History Taking &General examination

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

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History Taking &General examination

  1. 1. History Taking
  2. 2. Personal History <ul><li>Name </li></ul><ul><li>Age </li></ul><ul><li>Sex </li></ul><ul><li>Occupation </li></ul><ul><li>Residence </li></ul><ul><li>Marital state, number of children </li></ul><ul><li>Menstrual history in some cases </li></ul><ul><li>Special habits of medical importance (e.g. smoking: number of cigarettes & duration) </li></ul><ul><li>Social history </li></ul>
  3. 3. Complaint: In the patient’s own words & duration
  4. 4. History of the present illness <ul><li>Symptoms are analyzed in relation to each other and chronologically. </li></ul><ul><li>Onset : Sudden ,acute or gradual. </li></ul><ul><li>Course: - Progressive </li></ul><ul><li>- Stationary </li></ul><ul><li>- Regressive </li></ul><ul><li>- Fluctuating </li></ul><ul><li>- Responce to Tx </li></ul><ul><li>Negative information in some cases may be important e.g. central chest pain not related to effort </li></ul><ul><li>Review of other systems </li></ul>
  5. 5. Past history: <ul><li>Previous illness </li></ul><ul><li>Drugs </li></ul><ul><li>Pregnancies. </li></ul><ul><li>Family history: </li></ul><ul><li>Similar disease </li></ul><ul><li>DM </li></ul><ul><li>Hypertension </li></ul><ul><li>Allergy </li></ul><ul><li>Trauma </li></ul><ul><li>Surgery </li></ul><ul><li>Blood transfusion </li></ul><ul><li>Travel abroad </li></ul><ul><li>Radiotherapy </li></ul>
  6. 6. Example of a symptom’s analysis Pain : ask about 1-Site: <ul><li>Midline pain arise from single structure </li></ul><ul><li>( heart -liver- pancrease -GIT). </li></ul><ul><li>Localized or diffuse </li></ul><ul><li>Diaphragmatic pleura --> tip of shoulder </li></ul><ul><li>Myocardial ischemia --> retrosternal, Lt arm, Lt shoulder </li></ul>3-Character of pain: aching, colicky, stabbing, burning……. 2- Radiation :
  7. 7. 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. <ul><li>Morning headache in migraine & HTN </li></ul><ul><li>After rising in frontal sinusits. </li></ul><ul><li>At the end of the day in tension headache </li></ul>
  8. 8. 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
  9. 9. General Examination
  10. 10. Routine Data or Vital Signs : <ul><li>Temperature </li></ul><ul><li>Pulse </li></ul><ul><li>Blood pressure </li></ul><ul><li>Respiratory rate </li></ul>
  11. 11. Radial Artery
  12. 12. Pulse Examination
  13. 13. Sphygmomanometer cuff
  14. 14. Length of the cuff
  15. 15. Stethoscope
  16. 16. Brachial Artery
  17. 17. BP measurement
  18. 18. Temperature Normal: 36 .5 - 37.2 0 c -Diurnal variation -Age -Menstrual cycle variation Fever: T> 37.4 0 c -Infection -Tissue injury
  19. 19. Hyperpyrexia :T> 41.5 0 c <ul><li>Neoplastic causes </li></ul><ul><li>Collagen diseases </li></ul><ul><li>Drugs </li></ul><ul><li>Endocrine causes </li></ul><ul><li>CNS causes </li></ul>
