3. Objectives
At the end of the session you should be able to
take appropriate medical history and perform
thorough physical examination
know and differentiate normal findings from abnormal
findings
relate abnormal findings with underlying pathologies
4. INTRODUCTION
The word 'patient' is derived from the Latin ‘patiens’,
meaning sufferance or forbearance.
The overall purpose of medical practice is to relieve
suffering/pain.
In order to achieve this purpose, it is important to make a
diagnosis, to know how to approach treatment, and to
design an appropriate scheme of management for each
patient.
It is therefore essential to understand each person as fully
as possible, whatever their social class or ethnic and
cultural background.
5. The thorough doctor will not only elucidate the
problems posed by disease, but also apply his or her
skill to advise patients and families how to manage
these problems.
The distinction between cure of disease and relief of
symptoms remains as valid today as in the past.
No patient should leave a medical consultation
feeling that nothing can be done to help them, even
when the disease is incurable.
6. Clinical methods - the skills health professional
use to achieve this aim of excellence in clinical
practice - are acquired during a lifetime of
medical work i.e. clinical methods are acquired by
a combination of study and experience, and
there is always something new to learn.
The initial aims of any first consultation are to
understand the patient's own perception of their
problem and to start or complete the process of
diagnosis.
7. This double aim requires a knowledge of
disease and its patterns of presentation,
together with an ability to interpret a
patient's symptoms and signs.
Appropriate skills are needed to elicit the
symptoms from the patient's description and
conversation, and the signs by observation
and physical examination.
8. There are two main steps to making a diagnosis:
To establish the clinical features by history and
examination - this represents the clinical
database
To interpret the clinical database in terms of
disordered function and potential causative
pathologies, whether physical, mental, social, or
a combination of these.
10. THE HEALTH HISTORY…
• Disease is the explanation that the clinician
brings to the symptoms.
• It is the way that the clinician organizes what
he or she learns from the patient into a
coherent picture that leads to a clinical
diagnosis and treatment plan.
• Illness can be defined as how the patient
experiences symptoms.
11. Comprehensive Health History
the comprehensive history includes Identifying
Data and Source of the History, Chief
Complaint(s),Present Illness, Past History, Family
History, Personal and Social History, and Review
of Systems.
12. Should include all the facts of medical significance
in the life of the patient
Recent events should be given the most attention
The patient should, at some early point, have the
opportunity to tell his or her own story of the
illness without frequent interruption and, when
appropriate, receive expressions of interest,
encouragement, and empathy from the physician.
13. Any event related by the patient, however trivial or seemingly
irrelevant, may provide the key to solving the medical
problem.
Putting the patient at ease to the greatest extent possible
contributes substantially to obtaining an adequate history.
An informative history is more than an orderly listing of
symptoms i.e. by listening to patients and noting the way in
which they describe their symptoms, physicians can gain
valuable insight into the problem.
14. Inflections of voice, facial expression, gestures, and
attitude, i.e., "body language," may reveal important
clues to the meaning of the symptoms to the patient.
The social history also can provide important insights into
the types of diseases that should be considered.
The family history often reveals risk factors for common
disorders, such as coronary heart disease, hypertension,
asthma and rare Mendelian disorders.
15. Input from by stander/relative may be required to
ensure completeness and accuracy of the history.
The process of history-taking provides an opportunity to
observe the patient's behavior and watch for features to
be pursued more thoroughly during the physical
examination.
A beginning that focuses on issues that may be more
factual and less emotive can be more rewarding and lead
to a more satisfactory consultation.
16. Components of Clinical History
• Identification
• Previous admission
• Chief compliant
• History of present illness
• Past medical and surgical illness
• Personal and social history
• Family history
• Systemic review
17. Identifying Data
• Identifying data—such as name, age, gender,
occupation, marital status, patient address,
religion and sometimes ethnicity
• Source of the history—usually the patient, but
can be family member, friend, letter of
referral, or the medical record
• If appropriate, establish source of referral,
since a written report may be needed
18. Previous admission
o where/when was the admission?
o what was the diagnosis,what was done for him/her,
how long did s/he stay in the hospital, what was the
condition on discharge
Chief Complaint(s)
The one or more symptoms or concerns
causing the patient to seek care with duration e.g.
cough of 2weeks duration, abdominal pain of 3days
duration and vomiting of 1day duration
Make every attempt to quote the patient’s own
words with or without some modification.
