accommodation (follows finger from far to near)

Six Cardinal Positions of Gaze

Convergence and Accommodation

Need our picture

Needs illustration

18.Visual fields - both eyes independently 19. Visual fields - eight cardinal directions for each eye (N,NE, E, SE, S, SW, W NW) 20. Visual fields - simultaneous stimulation (each eye should only be able to see on hand the one on that side) 21. Visual Fields Examiners hands or object to view introduced in the plane half-way between patient and examiner

Swinging Flashlight Test

22. Pupillary response to light direct (same eye the light is directed into) 23. Pupillary response indirect (eye light is not directed into) 24. Swinging flashlight test (start in one eye, quickly move to other eye, wait then fast back to original eye and wait)

36. E. EARS: Inspects externally bilaterally (including behind ears) 37. Palpates auricles bilaterally 38. Otoscopic examination bilaterally 39. Otoscopic examination performed without pain 40. Auricles pulled superiorly, posteriorly, and away from patient 41. Auditory acuity tested (eyes closed if finger rub and you can see movement of hands or arm) 42. Auditory acuity tested correctly (each ear independently, etc.)

Nasal Speculum Palpate sinuses

Look everywhere Say ah

48. G. MOUTH Should use light source for inspection 49. Inspect lips, gums, buccal mucosa, teeth 50. Inspect tongue, posterior pharynx 51. Inspect floor of mouth (under tongue) 52. Elevation of palate ("ah") 52. Examination done with minimal discomfort

Inspect Carotids: palpate, auscultate (2) Thyroid: isthmus and both lobes 10 lymph node areas

54.H. NECK Inspects anterior neck for symmetry 55.Carotid arteries palpated 56.Carotid arteries correctly palpated, singly, (lower third of neck), fingers or th 57.Auscultation of carotid arteries (lower carotids bilaterally) 58.Auscultation of carotid arteries (upper carotids bilaterally) 59.Thyroid gland palpated: Palpation from behind, chin is slightly extended (can palpate from front) 60.Hands in proper position (below the cricoid cartilage) 61.Palpates the isthmus and has patient swallow 62.Palpates the lobes and has patient swallow 63. I. LYMPH NODES - HEAD AND NECK Periauricular (in front of the ear)64. 65.Posterior auricular (behind the ear) 66.Occipital (base of skull) 67.Tonsillar (angle of jaw) 68.Submaxillary (mid-jaw) 69.Submental (under chin) 70.Posterior cervical (back of neck) 71. Superficial cervical (on top of the sternomastoid muscle) 72. Deep cervical (deep in the sternomastoid muscle) 73. Supraclavicular

percussive auscultation What else ?

1) Ask the patient to lie supine. 2) Ask the patient to lower his gown to waist level. 3) Stand at the feet of patient. 4) Inspect the shape of the chest (ratio of antero-posterior and transverse diameters). 5) Inspect the symmetry of the patients chest on both sides with comparison.

Pectus carinatum

Pectus excavatum

6) Inspect patients chest normal breathing movement. 7) Inspect patients chest for accessory muscle use. 8) Inspect patients chest for retraction of lower intercostal spaces. 9) Stand again to the right of patient and look tangentially for apical and epigastric pulsation. 10) Inspect the chest wall and skin for swelling, scars, skin eruption or engorged veins.

1) Stand to the right of the patient. 2) Ask the patient to lie supine. 3) Palpate upper lung zone to confirm the movement by placing the palms in the infraclavicular fossa and the two thumbs in the midline at the level of suprasternal notch. Let the patient inspire deeply and let your thumbs follow chest movement. 4) Palpate middle lung zone by putting the palm in the middle part with tips of thumbs in the midline. Let the patient inspire deeply and let your thumbs follow chest movement.

5) Palpate lower lung zone by putting the palm in the lower part with tips of thumbs in the midline. Let the patient inspire deeply and let your thumbs to follow chest movement. 6) Palpate for palpable rhonchi, pleural rub or chest wall tenderness by putting the palm on various areas of chest wall. 7) Palpate for Tactile vocal fremitus a) Place the palm of hand over various area of chest wall in the direction of bronchial tree away from midline with comparison. b) Ask the patient to repeat the words 99

Increased TVF
Consolidation

Decreased TVF
Thick

Cavitation
Collapse

with patent main

bronchus

chest wall Pleural effusion Pleural fibrosis Pneumothorax Emphysema Collapse

a) Stand to the right of the patient. b) Ask the patient to sit up with the head straight. c) Inspect for tracheal position Trills sign. d) Tracheal shift: Insert the index finger in horizontal position in the pouch between the medial end of sternomastoid and the lateral aspect of trachea with comparison. e) Check the cricosternal distances. This is the distance between the cricoid cartilage and the suprasternal notch. If it is less than 3 finger breadths, this indicates hyperinflation of the lung. f) Tracheal descent: place the tip of the index finger on the thyroid cartilage during inspiration to observe its descent.

