History Taking &General examination
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History Taking &General examination

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A brief Presentation of Salient points to be considered while taking history and genaral examination.

A brief Presentation of Salient points to be considered while taking history and genaral examination.

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History Taking &General examination History Taking &General examination Presentation Transcript

  • History Taking
  • Personal History
    • Name
    • Age
    • Sex
    • Occupation
    • Residence
    • Marital state, number of children
    • Menstrual history in some cases
    • Special habits of medical importance (e.g. smoking: number of cigarettes & duration)
    • Social history
  • Complaint: In the patient’s own words & duration
  • History of the present illness
    • Symptoms are analyzed in relation to each other and chronologically.
    • Onset : Sudden ,acute or gradual.
    • Course: - Progressive
    • - Stationary
    • - Regressive
    • - Fluctuating
    • - Responce to Tx
    • Negative information in some cases may be important e.g. central chest pain not related to effort
    • Review of other systems
  • Past history:
    • Previous illness
    • Drugs
    • Pregnancies.
    • Family history:
    • Similar disease
    • DM
    • Hypertension
    • Allergy
    • Trauma
    • Surgery
    • Blood transfusion
    • Travel abroad
    • Radiotherapy
  • Example of a symptom’s analysis Pain : ask about 1-Site:
    • Midline pain arise from single structure
    • ( heart -liver- pancrease -GIT).
    • Localized or diffuse
    • Diaphragmatic pleura --> tip of shoulder
    • Myocardial ischemia --> retrosternal, Lt arm, Lt shoulder
    3-Character of pain: aching, colicky, stabbing, burning……. 2- Radiation :
  • Pain (cont .) 4-Severity of pain 5-Duration: e.g. - Trigemimd neuralgia ( seconds) - Intestinal colic (minutes) 6-Frequency & Periodicity 7-Time of occurence: e.g.
    • Morning headache in migraine & HTN
    • After rising in frontal sinusits.
    • At the end of the day in tension headache
  • Pain (cont .) 8- Aggravating factors : e.g. swallowing in esophagitis 9- Relieving factors: e.g. stop walking in ischemic pain 10-Associated phenomena: e.g. marked swaeting in cardiac pain
  • General Examination
  • Routine Data or Vital Signs :
    • Temperature
    • Pulse
    • Blood pressure
    • Respiratory rate
  • Radial Artery
  • Pulse Examination
  • Sphygmomanometer cuff
  • Length of the cuff
  • Stethoscope
  • Brachial Artery
  • BP measurement
  • Temperature Normal: 36 .5 - 37.2 0 c -Diurnal variation -Age -Menstrual cycle variation Fever: T> 37.4 0 c -Infection -Tissue injury
  • Hyperpyrexia :T> 41.5 0 c
    • Neoplastic causes
    • Collagen diseases
    • Drugs
    • Endocrine causes
    • CNS causes
    • Shock.
    • Hypothyroidism
    • Panhypopituitarism
    • Starvation
    • Damage to anterior hypothalamus
    • Old age
    • Drugs e.g. phenothiazine
    Hypothermia:
  • Types of fever
    • Continuous Fever: Day & night changes < 1 0 C -Pneumonia
    • -Meningitis
    • Relapsing Fever: Brucellosis- spirochaetal relapsing fever- Bel Epstein fever (Hodgkin’s disease)- charcoat fever (biliary obstruction)
    • Intermittent Fever: reaches base line during day
    • - Malaria
    • Remittent Fever : variation > 1 0 C
    • -Septic conditions
  • Color changes
    • Normal complexion depends on:-
    • Thickness of skin
    • Edema and Myxoedema  pallor
    • Vascularity , Hb
    • Reduced Hg > 5 gm  cyanosis
    • Presence of pigments .