  20. 20. <ul><li>Shock. </li></ul><ul><li>Hypothyroidism </li></ul><ul><li>Panhypopituitarism </li></ul><ul><li>Starvation </li></ul><ul><li>Damage to anterior hypothalamus </li></ul><ul><li>Old age </li></ul><ul><li>Drugs e.g. phenothiazine </li></ul>Hypothermia:
  21. 21. Types of fever <ul><li>Continuous Fever: Day & night changes < 1 0 C -Pneumonia </li></ul><ul><li>-Meningitis </li></ul><ul><li>Relapsing Fever: Brucellosis- spirochaetal relapsing fever- Bel Epstein fever (Hodgkin’s disease)- charcoat fever (biliary obstruction) </li></ul><ul><li>Intermittent Fever: reaches base line during day </li></ul><ul><li>- Malaria </li></ul><ul><li>Remittent Fever : variation > 1 0 C </li></ul><ul><li>-Septic conditions </li></ul>
  22. 22. Color changes <ul><li>Normal complexion depends on:- </li></ul><ul><li>Thickness of skin </li></ul><ul><li>Edema and Myxoedema  pallor </li></ul><ul><li>Vascularity , Hb </li></ul><ul><li>Reduced Hg > 5 gm  cyanosis </li></ul><ul><li>Presence of pigments . </li></ul><ul><li>Bilirubin ++ --> jaundice </li></ul><ul><li>Caroten causes yellowish discoloration </li></ul>
  23. 23. Pallor <ul><li>Look for mucous membrane in inner aspect of lips </li></ul><ul><li>Hb < 6 gm/dl --> pale palmar creases </li></ul><ul><li>Causes of pallor: </li></ul><ul><li>Anemia </li></ul><ul><li>Anxiety </li></ul><ul><li>Shock </li></ul><ul><li>Edema </li></ul>
  24. 24. Cyanosis <ul><li>Bluish discoloration </li></ul><ul><li>-Central ~~~ lateral aspect of under surface </li></ul><ul><li>of the tongue (warm hands) </li></ul><ul><li>-Peripheral ~~~ extremities (cold hands) </li></ul><ul><li>D.D of central cyanosis: ++ methemoglobin </li></ul><ul><li>N.B red cyanosis is due to CO poisoning </li></ul>
  25. 25. Cyanosis
  26. 26. 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
  27. 27. Body Built 2 <ul><li>Factors affecting the body built : </li></ul><ul><li>Racial </li></ul><ul><li>Familial </li></ul><ul><li>Genetic </li></ul><ul><li>Endocrine </li></ul><ul><li>Malnutrition in young age </li></ul><ul><li>Child hood disease. </li></ul>Body Built
  28. 28. Decubitus : <ul><li>Rigid dorsal decubitus </li></ul><ul><li>Lateral decubitus </li></ul><ul><li>Coild up </li></ul><ul><li>Opisthotonus </li></ul><ul><li>Orthopnea </li></ul><ul><li>prayers posture </li></ul><ul><li>Squatting </li></ul><ul><li>Tri Pod position </li></ul>
  29. 29. Tri Pod position Patient with emphysema bending over in Tri-Pod Position
  30. 30. Examination of the HEAD & FACE
  31. 31. HEAD & FACE Head : Face : <ul><li>Size </li></ul><ul><li>Shape </li></ul><ul><li>Localized swelling </li></ul><ul><li>Expression </li></ul><ul><li>Edema and swelling </li></ul><ul><li>Complexion </li></ul><ul><li>Color change ( pallor - cyanosis - jaundice) </li></ul><ul><li>Individual organs </li></ul><ul><li>Asymmetry </li></ul><ul><li>Malar flush ------ </li></ul>
  32. 32. Facial swelling causing asymmetry Facial swelling
  33. 33. Facial swelling:Rt periorbital
  34. 34. Normal Eye
  35. 35. Jaundice
  36. 36. Jaundice2
