Clinical methods

1. CLINICAL METHODS

2. Making A Diagnosis
Diagnosis should precede treatment whenever
possible. There are 2 steps in making
diagnosis:
1. Observation by clinical methods:
• History taking
• Physical examination
• Ancillary investigations
2. Interpretation of the information obtained

3. A. History Taking
1. Put patient at ease
• Introduce yourself
• It helps to shake hands
• Good rapport by asking questions like age,
occupation, marital status
2. Presenting complaint (PC)
• The trouble recently
• Record the patient own words
3. History of Presenting Complaint (HPC)
• When the PC started

4. History Taking
• Progress since then
• Can use the following acronyms: SOCRATES-
S=site O=onset C=character R=radiation
A=association T=timing E=exacerbation
S=severity
4. Direct Questioning (DQ)
• Specific questions about the diagnosis you have
in mind
• Review of the relevant systems

5. History Taking
5. Past Medical History (PMH)
• Attended hospital?
• Illnesses
• Ask about: DM, asthma, TB, jaundice, HPT,
PUD, epilepsy, heart disease.
6. Drug History (DH)
• Pills, injections
• Allergies
• herbs

6. History Taking
7. Social History (SH)
• Job
• Marital status
• Lifestyle- alcohol, smoking, drugs
8. Family History
• Heart disease
• HPT, TB, DM
9. Functional Enquiry-helps uncover undeclared
symptoms

7. History Taking
• Cardiopulmonary symptoms
• Genitourinary symptoms
• O&G symptoms
• GIT symptoms
• Neurological symptoms
• musculoskeletalsymptoms

8. B. Physical Examination
Order For Routine Examination
• General examination
• Systemic examination-cardiovascular,
respiratory, gastrointestinal/genitourinary,
neurological, musculoskeletal as follows:
1. Inspection- look
2. Palpation- feel
3. Percussion- tapping with a finger over the
other placed over a surface
4. Auscultation- listen with a stethoscope

9. Physical Examination
1. General examination.
• How sick is he/she?
• In pain?
• Pattern of breathing
• Shape-obese, cachetic
• Behaviour- oriented?
• Hydration status
• Check for cyanosis (central or peripheral)
• Jaundice, pallor, clubbing, koilonychia

10. Physical Examination
2. Cardiovascular System
Presenting symptoms-chest pain, palpitations, dizziness,
blackouts, ankle swelling, dyspnoea (exertional,
orthopnoea, PND)
Inspection/palpation
• Appearance- ill or well, dyspnoea, pale.
• Hands- clubbing (congenital heart disease, endocarditis).
• Feet-pitting oedema
• BP- note the pulse pressure (difference between the
systolic & diastolic pressure). Narrow in aortic stenosis &
hypovolaemia and widen in aortic regurgitation & septic
shock

11. Cardiovascular System
• Jugular veins- observe the patient at 45 degrees
with head slightly turned to the left; raised
jugular venous pressure in fluid overload.
• Pulse- radial, brachial, carotid femoral, popliteal
& dorsalis pedis pulse to determine the rate and
rhythm (regular/irregular)
• Praecordium- inspect for scars of cardiac
operations; palpate the apex beat (5th
left
intercostal space in the mid-clavicular line).
Auscultation
There are 4 main auscultatory areas

12. Cardiovascular System
• Apex- mitral area for 1st
and 2nd
heart sounds. Are
they normal? Listen for added sounds or
murmurs.
• Lower left sternal edge- tricuspid area
• Left of manubrium in the 2nd
intercostal space –
pulmonary area.
• Right of the manubrium in the 2nd
intercostal
space- aortic area
Also listen in the left axilla- radiation of mitral
incompetence

13. Cardiovascular System
Also listen over the carotids for radiation of
aortic stenosis.
Heart Sounds
• First heart sounds-closure of mitral & tricuspid
valves
• Second heart sounds- closure of aortic &
pulmonary valves
• Third heart sounds- may occur just after the 2nd
heart sound eg mitral regurgitation, VSD

14. Cardiovascular System
• Fourth heart sound- may occur just before the
first heart sound eg aortic stenosis or HPT heart
disease.
Murmurs
• Ejection systolic murmur- immediately after the
1st
heart sound-in high output states eg
pregnancy, tachycardia
• Early diastolic murmur- heard immediately after
the 2nd
heart sound eg pulmonary regurgitation

15. Cardiovascular System
• Pansystolic murmur- after the 1st
heart sound
through to the 2nd
heart sound eg mitral &
tricuspid regurgitation, VSD.
• Mid diastolic murmur- midway after 2nd
heart
sound to the beginning of the 1st
heart sound
eg aortic regurgitation