1- Stand to the right of the patient. 2- Ask the patient to lie supine. 3- Use light percussion. 4- Krnigs isthmus: Percuss both areas right and left from dullness to resonance (start from the neck) with comparison. 5- Percuss both clavicles directly (over medial third) 6- Percuss the infraclavicular regions. 7- Percuss both parasternal lines right and left, from the second space to the sixth space with comparison. 8- Spare bare area to be percussed late with special areas percussion. 9- Percuss both midclavicular lines right and left, from the second space to the sixth space with comparison. 10-Comment on dullness found.

1-Stand to the right of the patient. 2-Ask the patient to lie supine and raise his hands above his head. 3-Use light percussion. 4-Percuss both anterior axillary lines right and left, from the fourth space to the eighth space with comparison. 5-Percuss both middle axillary lines right and left, from the fourth space to the eighth space with comparison. 6-Percuss both posterior axillary lines right and left, from the fourth space to the eighth space with comparison. 7-Comment on dullness found.

1- Stand to the right of the patient. 2- Ask the patient to lie supine. 3- Use heavy percussion. 4- Start in the right midclavicular line from second space down to the first dullness. 5- Decide the upper border of the liver.

1- Stand to the right of the patient. 2- Ask the patient to lie supine and raise his hands above his head. 3- Use light percussion. 4- Percuss both anterior axillary lines right and left, from the fourth space to the eighth space with comparison. 5- Percuss both middle axillary lines right and left, from the fourth space to the eighth space with comparison. 6- Percuss both posterior axillary lines right and left, from the fourth space to the eighth space with comparison. 7- Comment on dullness found.

1- Stand to the right of the patient. 2- Ask the patient to sit and stand behind him. 3- Use light percussion. 4- Percuss both areas right and left from dullness to resonance with comparison. 5- Comment on dullness found.

1) Stand to the right of the patient 2) Ask the patient to lie supine. 3) Auscultate both midclavicular lines right & left, from the second space to the sixth space with comparison. 4) Ask the patient to say 99 and auscultate both midclavicular lines right & left, from the second space to the sixth space with comparison

1) Auscultate both midaxillary lines right & left, from the fourth space to the eighth space with comparison 2) Ask the patient to say 99 and auscultate both midaxillary lines right & left, from the fourth space to the eighth space with comparison Comment on : a) Breath sounds (character, intensity) b) Adventitious sounds (wheeze, crepitations) c) Type of wheeze if present ( inspiratory or expiratory, localized or generalized ) d) Type of crepitations if present (fine or coarse, change with cough) e) Vocal resonance

1) Stand behind the patient in a midline position. 2) The patient should be sitting with the posterior thorax exposed. 3) Inspect the cervical, thoracic and upper lumbar spine for deformity. 4) Assess for costovertebral tenderness by placing the ball of one hand in the costovertebral angle and strike it with the ulnar surface of your fist 5) Inspect for scars.

1) Stand behind the patient in a midline position. 2) The patient should be sitting with the posterior thorax exposed. 3) Assess extent and symmetry of lower thoracic expansion by

4) With palms of hands, assess symmetry of fremitus throughout lung fields.

a) Place your thumbs at the level of the 10th ribs with your fingers loosely grasping the rib cage and gently slide them medially. b) Ask the patient to inhale deeply and observe whether your thumbs move apart symmetrically.

A.

B.

1-Stand to the right of the patient. 2-Ask the patient to sit and his hands folded across the anterior chest wall. 3-Use heavy percussion. 4-Percuss suprascapular area with comparison 5-Percuss both scapulae directly. 6-Percuss both infrascapular areas to the 10th space comparing right and left sides. 7-Percuss interscapular area on the right and left sides with comparison 8-Comment on dullness found.

1) Stand to the right of the patient. 2) Ask the patient to sit and his hands folded across the anterior chest wall 3) Auscultate both scapular lines right & left, from the apex to the tenth space with comparison. 4) Ask the patient to say 44 and auscultate both scapular lines right & left, from the apex to the tenth space.

