CASE HISTORY (GM)Vital data             Name – to identify the patient & to communicate, give clue to country, state , rel...
 Progress     Diurnal variation     Any otherBREATHLESSNESS     Duration     Onset                  Gradual in onset...
 Tenesmus – painful defeacation                 Abdominal distension                 Time of day – nocturnal diarrhea –...
Consanguinity in the parentsMenstrual history           Age at menarche           Duration of each cycle           Regular...
Vital signs              Temperature-thermometer bulb under the tongue, rectal temp>oral>axilla              Pulse- radial...
c)    Quincke’s sign – pressing on edge of nail, makes it blanch & each pulse comes and goes         d)    Water hammer pu...
a)   Pericardial rub                                                   b)   Opening snap                                  ...
c)   Chest expansion – inspiration minus expiration ( in emphysema only about 1 cm                                        ...
b.   Spleen                                       c.   Other lumps                      Auscultation                     ...
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Case history

  1. 1. CASE HISTORY (GM)Vital data Name – to identify the patient & to communicate, give clue to country, state , religion Age – childhood problems(congenital), middle age & elderly ( degenerative, neoplastic & vascular) Sex – Males – xlinked diseases, CAD, CA lung cirrhosis, Females – autoimmune disease Sle, thyroiditis Religion – (Jews &muslims - circumcision – Ca penis less probability, Muslims – no alcohol –liver damage less probability, Sikhs- no smoking – less chance of Ca lung, hindus(vegan) – no meat – less chance of Ca colon ) Address – for future communication, certain areas may be endemic for some diseases Occupation –Industrial pollution-cotton, chemicals, mesothebioma – asbestos, Ca bladder – dye, Silicosis – mines, agricultural rist – leptospirosis, poisoning, epilepsy – drivers Marital status – may give clue to possibility of homosexualityChief complaints The complaint that made the patient come to the hospital on that particular day In patients own words Duration Chronological order Avoid medical terms Avoid leading questionsHistory of presenting illnessEach chief complaint is to be elaborated one by oneDuration, onset, progress etcNo leading questionsNegative history – haemoptysis, black stools, yellow urine etc CHEST PAIN  Duration  Site  Onset  Type  Radiation  Aggravating factors  Relieving factors  Associated symptoms (sweating, dyspnoes, haemoptosis, palpation) PALPITATION  Duration  Onset  Regular/irregular  Aggravating factors  Relieving factors  Associated symptoms (tremors, heat intolerance, loss of weight, dyspnea, flushing, headache, perspiration) SYNCOPE  Precipitating cause (prolonged standing, pain, acute emotion, excess heat, cough, exertion etc)  Time of day (when 1st getting up in the morning- suggestive of orthotatic hypotension)  H/o blood or fluid loss  Use of drugs like nitrates/ anti- hypertensive  Associated features OEDEMA  Duration  Where did it appear first
  2. 2.  Progress  Diurnal variation  Any otherBREATHLESSNESS  Duration  Onset  Gradual in onset – normal  Sudden – laryngeal oedema, foreign body inhalation, pulmonary embolism, acute asthma  Severity at night  Progress  Periodic / recurense  Relation to posture  Presence of wheeze  Associated features (cough, palpitation, fatigue, fever, oedema of legs etc)  Type – NYHA classification  Class I – no symptoms during routine activity  Class II – symptoms during routine activity  Class III – symptoms less than routine activity  Class IV – symptoms at restCOUGH  Duration  Onset  Type  Diurnal variation  Postural variation  Seasonal variation  Sputum  Quantity – teaspoon(5ml), tablespoon (15ml)  Quality – mucoid, watery, muco purulent  Colour  Odur – foul smell- severe bacterial infection  HaemoptysisABDOMINAL PAIN  Duration  Onset  Site  Type  Radiation  Aggravating factors  Relieving factors  Associated symptomsANOREXIA (loss of apetite)  Duration  H/o emotional upset  H/o fever  H/o weight loss  H/o alcoholism  H/o drug intake  Associated symptomsCONSTIPATION  Duration  Pain  H/o constipation alternating with diarrhea  H/o drug intakeDIARRHOEA  Duration