    • Bilirubin ++ --> jaundice
    • Caroten causes yellowish discoloration
  • Pallor
    • Look for mucous membrane in inner aspect of lips
    • Hb < 6 gm/dl --> pale palmar creases
    • Causes of pallor:
    • Anemia
    • Anxiety
    • Shock
    • Edema
  • Cyanosis
    • Bluish discoloration
    • -Central ~~~ lateral aspect of under surface
    • of the tongue (warm hands)
    • -Peripheral ~~~ extremities (cold hands)
    • D.D of central cyanosis: ++ methemoglobin
    • N.B red cyanosis is due to CO poisoning
  • Cyanosis
  • Body Built 1 Body Built (weight & Hight) BMI = BW (kg) / Ht (m 2 ) >40 30-40 25-30 20-25 Morbid Obesity Obese Over weight Normal
  • Body Built 2
    • Factors affecting the body built :
    • Racial
    • Familial
    • Genetic
    • Endocrine
    • Malnutrition in young age
    • Child hood disease.
    Body Built
  • Decubitus :
    • Rigid dorsal decubitus
    • Lateral decubitus
    • Coild up
    • Opisthotonus
    • Orthopnea
    • prayers posture
    • Squatting
    • Tri Pod position
  • Tri Pod position Patient with emphysema bending over in Tri-Pod Position
  • Examination of the HEAD & FACE
  • HEAD & FACE Head : Face :
    • Size
    • Shape
    • Localized swelling
    • Expression
    • Edema and swelling
    • Complexion
    • Color change ( pallor - cyanosis - jaundice)
    • Individual organs
    • Asymmetry
    • Malar flush ------
  • Facial swelling causing asymmetry Facial swelling
  • Facial swelling:Rt periorbital
  • Normal Eye
  • Jaundice
  • Jaundice2
  • Eye Lids Edema Xanthelasma Dark ring Ptosis 3rd nerve paralysis - Horner’s syndrome Myathenia gravis Congenital retraction Thyrotoxicosis
  • Edema of the eye lids
  • Eye ball
    • Exophthalmus:
    • Congenital
    • Local condition
    • Cavernous sinus
    • A.V aneurysm
    • Thyrotoxicosis
    • Enophthalmus: dehydration -----
  • Pupils
    • Pupils : size – equality - light reaction
    • Small pinpoint pupils
    • Mid position fixed pupil: (4-6mm) slightly dilated with no light reaction  Mid brain damage
    • Horner syndrome
    • pontine Hge
    • Drugs: morphine, heroin , narcoti
    • Sympath. Damage
    • Hypothalamic
    • Metabolic
    < 1mm ( 1- 2.5 nm ) Unilateral Bilateral small pupils
  • Horner syndrome
  • Pupils 2 “ Large” dilated pupils anoxia Bilaterally dilated pupils (fixed): drugs (atropine - phenothiazine- tricyclic antidepressants) (Reactive) Unilaterally dilated pupil ( Fixed dilated) Oculomotor paralysis Temporal lobe herniation ---Mid brain .
    • Cocaine
    • Amphetamine,
    • LSD
    • (Sympath. Agonists )
  • Conjunctiva
    • Hemorrhage
    • Subconjunctivl haemorrage with severe cough
    • Hypertension
    • Septicaemia
    • Bleeding tendency
    Chemosis: edema
  • Conjunctivitis
  • Sclera
    • Scleritis
    • Episcleritis
  • Scleritis
  • Nodular Episcleritis in a patient with CD
  • Cornea Nose Ear
    • Tophi
    • Discoloration
    • Cyanosis
    • Ochronosis
    • Dischrge
  • Parotid glands
    • Unilateral enlargement as in acute parotitis
    • Bilateral enlargement as in Sjogren Syndrome
  • Unilaterally enlarged parotid
  • Mouth: Lips
    • Color
    • Angular stomatitis
    • Chelitis
    • Hypertrophy
    • Herpes labialis
    • Acromegaly
    • Telangiectasia
    • Myxoedema
    • Trauma
    • Angioedema
  • Breath
    • Fetid breath (Fetor oris)
    • Alcohol
    • Acetone : D.K.A
    • Ammonia ---> uraemia
    • Fetor hepaticus
    • Local oral condition
    • pyorrhea
    • Suppurative lung syndrome
    • Pyloric obstruction
  • Mouth : Dryness and increased salivation
    • Dehydration
    • Mouth breathing
    • Anxiety
    • Drugs, e.g. anticholinergics
    • Sj ö gren syndrome
    • Causes of Dry Mouth
    • Ptyalism: increased salivation
  • Normal oral cavity
  • Left peritonsillar abscess
  • Teeth
    • Loose teeth: - D.M - Hyperparathyroidism
    • Wide spaced teeth: acromegaly
    • Discoloration:
    • Tobacco
    • Poor oral hygiene
    • Flourosis
    xxxxx
  • Tooth abscess Tooth Abscess
  • Gums
    • Pyorrhea
    • Bleeding as in:
    • Hypertrophy as in:
    • Addison
    • Heavy metal ( lead and bisthmus) poisoning
    • Drugs like epanutin