  37. 37. Eye Lids Edema Xanthelasma Dark ring Ptosis 3rd nerve paralysis - Horner’s syndrome Myathenia gravis Congenital retraction Thyrotoxicosis
  38. 38. Edema of the eye lids
  39. 39. Eye ball <ul><li>Exophthalmus: </li></ul><ul><li>Congenital </li></ul><ul><li>Local condition </li></ul><ul><li>Cavernous sinus </li></ul><ul><li>A.V aneurysm </li></ul><ul><li>Thyrotoxicosis </li></ul><ul><li>Enophthalmus: dehydration ----- </li></ul>
  40. 40. Pupils <ul><li>Pupils : size – equality - light reaction </li></ul><ul><li>Small pinpoint pupils </li></ul><ul><li>Mid position fixed pupil: (4-6mm) slightly dilated with no light reaction  Mid brain damage </li></ul><ul><li>Horner syndrome </li></ul><ul><li>pontine Hge </li></ul><ul><li>Drugs: morphine, heroin , narcoti </li></ul><ul><li>Sympath. Damage </li></ul><ul><li>Hypothalamic </li></ul><ul><li>Metabolic </li></ul>< 1mm ( 1- 2.5 nm ) Unilateral Bilateral small pupils
  41. 41. Horner syndrome
  42. 42. 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 . <ul><li>Cocaine </li></ul><ul><li>Amphetamine, </li></ul><ul><li>LSD </li></ul><ul><li>(Sympath. Agonists ) </li></ul>
  43. 43. Conjunctiva <ul><li>Hemorrhage </li></ul><ul><li>Subconjunctivl haemorrage with severe cough </li></ul><ul><li>Hypertension </li></ul><ul><li>Septicaemia </li></ul><ul><li>Bleeding tendency </li></ul>Chemosis: edema
  44. 44. Conjunctivitis
  45. 45. Sclera <ul><li>Scleritis </li></ul><ul><li>Episcleritis </li></ul>
  46. 46. Scleritis
  47. 47. Nodular Episcleritis in a patient with CD
  48. 48. Cornea Nose Ear <ul><li>Tophi </li></ul><ul><li>Discoloration </li></ul><ul><li>Cyanosis </li></ul><ul><li>Ochronosis </li></ul><ul><li>Dischrge </li></ul>
  49. 49. Parotid glands <ul><li>Unilateral enlargement as in acute parotitis </li></ul><ul><li>Bilateral enlargement as in Sjogren Syndrome </li></ul>
  50. 50. Unilaterally enlarged parotid
  51. 51. Mouth: Lips <ul><li>Color </li></ul><ul><li>Angular stomatitis </li></ul><ul><li>Chelitis </li></ul><ul><li>Hypertrophy </li></ul><ul><li>Herpes labialis </li></ul><ul><li>Acromegaly </li></ul><ul><li>Telangiectasia </li></ul><ul><li>Myxoedema </li></ul><ul><li>Trauma </li></ul><ul><li>Angioedema </li></ul>
  52. 52. Breath <ul><li>Fetid breath (Fetor oris) </li></ul><ul><li>Alcohol </li></ul><ul><li>Acetone : D.K.A </li></ul><ul><li>Ammonia ---> uraemia </li></ul><ul><li>Fetor hepaticus </li></ul><ul><li>Local oral condition </li></ul><ul><li>pyorrhea </li></ul><ul><li>Suppurative lung syndrome </li></ul><ul><li>Pyloric obstruction </li></ul>
  53. 53. Mouth : Dryness and increased salivation <ul><li>Dehydration </li></ul><ul><li>Mouth breathing </li></ul><ul><li>Anxiety </li></ul><ul><li>Drugs, e.g. anticholinergics </li></ul><ul><li>Sj ö gren syndrome </li></ul><ul><li>Causes of Dry Mouth </li></ul><ul><li>Ptyalism: increased salivation </li></ul>
  54. 54. Normal oral cavity
  55. 55. Left peritonsillar abscess
  56. 56. Teeth <ul><li>Loose teeth: - D.M - Hyperparathyroidism </li></ul><ul><li>Wide spaced teeth: acromegaly </li></ul><ul><li>Discoloration: </li></ul><ul><li>Tobacco </li></ul><ul><li>Poor oral hygiene </li></ul><ul><li>Flourosis </li></ul>xxxxx