  3. 3.  Tenesmus – painful defeacation  Abdominal distension  Time of day – nocturnal diarrhea – something pathological  Relation t food  Abdominal pain  Nature of stools DYSPHAGIA (difficulty in swallowing)  Duration  Pain on swallowing – odynophagia  For solids or liquids  Sticking sensation HAEMATEMESIS ( vomiting of blood)  Duration  Amount  Pain abdomen  Alcohol consumption  Drug intake  Anorexia  Associated symptoms - malena VOMITING  Duration  Relation to food  Associated pain  Drug history  Vomitus JAUNDICE  Duration  Contact with jaundiced patient  Alcohol intake  Drug history  Abdominal pain  H/o fever  Pruritus  Loss of weight  Color of urine  Color of stoolsPast history Past history of major illness Injuries Operations Blood transfusions Do not accept ready-made diagnosis by patient (typhoid, disc problem, rheumatism, heart attack etc) without confirmationPersonal history Diet – veg/mixed/non-veg Appetite – normal/ increased/decreased Sleep – normal / disturbed (reason for disturbed sleep) Bowel – no. of times per day & also during night Bladder - no. of times per day & night Habits – smoking / alcohol / tobacco / pan paragetcFamily history History of diabetes, hypertension, CAD, asthma etc in the family
  4. 4. Consanguinity in the parentsMenstrual history Age at menarche Duration of each cycle Regular / irregular cycle Approximate volume loss per each cycle Age at menopause Post menopausal bleedingObstetric history No. of times conceived No. of living children No. of abortions Mode of delivery ComplicationsTreatment history Previous medical or surgical treatment Present medications the patient is on Drug allergyGENERAL PHYSICAL EXAMINATION Consciousness Orientation Physique – Built - Nourishment – Hair – straight, curly, wavy, sparse- look for presence &colour of scalp hair, presence & distribution of hair over the body. Color of hair –  White hair – albinism  Grey hair – ageing  Poliosis – patchy loss of pigmentation of hair in the region of an adjoining vitilgo  Flag sign – brownish discoloration of hair interspersed with normal colour of hair - PEM Eye brows- Eyes – ptosis (unilateral or bilateral), pallor, cyanosis, icterus, cataract(early formation – hypoparathyroidism, hyperparathyroidism, DM), subconjuctiavalhaemorrhage(whooping cough, leptospirosis), blue sclera(osteogenesis imperfect)wide spaced eyes can mean hypertelorism, enlargement of lacrimal glands (sjogrens syndrome) Pallor- look in conjunctiva Icterus- look on sclera - yellowish discoloration Cyanosis- look for bluish discoloration on tongue, nail etc Face-scar or pigmentation Neck - Lymphatic & salivary glands Thyroid – Pulsations – Oral cavity -Tongue & mucous membrane – Teeth & gum- Skin – scar or pigmentations Hands – acromegaly, polydactyly, absence of digits etc nails –clubing, spoon shaped( koilonychias) Feet – Axillae – lymph nodes Abdomen- Edema- pedal edema
  5. 5. Vital signs Temperature-thermometer bulb under the tongue, rectal temp>oral>axilla Pulse- radial artery for 1 min  Rate- normal 60-100, sinus bradycardia(<60),sinus tachycardia(>100)  Rhythm-  Regular  irregular(regularly irregular-ectopic/ irregularly irregular-atrial fibrilation)  Volume- what we feel –  high(anaemia, pregnancy, thyrotoxicosis)  normal  low(shock, hypovolaemis,hypotension)  Character  Water hammer pulse - in the upper limb inner aspect of forearm is held & raised above the level of the heart. – we can feel the pulse on the palm—aortic regurgitation  Slow rising pulse-aortic stenosis- felt on the carotids ( left side- right hand thumb medial to sternocleidomastoid, right side-left hand thumb)  Regularity  Radio femoral & radio radial delay- one hand on patients upper limb and other hand on femoral-coarctation of aorta)  Peripheral pulses – brachial, cubital, temporal, carotid, femoral, popliteal, dorsalispaedis, posterior tibial Blood pressure- B.P cuff 1” above the cubital fossa, should be able to insert one finger inside , tube should be medial. First do palpatory method to get approximate value(to avoid silent gap)- feel radial pulse & increase the pressure- systolic B.p when pulse disappears. Then use stethoscope and increase pressure to 30mm above the previous value –apearance of sound- systolic, disappearance of sound - diastolic Respiratory rate- normal – 12 to 18 breaths/ minSYSTEMIC EXAMINATION CARDIOVASCULAR SYSTEM  Peripheral cardiovascular system  Pulse - Rate - Rhythm - Volume - Character - Equality - Radio-femoral delay - Peripheral pulses  Blood pressure  JVP (b/w two clavicular heads, 2 scales are used, 1st scale at the pulsation level parallel to , 2nd scale at sternal angle & vertical distance is measured) - Pressure - Waves Peripheral signs of wide pulse pressure a) Pistol shot sound – stethoscope on femoral artery b) De Murset’s sign – when sitting idle, head nods with pulse