    • Monocytic leukemia
    • Pigmentation as in:
    • Chronic liver disease
    • Thrombocytopenia
  • Tongue 1
    • color
    • pale
    • Bright red ( firy tongue- pellagra)
    • Atrophic glossitis ( iron  , B12  , riboflavin  - pellagra)
    • Black --> iron mixture
    • coated --> dehydration
    • Strawberry tongue scarlet feve
    • Leukoplakia: precancerous
    • Pigment : Addison’s disease
  • Tongue 2
    • Dry tongue (see causes of dry mouth)
    • Scrotal tongue (mongolism)
    • Tremors
    • Large tongue (macroglossia) as in acromegaly
    • Anxiety
    • Smoking
    • Parkinsonism
    • Chronic Alcoholism
  • Buccal mucosa 1
    • Stomatitis
    • (Red, swollen& tender)
    • Catarrhal
    • Ulcerative
    • Monilia
    • Aphthous
    • Vincent’s angina
    • Pigmentation
    • Dark skinned
    • Addison disease
    • Intestinal polyposis
    • Arsenic
    • Hemochromatosis
  • Buccal mucosa 2
    • Enanthema : Koplik’s spots
    • Petechial Hge: Infective endocarditis - leukaemia
    • Palate:
    • Tonsils
    • Deformity
    • Paralysis
    • Vesicles
  • Neck
    • Insepction
    • Palpation
    • Lymph Nodes
    • Salivary glands
    • Thyroid
    • other swellings
    • Deformity
    • Asymmetry
    • Position
    • Limitation of movement
    • Pulsations
  • Thyroid gland:anatomy Isthmus
  • Palpation of the thyroid gland:posterior approach
  • Palpation of the thyroid gland: anterior approach
  • Neck veins Jugular Vein Carotid Artery No pulsations palpable. Palpable pulsations. Pulsations obliterated by pressure above the clavicle. Pulsations not obliterated by pressure above the clavicle. Level of pulse wave decreased on inspiration; increased on expiration. No effects of respiration on pulse. Usually two pulsations per systole (x and y descents). One pulsation per systole. Prominent descents. Descents not prominent. Pulsations sometimes more prominent with abnominal pressure. No effect of abdominal pressure on pulsations
  • Cervical lymph nodes
  • Examination of Axillae
    • Lymph nodes
    • Any swelling
  • Examination of the axilla 1
  • Axillary lymphadenopathy
  • Examination of the axilla 2
  • Examination of the Breast
    • Gynecomastia:
    • Physialogicl
    • Drugs
    • Liver cell failure
    • Klinefelter
    • Testiculr atrophy and tumors
    • Adrenal tumors
    • Estrogen
    • Spironolactone
    • Chloropromazine
  • Epitrochlear LN
  • Examination of the Upper Limbs:Edema
  • DVT of the right arm
  • Cellulitis of the upper limb Examination of upper limbs:Cellulitis
  • Cellulitis of the upper limb 2
  • Examination of Hands
    • Shape & Size
    • Wasting of the muscles
    • Signs of peripheral vascular disease
    • Staining of nails: as in heavy cig smokers
    • White nails uraemia - liver cell failure
    • Splinter Hg S.A.B.E
    See also joint examination
  • Acromegaly
  • Peripheral Vascular Disease of the UL
  • Wasting of the thenar eminance
  • Nicotine staining
  • Wrist: Ganglion
  • Skin 1
    • Pigmentation
    • Texture
    • Elasticity
    • Thickness
    • Striae
    • Eruption
  • Skin 2
    • Pigmentation
    • Leucoderma: -Vitiligo -leprosy - SLE
    • - Pityriasis versicolor
    • Cloasma
    • Sun burn
    • Post- inflammatory
    • X-ray
    • Neurofibromatosis
    • Addison’s disease
    • Pellagra
    • Hemochromatosis
    • Ochronosis
    • Arsenic
    Locaalized Generalized
  • Skin 3 2-Texture:
    • Dryness
    • Sweating
    • Dehydration
    • Myxedema
    • Anxiety
    • Thyrotoxicosis
    • Respiratory failure
    • Hyroglycaemia
    • Toxemia
  • Skin 4 3.Elasticity : cutis loxa - old age - progeria 4.Thickness : -Acromegaly - Elephantiasis - Occupational 5.Striae:
    • Pregnancy
    • Obesity
    • Cushing’s syndrome
  • Skin 5 6-Eruption:
    • Distribution: distribution of sensory nerve  HZ
    • Arrangement:
    • Morphology:
    • Linear  lymphangitis
    • Annular  psoriasis
    • Serpiginous  Syphilis
    • Irregular  urticria
    • Monomorphic
    • Pleomorphic
    • Type: Macule- papule- nodule- plaque- vesicles- bullae- pustule - wheals - scales - crust – erosion - fissure- ulcers –
    • scar - atrophy - sclerosis.