16. Cardiovascular System
Investigations
• ECG- electrical activity of the heart
• Chest x-ray- for cardiac enlargement,
calcification, fluid in the pericardium
• Echocardiography- visualise heart valves
Cardiovascular disorders (diseases)
-Hypertension
-stroke (cerebrovascular accident)
-heart failure

17. Cardiovascular System
-cardiac arrhythmias
-congenital heart disease
-rheumatic fever

18. Physical Examination
3. Respiratory System
Presenting symptoms- cough, dyspnoea,
wheeze, chest pain, stridor, fever/night sweats.
Inspection
Undress to the waist and sit up in bed
• Ill looking, cachectic
• Using accessory muscles of respiration
(sternomastoid, platysma)
• Stridor; respiratory rate.

19. Respiratory System
• Breathing pattern
-kussmaul (rapid, deep respiration)
-cheyne-stokes (apnoea alternating with
hyperpnoea)
• Look for chest wall deformities
-pigeon chest (pectus carinatum)
-funnel chest (pectus excavatum)
-hump back (kyphosis)
-scoliosis

20. Respiratory System
• Look for chest movement- is it symmetrical?
• Examine the hands for clubbing, peripheral
cyanosis, tar staining in smokers
• Examine sputum if available
– black carbon specks-suggest smoking
– Yellow/green/rusty-infection eg pneumonia
– Bloody-malignancy, TB, trauma
– Frothy- pulmonary oedema.

21. Respiratory System
Palpation
• Check for cervical lymphadeopathy from behind
with patient sitting
• Trachea- central or displaced. Displaced to
same side of pathology is in collapse but to
opposite side of pathology is in effusion.
• Chest expansion-use both hands to compare
chest expansion on both sides. Patient to lie flat
during the examination. <5cm on deep
inspiration is abnormal & implies pathology
below.

22. Respiratory System
• test tactile vocal fremitus- ask patient to say 999
whilst palpating the chest wall over different
respiratory segments & comparing both sides.
Increase vocal fremitus implies consolidation.
The more sensitive test is vocal resonance ie
using stethoscope to listen whilst the patient
says 999- This is also called whispering
pectoriloquy.

23. Respiratory System
Percussion
Percuss symmetrical areas of anterior, posterior
& axillary regions. Percuss supraclavicular fossa
for the apex of the lungs.
• Dullness-collapse, consolidation, fibrosis, pleural
effusion. NB cardiac dullness & liver dullness
are normal. If resonant over the liver & heart it
implies overexpansion of the lungs eg asthma,
emphysema.
• Hyperresonant- pneumothorax, COPD

24. Respiratory System
Auscultation
Listen with the diaphragm of the stethoscope
over symmetrical areas of the anterior, posterior,
& axilla & the bell over the supraclavicular fossa
Breath sounds
• Normal- vesicular- rustling quality
• Bronchial- hollow quality eg consolidation,
fibrosis
• Diminished- effusions, thickening, asthma,

25. Respiratory System
COPD, pneumothorax.
• silent chest- life threatening asthma due to
severe bronchospasm preventing adequate air
entry
Added Sounds
• Rhonchi- air passing through narrow airways eg
asthma, COPD.
• crepitations (crackles)
-fine & high pitched-pulmonary oedema
-coarse & low pitched-pneumonia

26. Respiratory System
• Pleural rub-movement of visceral pleura over
parietal pleura when both surfaces are
roughened eg adjacent pneumonia, pulmonary
infarction.
Investigations
1. Sputum-naked eye examination
• Pink frothy-pulm. Oedema
• Bloody- malignancy, TB, trauma.
• Yellow/green/rusty- infection eg peumonia,
bronchiectasis

27. Respiratory System
• Black carbon specks- smoking
• Clear- probably saliva
2 FBC
3 Chest x-ray- nature & location of the disease
4 Bronchoscopy
5 Pleural biopsy/aspirate

28. Respiratory System
Some Physical Signs
1. Pleural effusion
• Reduced chest expansion
• Reduced air entry
• Reduced vocal resonance
• Percusssion- stony dull
2 Lung collapse
• Reduced chest expansion
• Reduced breath sounds

29. Respiratory System
• Reduced percussion note
3 Pneumothorax
• Reduced chest expansion
• Reduced breath sounds
• Increased percussion note
4 Fibrosis
• Reduced chest expansion
• Reduced percussion note
• Bronchial breath sounds with/without crackles