19. Present Illness
• Amplifies the Chief Complaint, describes how
each symptom developed
• Usually begins with elaboration of chief
compliant(s)
• Includes patient’s thoughts and feelings about
the illness
• Pulls in relevant portions of the Review of
Systems (see below)
• May include medications, allergies, habits of
smoking and alcohol, since these are frequently
pertinent to the present illness
20. • This section of the history is a complete, clear,
and chronologic account of the problems
prompting the patient to seek care.
• The narrative should include the onset of the
problem, the setting in which it has developed, its
manifestations, and any treatments.
• The principal symptoms should be well
characterized, with descriptions of “the seven
attributes of a symptom”
21. 1. Location. Where is it? Does it radiate?
2. Quality. What is it like?
3. Quantity or severity. How bad is it?
4. Timing. When did (does) it start? How long did
(does) it last? How often did (does) it come?
5. Setting in which it occurs. Include environmental
factors, personal activities, emotional reactions, or
other circumstances that may have contributed to
the illness.
6. Remitting or exacerbating factors. Does anything
make it better or worse?
7. Associated manifestations. Have you noticed
anything else that accompanies it?
22. .
• It is also important to include “pertinent
positives” and “pertinent negatives” from
sections of the past history,family,personal &
social history and review of systems related to
the chief complaint(s).
• These designate the presence or absence of
symptoms relevant to the differential diagnosis,
which refers to the most likely diagnoses
explaining the patient’s condition.
23. e.g. whenever a patient complains of pain there
should follow a series of clarifying questions
• site
• radiation
• character
• severity
• time course
• aggravating/ relieving factors
• associated symptoms
24. The other characteristics are vital in analysing
what might be the cause of pain.
some painful conditions have classic sites for
the pain and the radiation (myocardial
ischemia is classically felt in the centre of the
chest, radiating to the left arm).
pain from a hollow organ is classically colicky
(such as biliary or renal colic).
The pain of a subarachnoid haemorrhage is
classically very sudden, 'like a hammer blow on
the head'.
25. Some pains have clear aggravating or
relieving factors (peptic ulcer pain is
classically worse when hungry and better
after food).
Colicky right upper quadrant abdominal
pain accompanied by jaundice suggests a
gallstone obstructing the bile duct;
headache accompanied by preceding
flashing lights suggests migraine.
26. Past History
• Lists childhood illnesses
• Lists adult illnesses with dates for at least four
categories: medical; surgical; obstetric/
gynecologic; and psychiatric
• Includes health maintenance practices such as:
immunizations, screening tests, lifestyle issues,
and home safety
27. Family History
• Outlines or diagrams of age and health, or age
and cause of death of siblings, parents, and
grandparents
• Documents presence or absence of specific
illnesses in family, such as hypertension, coronary
artery disease, etc.
Personal and Social History
• Describes educational level, family of origin,
current household, personal interests, and
lifestyle such as smoking, alcohol consumption…
28. Review of Systems
• Documents presence or absence of common
symptoms related to each major body system
• Enable health workers not to miss important
symptoms
• Think about asking series of questions going from
“head to toe.”
• Pertinent symptoms should be recorded in the
present illness
29. HEENT
• Head: Headache, head injury, dizziness,
lightheadedness.
• Eyes: Vision, glasses or contact lenses, last
examination, pain, redness, excessive tearing,
double vision, blurred vision, flashing lights
• Ears: Hearing loss, tinnitus, vertigo, earaches,
discharge.
• Nose and sinuses: Frequent colds, nasal stuffiness,
discharge, or itching, hay fever, nosebleeds
30. Throat (or mouth and pharynx):Condition of teeth, gums,
bleeding gums, sore tongue, dry mouth, frequent sore
throats, hoarseness.