  57. 57. Tooth abscess Tooth Abscess
  58. 58. Gums <ul><li>Pyorrhea </li></ul><ul><li>Bleeding as in: </li></ul><ul><li>Hypertrophy as in: </li></ul><ul><li>Addison </li></ul><ul><li>Heavy metal ( lead and bisthmus) poisoning </li></ul><ul><li>Drugs like epanutin </li></ul><ul><li>Monocytic leukemia </li></ul><ul><li>Pigmentation as in: </li></ul><ul><li>Chronic liver disease </li></ul><ul><li>Thrombocytopenia </li></ul>
  59. 59. Tongue 1 <ul><li>color </li></ul><ul><li>pale </li></ul><ul><li>Bright red ( firy tongue- pellagra) </li></ul><ul><li>Atrophic glossitis ( iron  , B12  , riboflavin  - pellagra) </li></ul><ul><li>Black --> iron mixture </li></ul><ul><li>coated --> dehydration </li></ul><ul><li>Strawberry tongue scarlet feve </li></ul><ul><li>Leukoplakia: precancerous </li></ul><ul><li>Pigment : Addison’s disease </li></ul>
  60. 60. Tongue 2 <ul><li>Dry tongue (see causes of dry mouth) </li></ul><ul><li>Scrotal tongue (mongolism) </li></ul><ul><li>Tremors </li></ul><ul><li>Large tongue (macroglossia) as in acromegaly </li></ul><ul><li>Anxiety </li></ul><ul><li>Smoking </li></ul><ul><li>Parkinsonism </li></ul><ul><li>Chronic Alcoholism </li></ul>
  61. 61. Buccal mucosa 1 <ul><li>Stomatitis </li></ul><ul><li>(Red, swollen& tender) </li></ul><ul><li>Catarrhal </li></ul><ul><li>Ulcerative </li></ul><ul><li>Monilia </li></ul><ul><li>Aphthous </li></ul><ul><li>Vincent’s angina </li></ul><ul><li>Pigmentation </li></ul><ul><li>Dark skinned </li></ul><ul><li>Addison disease </li></ul><ul><li>Intestinal polyposis </li></ul><ul><li>Arsenic </li></ul><ul><li>Hemochromatosis </li></ul>
  62. 62. Buccal mucosa 2 <ul><li>Enanthema : Koplik’s spots </li></ul><ul><li>Petechial Hge: Infective endocarditis - leukaemia </li></ul><ul><li>Palate: </li></ul><ul><li>Tonsils </li></ul><ul><li>Deformity </li></ul><ul><li>Paralysis </li></ul><ul><li>Vesicles </li></ul>
  63. 63. Neck <ul><li>Insepction </li></ul><ul><li>Palpation </li></ul><ul><li>Lymph Nodes </li></ul><ul><li>Salivary glands </li></ul><ul><li>Thyroid </li></ul><ul><li>other swellings </li></ul><ul><li>Deformity </li></ul><ul><li>Asymmetry </li></ul><ul><li>Position </li></ul><ul><li>Limitation of movement </li></ul><ul><li>Pulsations </li></ul>
  64. 64. Thyroid gland:anatomy Isthmus
  65. 65. Palpation of the thyroid gland:posterior approach
  66. 66. Palpation of the thyroid gland: anterior approach
  67. 67. 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
  68. 68. Cervical lymph nodes
  69. 69. Examination of Axillae <ul><li>Lymph nodes </li></ul><ul><li>Any swelling </li></ul>
  70. 70. Examination of the axilla 1
  71. 71. Axillary lymphadenopathy
  72. 72. Examination of the axilla 2
  73. 73. Examination of the Breast <ul><li>Gynecomastia: </li></ul><ul><li>Physialogicl </li></ul><ul><li>Drugs </li></ul><ul><li>Liver cell failure </li></ul><ul><li>Klinefelter </li></ul><ul><li>Testiculr atrophy and tumors </li></ul><ul><li>Adrenal tumors </li></ul><ul><li>Estrogen </li></ul><ul><li>Spironolactone </li></ul><ul><li>Chloropromazine </li></ul>