Pleural effusion reduced tactile vocal fremitus reduced chest expansion stony dull reduced air entry no added sounds reduced vocal resonance

Consolidation increased tactile vocal fremitus reduced expansion dull percussion bronchial breathing coarse creps increased vocal resonance whispering pectoriloquy

Pneumothorax deviated trachea reduced tactile vocal fremitus hyper-resonance reduced air entry reduced vocal resonance

Collapse deviated trachea reduced tactile vocal fremitus dull percussion reduced air entry +/- creps

The normal breath sounds over lung tissue are vesicular breathing. The vesicular breathing is lower pitched and softer than bronchial breathing.

Expiration is shorter (I > E) and no pause between inspiration and expiration.

The breath sounds are symmetrical and louder in intensity in bases compared to apices in erect position and dependent lung areas in decubitus position. No adventitious sounds are heard.

The breath sounds over tracheobronchial tree are bronchial breathing. only place where tracheobronchial trees are close to chest wall without surrounding lung tissue are Trachea right sternoclavicular joints posterior right interscapular space. These sites where bronchial breathing can be normally heard. bronchial breath sounds have a higher pitch, louder, inspiration and expiration are equal and pause between inspiration and expiration.

prolonged expiratory phase (E > I) indicates airway narrowing, as in: Bronchial asthma.
Chronic bronchitis

Jugular venous pulsation Inspection Palpation Auscultation Special maneuvers

Jugular venous pulsation Inspection Palpation

Valve areas PMI Diaphragm Bell
Left lateral decubitus

Auscultation

Special maneuvers

Tricuspid, mitral

Left lateral decubitus, apex, bell Sit up, lean, LLSB, exhale, diaphragm

103.L. CARDIAC Inspection jugular vein (remember can be done at 0, 15, 30, will likely move table position) 104. Inspection done correctly; right side, head tilted left, patient elevated 105. Inspection, palpation and auscultation for rest of cardiac examination performed at 30 degrees 106.Inspection of all 4 areas 107.Palpation of aortic area (right second intercostal space just lateral to sternum) 108. Palpation of pulmonic area (left second intercostal space just lateral to sternum) 109.Palpation of right ventricular area (left lower sternal border) 110.Palpation of apical area (about fifth intercostal space mid-clavicular line) 111.If apical impulse not palpable, patient in left lateral decubitus 112.Palpation done with fingerpads in all 4 areas 113.Auscultation with Diaphragm Aortic area 114.Auscultation with Diaphragm Pulmonic area 115.Auscultation with Diaphragm Tricuspid area (left lower sternal border) 116.Auscultation with Diaphragm Mitral area (apical area) 117.Auscultation with Diaphragm Sitting, left lower sternal border, patient fully exhaled 118.Auscultation with bell. Tricuspid area 119.Auscultation with bell. Mitral area 120.Auscultation with bell. Mitral area in the left lateral decubitus position 121.Done correctly - Bell applied light pressure, not heavy (remember newer stethoscopes diaphragm lightly OK) 122Other. Stethoscope placed in examiner's ears correctly

Inspection Auscultation Percussion Palpation

Inspection Auscultation Percussion Palpation

All 4 quadrants Liver span All 4 quadrants Liver Spleen Kidneys Aorta
Right lateral ducubitus

Palpate R Kidney

Palpate L Kidney

123. M. ABDOMEN. Inspection with adequate exposure (lower chest to pelvis) 124. Auscultation: Listens at least 10 secs. (one place or can move to several areas, must listen for at least 10 secs) 125. Percussion: L abdomen above below umbilicus 126.Percussion: R abdomen above below umbilicus 127. Percussion: Liver span (measure liver span, may do scratch test) 128. Palpation: Lightly, all 4 quadrants 129.Palpation: Deeply, all 4 quadrants 130. Palpation: Liver (attempts to do) 131. Palpation: Liver (correctly palpating deepest full inspiration, 1 hand under one hand palpating or 2 palpating) 132. Palpation: Spleen (attempts to do) 133. Palpation: Spleen (correctly - position, breaths, palpating deepest full inspiration, 1 hand under L side, 1 feeling) 134. Palpation: Spleen (if not palpable, R lateral decubitus) 135. Palpation: R kidney (take a deep breath, capture kidney, exhale, slowly release kidney 136. Palpation: L kidney (take a deep breath, capture kidney, exhale, slowly release kidney) 137. Palpation: For abdominal aorta (to feel both the left and right walls of the aorta) 138. Palpation: Inspects patients face during palpation (at least 50% of the time) 139. In correct order: Inspection, auscultation, percussion and palpation 140. Abdominal Examination was done at 0.

DR. TAREK NASSAR

MRCP. MMED.MBBCH