Lymphogladular system: neck swelling, lump in the neck,
lump in the breast, breast pain or discomfort, nipple
discharge, any groin/axillary swelling noticed by patient
Respiratory: Cough, sputum (color, quantity), hemoptysis,
dyspnea,wheezing, pleurisy
Cardiovascular system: chest pain or discomfort,
palpitations, dyspnea, orthopnea, paroxysmal nocturnal
dyspnea, edema, intermittent claudication
31. Gastrointestinal system: trouble swallowing,
heartburn, appetite, nausea, color and size of
stools, change in bowel habits, rectal bleeding or
black or tarry stools, hemorrhoids,
abdominal/right upper quadrant pain, food
intolerance, excessive belching or passing of gas.
Genitourinary system: Frequency of urination,
polyuria, nocturia, urgency, burning or pain on
urination, hematuria, flank pain, urethral/vaginal
discharge or other symptoms of sexually
transmitted disease
32. Musculoskeletal system: muscle or joint pains, redness,
stiffness, presence of any swelling, weakness, or
limitation of motion or activity; include timing of
symptoms (for example, morning or evening), duration,
location and any history of trauma.
Integumentary system-rashes, sores, itching, dryness,
color change, changes in hair or nails.
Neurologic system: Fainting, seizures, weakness,
paralysis, numbness or loss of sensation, tingling or
“pins and needles,” tremors or other involuntary
movements.
33. Typical 'garrulous' history
Dr: 'Tell me what has led to you coming here
today.‘
Pt: 'Well Doctor, you see it was like this, I woke up
one day last week - I'm not quite sure which day
it was - it might have been Tuesday - or no, I
remember it was Monday because my son came
round later to visit - he always comes on a
Monday because that's his day off College - he's
studying law - I'm so pleased that he's settled
down to that - he was so wild when he was
younger - do you know what he did once
34. Dr (interrupting): 'Can you tell me what did happen
when you woke up last Monday?‘
Pt: Oh yes - it was like this - I am not sure what
woke me up - it may have been the pain - no -
more likely it was the dustmen collecting the
rubbish - they do come so early and make such a
noise - that day it was even worse because their
usual dustcart must have been broken and they
came with this really old noisy one
35. Dr(interrupting): 'So you had some pain when you
woke up then?‘
Pt: Yes - I think it must have been there when I
woke up because I lay in bed wondering where
on earth there might be some indigestion remedy
- I knew I had some but I am one of those people
who can never remember where things are - do
you know what I managed to lose last year
Dr (interrupting): 'Was the pain burning or
crushing?'
36. Pt: 'Well that depends on what you mean by’
Dr (interrupting): 'Yes but did you have any
crushing pain?‘
The doctor gradually changes from very open-
ended to very closed questions in order to try
and get some information that is useful to
building up the diagnostic picture - eventually
a question is asked that just has a yes/no
answer.
37. THE SEQUENCE OF THE INTERVIEW
• Greeting the patient and establishing rapport
• Inviting the patient’s story
• Establishing the agenda for the interview
• Expanding and clarifying the patient’s story;
generating and testing diagnostic hypotheses
• Creating a shared understanding of the problem(s)
• Negotiating a plan (includes further evaluation,
treatment, and patient education)
• Planning for follow-up and closing the interview.
38. Common respiratory symptoms
Cough: reflex response to stimuli that irritate
receptors in the larynx, trachea, or large bronchi.
It is the commonest symptom of diseases of the
lungs and air passages.
39. Inflammation of the respiratory mucosa, and
pressure or tension on the air passages as
from a tumor or enlarged peribronchial lymph
node may also cause coughing.
The following are types of questions we need
to ask: duration, how frequent is it?,when
does it occur?, Is it seasonal? are there factors
that seem to precipitate or aggravate it?,
whether it is dry or productive of sputum.
40. If the cough is productive, try to describe the color,
paroxysms, odor and volume of sputum using teaspoon or
coffee cup.
Large volume of purulent sputum suggests bronchiectasis
or lung abscess.
Hemoptysis: It is the expectoration of blood from the
respiratory tract. This has to be differentiated from
epistaxis and hematemesis.