30. Respiratory System
5 Consolidation
• Reduced chest expansion
• Reduced percussion note
• Increase vocal resonance
• Bronchial breath sounds with/without coarse
crackles

31. Respiratory System
Respiratory Disorders
-pneumonia
-asthma
-bronchitis
-bronchiolitis
-lung abscess
-bronchiectasis
-upper respiratory tract disorders
-T.B

32. Physical Examination
4. Gastrointestinal System (GIT)
Presenting symptoms- abdominal pains,
distension, nausea, vomiting, haematemesis,
diarrhoea, constipation, jaundice, dysphagia,
rectal bleeding, malaena stools, rectal bleeding
Inspection
• Is abdomen moving with respiration?
• Is there visible peristalsis?
• Visible pulsations-aneurysm

33. GIT
• Distension, scars
• Masses, herniae
• Striae (stretched marks as in pregnancy)
• Look at the genitalia-present or absent on both sides?
• Look at the hernia orifices for cough impulse-a bulge
when the patient coughs is positive
• Look for groin swellings

34. GIT
• Inspect for signs of chronic liver disease-
gynaecomastia, jaundice, scratch marks,
asterixis (flapping tremors), spider naevi,
purpura (purple stain skin), muscle
wasting, palmar erythema
• Inspect for signs of malignancy- pallor,
jaundice, virchow`s node (lymph node
enlargment in the left supraclavicular
fossa

35. GIT- Palpation
Start away from the site of pain and end there
last.
Whilst palpating be looking at the face to assess
pain
Palpate gently (superficial palpation) through
each quadrant. This is to elicit tenderness or
guarding or rebound tenderness.
Then do deep palpation to elicit masses
- Rovsing’s sign- for acute appendicitis ie pain
more in the RIF than the LIF if the LIF is pressed

36. GIT
- Murphy’s sign- stoppage of breathing when 2
fingers are placed over the RUQ and the patient
asked to breath in. This is due to pain caused by
an inflamed gall bladder impinging on your finger
• Palpating the liver- start from the RIF with the
patient breathing deeply whilst moving up 2cm
at a time until you hit the liver with the radial
border of the index finger.
• Palpating the spleen- start from the RIF and
move towards the LUQ with each breath.

37. GIT
Can differentiate from the left kidney because
- cannot get above it
- percussion over it is dull
-may have a palpable notch over the medial
border
• Palpating the kidney- by bimanual palpation.
One hand under the patient to push it up in the
renal angle and the other hand to ballot it
anteriorly

38. GIT
• Scrotal swelling-if you can go above the swelling
it is a mass in the scrotum eg hydrocele. If you
can not go above the swelling then it is coming
from the abdomen and descending into the
scrotum eg inguinoscrotal hernia.
To confirm a hydrocele you point a thin beam
of light from a torch. If it transilluminates it
means there is fluid- hydrocele.

39. GIT
Percussion
• Tympanitic- gas
• Dull- fluid, solid organ
-confirm fluid by fluid thrill- need an assistant
to place hand in the middle of the abdomen
longitudinally whilst flicking on one side of the
abdomen with one hand & the other hand on the
other side receiving the impulse
- also confirm by shifting dullness-

40. GIT
- The level of the right sided flank dullness
increases by lying on the right side and vice
versa on percussion
Auscultation
For bowel sounds
• Absent- ileus
• Increased and tinkling- obstruction

41. GIT
Investigation
• Endoscopy- direct vision
• Radiology- barium meal/enema, ultrasound
• Histopathology- biopsy
• Blood- FBC, blood film
• Stool- occult blood, parasites
GIT Disorders
-peptic ulcer disease
-diarrhoea

42. GIT
-haemorrhoids
-hepatitis
-hepatic encephalopathy
-chronic liver disease
-malnutrition
-intestinal worms
-diabetes mellitus

43. 5. Neurological/musculoskeletal System
Presenting Symptoms:
Headache, weakness, visual disturbances,
special senses (hearing, smell, taste),
dizziness, speech disturbances, fits, faints,
tremors, joint pains, joint swelling, back
pain

44. Physical Examination
Neurological System/Musculoskeletal
• Mental function- orientation in time, place,
person and memory (short/long term)
• speech- dysphonia-alteration in voice sound eg
laryngitis, vocal cord tumour
- dysphasia-impairment of language eg brain
damage
- difficulty in articulation eg cerebellar disease,
bulbar palsy

45. Physical Examination
• Skull& spine- for malformations
• Tendon reflexes- brisk in upper motor
neuron lesion, reduced/absent in lower
motor neuron lesion eg ankle, knee &
triceps reflexes
• Sensation- light touch with cotton

46. Physical Examination
• Conscious Level (coma scale)- an abbreviated coma
scale, AVPU, is used in the initial assessment of the
critically ill
-A –alert
-V –responds to vocal stimuli
-P –responds to pain
-U –unresponsive
For a reliable & objective way of recording the conscious
state of a person 3 types of response are assessed: best
motor, best verbal, eye opening (Gasgow Coma Scale).