  74. 74. Epitrochlear LN
  75. 75. Examination of the Upper Limbs:Edema
  76. 76. DVT of the right arm
  77. 77. Cellulitis of the upper limb Examination of upper limbs:Cellulitis
  78. 78. Cellulitis of the upper limb 2
  79. 79. Examination of Hands <ul><li>Shape & Size </li></ul><ul><li>Wasting of the muscles </li></ul><ul><li>Signs of peripheral vascular disease </li></ul><ul><li>Staining of nails: as in heavy cig smokers </li></ul><ul><li>White nails uraemia - liver cell failure </li></ul><ul><li>Splinter Hg S.A.B.E </li></ul>See also joint examination
  80. 80. Acromegaly
  81. 81. Peripheral Vascular Disease of the UL
  82. 82. Wasting of the thenar eminance
  83. 83. Nicotine staining
  84. 84. Wrist: Ganglion
  85. 85. Skin 1 <ul><li>Pigmentation </li></ul><ul><li>Texture </li></ul><ul><li>Elasticity </li></ul><ul><li>Thickness </li></ul><ul><li>Striae </li></ul><ul><li>Eruption </li></ul>
  86. 86. Skin 2 <ul><li>Pigmentation </li></ul><ul><li>Leucoderma: -Vitiligo -leprosy - SLE </li></ul><ul><li>- Pityriasis versicolor </li></ul><ul><li>Cloasma </li></ul><ul><li>Sun burn </li></ul><ul><li>Post- inflammatory </li></ul><ul><li>X-ray </li></ul><ul><li>Neurofibromatosis </li></ul><ul><li>Addison’s disease </li></ul><ul><li>Pellagra </li></ul><ul><li>Hemochromatosis </li></ul><ul><li>Ochronosis </li></ul><ul><li>Arsenic </li></ul>Locaalized Generalized
  87. 87. Skin 3 2-Texture: <ul><li>Dryness </li></ul><ul><li>Sweating </li></ul><ul><li>Dehydration </li></ul><ul><li>Myxedema </li></ul><ul><li>Anxiety </li></ul><ul><li>Thyrotoxicosis </li></ul><ul><li>Respiratory failure </li></ul><ul><li>Hyroglycaemia </li></ul><ul><li>Toxemia </li></ul>
  88. 88. Skin 4 3.Elasticity : cutis loxa - old age - progeria 4.Thickness : -Acromegaly - Elephantiasis - Occupational 5.Striae: <ul><li>Pregnancy </li></ul><ul><li>Obesity </li></ul><ul><li>Cushing’s syndrome </li></ul>
  89. 89. Skin 5 6-Eruption: <ul><li>Distribution: distribution of sensory nerve  HZ </li></ul><ul><li>Arrangement: </li></ul><ul><li>Morphology: </li></ul><ul><li>Linear  lymphangitis </li></ul><ul><li>Annular  psoriasis </li></ul><ul><li>Serpiginous  Syphilis </li></ul><ul><li>Irregular  urticria </li></ul><ul><li>Monomorphic </li></ul><ul><li>Pleomorphic </li></ul><ul><li>Type: Macule- papule- nodule- plaque- vesicles- bullae- pustule - wheals - scales - crust – erosion - fissure- ulcers – </li></ul><ul><li>scar - atrophy - sclerosis. </li></ul>
  90. 90. Skin 6 <ul><li>Dilated Blood vessels </li></ul><ul><li>Petechie 1-2 mm (Hess test) </li></ul><ul><li>Purpura: e.g. thrombocytopenia , Senile purpura </li></ul><ul><li>Ecchymosis > 5 mm </li></ul><ul><li>Collaterals </li></ul><ul><li>Telangiectsia. </li></ul><ul><li>Haemangioma </li></ul><ul><li>Vascular spiders </li></ul><ul><li>Campbell de Morgan spots </li></ul>
  91. 91. Telangiectasia