The most common site of bleeding is the airways, i.e., the
tracheobroncheal tree
41. a. Local causes
• Infection (acute or chronic bronchitis, pneumonia,
tuberculosis, lung abscess,etc.)
• Neoplastic conditions (bronchogenic ca and
endobronchial metastatic carcinoma).
b. Diffuse causes
coagulopathies
autoimmune disorders e.g., Good pastures
syndrome
conditions associated with elevated pulmonary
venous and capillary pressure e.g., mitral stenosis
or ventricular failure.
42. Dyspnea: is a non-painful but uncomfortable
awareness of breathing that is inappropriate to
the circumstances.
commonly results from cardiac or bronco-
pulmonary problems.
dyspnea should be characterized as to
whether it occurs at rest or only after certain
type of exertion and whether it is persistent
or intermittent.
It is also important to record some measures
of exercise tolerance such as the distance
walked before the patient has to stop and
rest.
43. Chest Pain: can arise from any one of the
following thoracic structures:
heart and aorta
trachea and large bronchi
esophagus
chest wall
parietal pleura
Chest pains associated with pulmonary diseases
usually arise from the pleura.
44. Pleuritic chest pain is sharp and stabbing, and is
aggravated by deep breathing or coughing.
It occurs when the underlying pleura is inflamed,
most commonly by infection in the underlying
lung.
Pain caused by spontaneous pneumothorax may
have more of an aching character than the
stabbing pain of pleurisy.
46. the purpose of the physical examination is to
identify the physical signs of disease
should be performed methodically and
thoroughly, with consideration for the patient's
comfort and modesty.
although attention is often directed by the history
to the diseased organ or part of the body, the
examination of a new patient must extend from
head to toe in an objective search for
abnormalities.
47. the key to a thorough and accurate physical
examination is developing a systematic
sequence of examination.
the results of the examination, like the details
of the history, should be recorded at the time
they are elicited
48. 5. RESPIRATORY SYSTEM
Introduction
• The respiratory system consists of the lungs, the
branching airways, the gaseous exchange
membranes, the rib cages, and the respiratory
muscles.
• Diseases of the respiratory system are one of the
commonest causes of mortality and morbidity
throughout the world.
49. Physical examination
Locating findings on the chest
To describe an abnormality on the chest, you
need to locate it in two dimensions: along the
vertical axis and around the circumference of the
chest.
To locate vertically, you must be able to number
the ribs and interspaces accurately.
50. The sternal angle (angle of Louis), the horizontal
bony ridge that joins the manubrium to the body of
the sternum, is the best guide anteriorly.
Posteriorly, the 12th rib gives you another possible
starting point for counting ribs and interspaces.
Findings may also be located according to their
relationship to the spinous processes of the
vertebrae. e.g. 7th cervical vertebra
51.
52.
53. General approach
• Arrange the patient’s gown so that you can see the chest
fully, but cover a woman’s anterior chest while you are
examining the back.
• Proceed in an orderly fashion or follow the cardinal step
of PE
inspection,
Palpation
Percussion
auscultation.
Compare one side of the chest with the other.
With this side-to side comparison, a patient serves as his
or her own control.
54. Examine the posterior thorax and lungs while the patient
is still in the sitting position.
The patient’s arms should be folded across the chest with
hands resting, if possible, on the opposite shoulders.
This position moves the scapulae partly out of the way
and increases your access to the lung fields.
Then ask the patient to lie down so that you can examine
the anterior thorax and lungs but possible to examine
both the back and the front of the chest with the patient
sitting.
55. When the patient cannot sit up with out aid, try
to get help so that you can examine the
posterior chest in the sitting position.
If this is impossible, roll the patient to one side
and then do your physical examination.
Respiratory system examination is incomplete if
it does not include general examination of the
patient.
56. General assessment of the patient in relation to the
respiratory system includes:
Observation of the patient’s physique and form
Listening to the voice of the patient for any hoarseness
and change of voice
Observation of the hands for pallor, cyanosis and
clubbing.
Inspecting the lips and tongue for central cyanosis
Listening to the patient’s breathing if there are
additional sounds like wheezes or strider.