47. Physical Examination
Best motor response: this has 6 grades
6-obeying command-patient does simple
things asked
5-localizing response to pain-put pressure
on fingernail or supraorbital or sternum.
Purposeful movement is a localised
response
4-flexes limb normally to pain
3-flees limb abnormally to pain

48. Physical Examination
2-extends limbs to pain
1-no response to pain
Best Verbal Response: this has 5 grades
5-oriented- knows where, the year, month,
season
4-confused- responds to questions but there
is some disorientation
3-inappropriate speech- random but no
conversational exchange

49. Physical Examination
2-incomprehensible speech- moaning but no
words
1-none
Eye Opening: this has 4 grades
4- spontaneous eye opening
3-eye opening in response to speech
2-eye opening in response to pain
1- no eye opening

50. Physical Examination
An overall score is made by summing the score
in the 3 areas assessed eg no response to
pain(1) + no verbalization(1) + no eye
opening(1) = 3
NB Severe injury < 8
Moderate injury 9-12
Minor injury 13-15

51. Neurological System
• Motor system- determine whether weakness is
upper motor neurone (UMN) lesion or lower
motor neurone (LMN) lesion
-UMN lesion- damage to motor pathways in the
frontal cortex through the internal capsule,
brainstem, and cord to the anterior horn cells of
the cord. Characteristics include weakness
involving the extensors of the upper limbs and
the flexors of the lower limbs. There is little
muscle wasting and increased muscle tone.

52. Neurological System
Babinski sign is positive- fanning of the toes and
dorsiflexion at the ankle when the sole is
scratched. Reflexes are brisk.
-LMN lesion- damage in the anterior horn cells in
the cord, nerve roots or peripheral nerves..
Muscle weakness corresponds to the cord
segment, nerve root or peripheral nerve. The
relevant muscles show wasting. Reflexes are
absent

53. Neurological System
• Power- Grade 0-no muscle contraction
- Grade 1-flicker of contraction
-Grade 2- some active movement
-Grade 3- active movement against gravity
-Grade 4- active movement against
resistance
-Grade 5-normal movement
• Signs of meningeal irritation

54. Neurological System
- kernig’s sign- the hip is flexed to 90 degrees
with the knee bent; pain is felt on attempting to
straighten the patient’s leg
-brudzinski’s sign-flexion of the neck which
causes the legs to be drawn up
• Cranial nerves
I- (olfactory)-smell
II- (optic)-visual acuity- pupil size, shape,
symmetry, reaction to light

55. Neurological System
III, IV, VI- (oculomotor, trochlear, abducens)-eye
movements
V-( trigeminal)-loss of sensation in the skin of the
face, crown of the head, the conjunctiva &
nasopharynx
VII- (facial)-drooping & weakness of half of the
face (Bell’s palsy)
VIII- (vestibuocochlear)-hearing
IX, X- (glossopharyngeal, vagus)-gag reflex

56. Neurological System
XI- (accessory)-cannot shrug shoulders
XII- hypoglossal)-tongue movement
• Joint examination
-for crepitus- put palm of one hand over the joint
and the other hand moves the limb forming the
joint. There would be crackling sensation if there
is crepitus eg osteoarthritis
-for fluid eg knee joint-squeeze from lower thigh
towards knee with one hand & tap the patella
with the other hand. If it ballots there is fluid

57. Neurological System
Neurological/ musculoskeletal disorders
-unconscious patient
-epilepsy
-low back pain
-osteoarthritis
-gout
-septic arthritis
-osteomyelitis

58. 6. GENITOURINARY SYSTEM
Presenting Symptoms- loin/scrotal pain, dysuria,
haematuria, urine frequency,
urethral/vaginal discharge, lower
abdominal pain
Physical examination( done on exam. of abdomen)
Palpate the loin for tenderness &
masses
Palpate the suprapubic region
for tenderness & masses
Rectal examination for prostate

59. Genitourinary system
Investigations:
Renal Function Test
Urine routine examination
Discharge for wet preparation, culture and
sensitivity
Ultrasonography
Plain abdominal x-ray
Cystoscopy

60. Genitourinary System
Genitourinary diseases:
UTI
STI
Schistosomiasis
BPH
Retention of Urine