  92. 92. Skin-Hair <ul><li>Fall of hair : </li></ul><ul><li>Look for Distribution: {head, face, axillae, and pubis) </li></ul><ul><li>Hirsutism: excessive growth of body hair of a female </li></ul><ul><li>Idiopathic </li></ul><ul><li>Racial </li></ul><ul><li>Endocrine: Cushing- adrenogenital syndrome- polycystic ovary. </li></ul><ul><li>Endocrine: Myxoedem - Addison’s disease - Sheehan’s syndrome- Eunchiadism </li></ul><ul><li>Infection </li></ul><ul><li>Localized fall of hair: Alopecia areata </li></ul>
  93. 93. Lymph nodes 1 <ul><li>Group {cervical (superfacial and deep) , scalene (Lt virchow), axillary, epitrochlear, inguinal }. </li></ul><ul><li>Size </li></ul><ul><li>Consistency </li></ul><ul><li>Tenderness </li></ul><ul><li>Matting </li></ul><ul><li>Mobility </li></ul><ul><li>Relation to surrounding structures. </li></ul>
  94. 94. Lymph nodes 2 <ul><li>Lymphadenopathy: </li></ul><ul><li>Localized : </li></ul><ul><li>Acute lymphadenitis </li></ul><ul><li>T.B </li></ul><ul><li>Hodgkin’ disease </li></ul><ul><li>Generalized: </li></ul><ul><li>Viral : glandulr fever </li></ul><ul><li>Leukemia . Lymphoma </li></ul><ul><li>Syphilis </li></ul><ul><li>Sarcoidosis </li></ul>
  95. 95. Examination of the Lower Limbs
  96. 96. Peripheral pulsation :Dorsalis pedis
  97. 97. Peripheral puls ations :Dorsalis pedis 2
  98. 98. Peripheral pulsations :post tibial artery
  99. 99. Peripheral pulsations : posterior tibial artery 2
  100. 100. Popliteal artery
  101. 101. Acute vascular insufficiency: mottled appearance
  102. 102. Chronic arterial insufficiency
  103. 103. Digital gangrene
  104. 104. Chronic Venous Insufficiency
  105. 105. Neuropathic ulcer in a diabetic patient
  106. 106. Lower limbs: edema 1 <ul><li>Inspection </li></ul><ul><li>Pressure over bony prominance for 5 to 30 sec just behind and below medial malleoli and sacrum </li></ul><ul><li>For soft tissue edema: </li></ul><ul><li>pinching  dimpling of skin ( Peou’d ‘orange) </li></ul><ul><li>press with the stethoscope </li></ul>
  107. 107. Lower limbs:Edema 2 <ul><li>Edema may be: </li></ul><ul><li>Hard as in chronic. lymphatic obstruction. </li></ul><ul><li>Soft </li></ul><ul><li>Causes of Soft Edema: </li></ul><ul><li>Localized edema: Inflammtory (hot, red, tender)- Angioneurotic - DVT- Paralysis --> paralyzed side </li></ul><ul><li>Generlized edema: </li></ul><ul><li>Renal </li></ul><ul><li>Cardiac </li></ul><ul><li>Nutritional </li></ul><ul><li>Hepatic </li></ul>
  108. 108. LL edema
  109. 109. Pitting edema of the lower limb
  110. 110. Erythema nodosum
  111. 111. Onychomycosis
  112. 112. Genitalia and Joints Genitalia Joints : <ul><li>Swelling </li></ul><ul><li>Deformity </li></ul><ul><li>Overlying skin </li></ul><ul><li>Tenderness </li></ul><ul><li>Atrophy of muscles </li></ul><ul><li>Limitation of movement </li></ul><ul><li>Hypermobility </li></ul><ul><li>Eruption </li></ul>
  113. 113. Rheumatoid arthritis
  114. 114. RA: boutonniere finger
  115. 115. Rheumatoid arthritis 2
  116. 116. Heberdens nodes Heberdens nodes
  117. 117. Gout: MCP joints
  118. 118. Leprosy

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