57. 1.Inspection
This part of physical examination includes:
• Looking for signs of respiratory distress
Flaring of ala-nasae
Intercostal retraction
Subcostal retraction
The use of accessory muscles in the neck
• The respiratory rate and rhythm
• Observing for the shape of the chest
58. Observing for the symmetrical movement of
the chest.
Unilateral impairment or lagging of respiratory
movement suggests disease of the underlying
lung or pleura.
Respiratory rate and rhythm
• The normal rate of respiration in a relaxed adult
is about 14-20 breaths per minute.
• Tachypnea is an increased respiratory rate
observed by the clinician.
59. • There are a number of disturbances of respiratory rhythm.e.g.chyne-
Stokes breathing is a deep and fast breathing followed by diminishing
respiratory effort and rate, sometimes associated with short apnea.
NB Read more on other rhythm abnormalities.
Shape of the chest
The normal chest is bilaterally symmetrical and elliptical in cross-
section.
Diseases of the ribs, spinal vertebra or lungs can distort the shape of
the chest.
60. • These chest deformities can lead to asymmetry of the chest
and may significantly restrict lung movement. The most
common chest deformities are:
• Kyphosis: posterior curvature of the spine.
• Lordosis: anterior curvature of the spine.
• Scoliosis: lateral curvature of the spine
• Gibbus: a posterior angular or wedge shaped deformity of
the spine.
It is caused by fracture or spinal tuberculosis (Pott’s
disease).
61. • Flattening of the chest e.g. Pulmonary fibrosis
• Barrel-shaped chest
• Pigeon chest(pectuscarinatum): seen in
bronchial asthma and chronic obstructive lung
diseases
Movement of the chest
Inspect whether both sides of the chest is
moving symmetrically or not.
62. Causes of asymmetrical chest expansion are
• Pleural effusion
• Pneumothorax
• Extensive consolidation
• Atelectasis Collapse of a part of the lung, or
failure of the lung to expand at birth
• Pulmonary fibrosis
63. 2.Palpation
Palpation of the chest has four potential uses.
a.Tracheal position: normally it is slightly deviated to the
right.
Feel for the trachea in the suprasternal notch and
decide whether it is central or deviated to one side by
inserting fingers between the suprasternal notch and
the insertion of the sternomastoids muscles.
64. b. Assessment of chest expansion
Manually: by placing the finger tips of both hands on
either side of the lower rib cage, so that the tip of the
thumbs meet in the midline in front of but not
touching the chest, then a deep breath by the patient
will increase the distance between the thumbs and
indicates the degree of expansion.
65.
66. If one thumb remains closer to the midline, this is a
conformation of diminished expansion on that side.
By using measuring tapes
chest expansion can easily be recorded with a tape
measure around the chest at the level of the nipple.
In a fit young man the chest may expand 5-8 cm, and in
patients with severe airway obstructive diseases it may
expand less then 1cm.
67. c. assessment of tactile fremitus
palpable vibrations transmitted through the
bronchopulmonary tree to the chest wall when the patient
speaks.
ask the patient to repeat the word ’ninety– nine’ or the
Amharic word “Arba-Arat” and compare both sides of the
chest symmetrically using the ball of your hand.
If fremitus is faint, ask the patient to speak more loudly or in
a deep voice.
68. • Fremitus is decreased or absent when the voice is soft
or when the transmission of vibrations from the
larynx to the surface of the chest is impeded.
• Causes include
an obstructed bronchus;COPD
pleural effusion
fibrosis (pleural thickening)
air (pneumothorax), or
infiltrating tumor; and a very thick chest wall.
69. Fremitus increases when the
transmission of sound increases, as
through the consolidated lung of lobar
pneumonia.
70. 3.Percussion
One of the most important techniques of
physical examination.
Helps you establish whether the underlying
tissues are air-filled, fluid-filled, or solid.
It penetrates only about 5 cm to 7 cm into the
chest, however, and therefore will not help
you to detect deep-seated lesions.
71. It is usually sufficient to percuss three or four areas anteriorly, three
or four areas on the back, and two in the axillae.
The findings on both sides of the chest should be compared
symmetrically.