  • Skin 6
    • Dilated Blood vessels
    • Petechie 1-2 mm (Hess test)
    • Purpura: e.g. thrombocytopenia , Senile purpura
    • Ecchymosis > 5 mm
    • Collaterals
    • Telangiectsia.
    • Haemangioma
    • Vascular spiders
    • Campbell de Morgan spots
  • Telangiectasia
  • Skin-Hair
    • Fall of hair :
    • Look for Distribution: {head, face, axillae, and pubis)
    • Hirsutism: excessive growth of body hair of a female
    • Idiopathic
    • Racial
    • Endocrine: Cushing- adrenogenital syndrome- polycystic ovary.
    • Endocrine: Myxoedem - Addison’s disease - Sheehan’s syndrome- Eunchiadism
    • Infection
    • Localized fall of hair: Alopecia areata
  • Lymph nodes 1
    • Group {cervical (superfacial and deep) , scalene (Lt virchow), axillary, epitrochlear, inguinal }.
    • Size
    • Consistency
    • Tenderness
    • Matting
    • Mobility
    • Relation to surrounding structures.
  • Lymph nodes 2
    • Lymphadenopathy:
    • Localized :
    • Acute lymphadenitis
    • T.B
    • Hodgkin’ disease
    • Generalized:
    • Viral : glandulr fever
    • Leukemia . Lymphoma
    • Syphilis
    • Sarcoidosis
  • Examination of the Lower Limbs
  • Peripheral pulsation :Dorsalis pedis
  • Peripheral puls ations :Dorsalis pedis 2
  • Peripheral pulsations :post tibial artery
  • Peripheral pulsations : posterior tibial artery 2
  • Popliteal artery
  • Acute vascular insufficiency: mottled appearance
  • Chronic arterial insufficiency
  • Digital gangrene
  • Chronic Venous Insufficiency
  • Neuropathic ulcer in a diabetic patient
  • Lower limbs: edema 1
    • Inspection
    • Pressure over bony prominance for 5 to 30 sec just behind and below medial malleoli and sacrum
    • For soft tissue edema:
    • pinching  dimpling of skin ( Peou’d ‘orange)
    • press with the stethoscope
  • Lower limbs:Edema 2
    • Edema may be:
    • Hard as in chronic. lymphatic obstruction.
    • Soft
    • Causes of Soft Edema:
    • Localized edema: Inflammtory (hot, red, tender)- Angioneurotic - DVT- Paralysis --> paralyzed side
    • Generlized edema:
    • Renal
    • Cardiac
    • Nutritional
    • Hepatic
  • LL edema
  • Pitting edema of the lower limb
  • Erythema nodosum
  • Onychomycosis
  • Genitalia and Joints Genitalia Joints :
    • Swelling
    • Deformity
    • Overlying skin
    • Tenderness
    • Atrophy of muscles
    • Limitation of movement
    • Hypermobility
    • Eruption
  • Rheumatoid arthritis
  • RA: boutonniere finger
  • Rheumatoid arthritis 2
  • Heberdens nodes Heberdens nodes
  • Gout: MCP joints
  • Leprosy