Normal lungs are resonant but dullness replaces resonance when
fluid or solid tissue replaces air-containing lung or occupies the
pleural space beneath your percussing fingers.
72. • E.g. lobar pneumonia, in which the alveoli are filled with
fluid and blood cells; and pleural accumulations of serous
fluid (pleural effusion), blood (hemothorax),pus (empyema),
fibrous tissue,or tumor.
• Causes of hyper resonance are:
Bilateral causes: Emphysema and bronchial asthma,COPD
Unilateral causes:Pneumothorax and large air filled bulla
in the lungs
73. 4.Auscultation
Involves:
Listening to the sounds generated by breathing
Listening for any adventitious (added) sounds
listening to the sounds of the patient’s spoken or
whispered voice as they are transmitted through
the chest wall(if abnormalities are suspected)
74. Breath sounds
Have both intensity and quality.
The intensity (loudness) of the breath sound
may be categorized as normal, reduced or
increased.
Normal breath sounds are:
a. Vesicular, or soft and low pitched- are heard
through inspiration, continue without pause
through expiration, and then fade away about
one third of the way through expiration.
Normally heard over most of both lungs
75. b.Bronchovesicular, intermediate - with
inspiratory and expiratory sounds about equal
in length, at times separated by a silent
interval.
Differences in pitch and intensity are often
more easily detected during expiration.
These are often heard in the first and second
interspaces anteriorly and between the
scapulae.
76. c. Bronchial, or louder and higher in pitch-
with a short silence between inspiratory and
expiratory sounds and expiratory sounds last longer
than inspiratory sounds.
The sound resembles that obtained by listening over
the trachea, although the noise there is louder.
Classically they are heard over an area of
consolidated lung in cases of pneumonia.
77. Bronchial breath sounds probably originate from larger
airways but when the lung between these airways and
chest wall is airless as a result of consolidation, collapse,
or fibrosis, the breath sounds are heard with relatively
little loss by filtration and attenuation.
Adventitious (added) sounds
Added sounds may arise in the lung or in the pleura.
78. Sounds resembling pleural friction rubs may be
produced by movements of the stethoscope on the
patient’s skin or cloths or of the examiner’s hands.
DISCONTINUOUS SOUNDS (CRACKLES OR RALES) are
intermittent, nonmusical, and brief like dots in time
Fine crackles are soft, high pitched, and very brief
(5–10 msec).
Coarse crackles are somewhat louder, lower in pitch,
and not quite so brief (20–30 msec).
79. Crackles may be due to abnormalities of the lungs
(pneumonia, fibrosis, early congestive heart failure) or of the
airways (bronchitis, bronchiectasis).
CONTINUOUS SOUNDS are > 250 msec, notably longer than
crackles like dashes(—) in time but do not necessarily persist
throughout the respiratory cycle. Unlike crackles, they are
musical.
• Wheezes - are relatively high pitched (around 400 Hz or
higher) and have a hissing or shrill quality.
80. Wheezes suggest narrowed airways, as in asthma,
COPD, or bronchitis.
• Rhonchi-are relatively low pitched (around 200 Hz
or lower) and have a snoring quality.
Rhonchi suggest secretions in large airways.
Transmitted Voice Sounds
If you hear abnormally located bronchial breath
sounds, continue on to assess transmitted voice
sounds.
81. With a stethoscope, listen on symmetrical areas over
the chest wall as you:
o Ask the patient to say ‘ninety nine.’ Normally the sounds
transmitted through the chest wall are muffled and
indistinct. Louder, clearer voice sounds are called
bronchophony.
o Ask the patient to say ’ee’ ,you will normally hear a
muffled long E sound. When ‘ee’ is heard as ‘ay’ an E to
A change or egophony is present
82. This can be appreciated over the area of
consolidation or above the level of pleural effusion.
o Ask the patient to whisper ‘ninety nine’ or ‘one-
two- three’ ,the whispered voice is normally heard
faintly and indistinctly, if at all. Louder, clearer
whispered sounds are called whispered
pectoriloquy.
o This can be appreciated over an area of
consolidation.