  6. 6. c) Quincke’s sign – pressing on edge of nail, makes it blanch & each pulse comes and goes d) Water hammer pulse – hold wrist & elevate above level of head & pulse can be felt on the palm  Central cardiovascular system  Inspection 1. Pricondrium– pectuscavinatum , pectusexcavatum 2. Apical impulse & trachea (apical impulse- lowermost & outermost definite cardia pulse seen of felt) (apical impulse- tapping, hyperkinetic, heaving-if ventricular hypertrophy) 3. Other pulsations a. Epigastric b. Lt. parasternal c. Pulmonary area d. Suprasternal e. Supraclavicular 4. Dilated veins 5. Scars & sinusesAortic area – Right intercoastal space- right of sternum 2ndintercoastal areaPulmonary area- Left 2ndintercoastal space near sternumMitral area – Apical impulse areaTricuspid area- Left lower sternal area2nd Aortic area – 3rd Left intercoastal space  Palpation 1. Apical impulse a. Location b. Character 2. Left parastenal heave – (right ventricular bypertrophy)(3 grades- 1(visualize), 2(can palpate), 3(even if pressure given the hand will be lifted) 3. Thrill – palpable murmur 4. Other pulsations 5. Tenderness – chostrochondral junction  Percussion 1. Right border – corresponds to Rt. Border of sternum 2. Left border- corresponds with apical impulse 3. Left 2nd space- pulmonary artery if dullUsing both middle fingers.Pleximeter – left middle fingerPlexar – Right middle finger Auscultation areas Aortic- 2ndintercoastal space – Rt. Side  Auscultation Pulmonary- 2ndintercoastal space – Lt side 1. Heart sounds Mitral – apical impulse Systolic mumur- 6 grades Tricuspid – lower left sternal border 1. Very soft 2. Murmur 2. Soft a) Systolic / diastolic 3. Moderate b) Site where best heard 4. Murmur with thrill c) Grade 5. Loud murmur with d) Conduction thrill e) With bell/ diaphragm- bell for low pithched – mitral stenotic valve, diaphragm for 6. Even if we lift stethoscope we high pitched can hear 3. Other sounds
  7. 7. a) Pericardial rub b) Opening snap c) Ejection clickChest areas are a. Supraclavicular area b. Infra clavicular area c. Mamary area d. Axillary area e. Infra axillary area f. Supra scapular area g. Infra scapular area RESPIRATORY SYSTEM  Upper respiratory tract  Nose & nasal cavity  Sinus points  Oro - pharynx  Lower respiratory tract  Inspection 1. Shape of chest- barrel shape – in copd patients, emphysema (decreased chest expansion), elliptical a) AP & transverse diameter, shape etc b) Intercoastal spaces (hallowing, bulging, flattening, retraction) c) Subcoastal angle d) Shoulder (drooping) e) Spines f) Spino-scapular distance g) Supraclavicular fossae 2. Respiratory movements a) Character (abdomino-thoracic, thoraco-abdominal) b) Equality c) Accessory muscles of respiration – d) Intercostal retraction 3. Mediastinum (will move to volume loss side, to check – check for trachea & apical impulse) a) Trail sign (trachea normally in centre or slight deviation to the right side, if trachea has shifted then the sternocleidomastoid would be prominent on that side during respiration, also we can insert our finger b/w trachea &sternoceidomastoid on both sides and see which side has more resistance) b) Apical impulse 4. Others a) Scars b) Sinuses c) Pulsations d) Dilated veins  Palpation 1. Confirmation of respiratory movements – (put hand on both sides & see the distance of movement of thumb from midline during breathing.- check if equal movement to both sides) 2. Position of mediastinum a) Trachea b) Apical impulse 3. Measurements a) Chest circumference during inspiration b) Chest circumference during expiration
  8. 8. c) Chest expansion – inspiration minus expiration ( in emphysema only about 1 cm expansion) ( normal 4-6cm) d) Antero-posterior diameter –(using two books-one in front of chest and one behind & measure distance b/w them) e) Transverse diameter (using two books-one on left side & other on right side) f) Right hemithorax-(center of sternum at level of nipple to spinal cord) g) Left hemithorax 4. Tactile vocal fremitus (TVF) – normal (equal) or decreased (effusion, consolidation). – put palmar aspect of hand & tell patient to tell 1,1,1,1 and check vibration on both sides 5. Tenderness 6. Palpable rales, rhonchi, rub etc.  Percussion 1. Clavicular percussion – directly using middle finger- resonant-(normal), dull- (tumour, fibrous) 2. Intercoastal percussion 3. Liver dullness- if emphysema present it will not be resonant on breathing as chest expansion is less 4. Tidal percussion 5. Cardiac dullness- within normal limits or obliterate (emphysema)  Auscultation 1. Breath sounds- normal/diminished 2. Type- vesicular (normal)/ bronchial (tubular/cavernous/amphoric) 3. Adventitious sounds- rhonchi, crepitations, rub 4. Vocal resonance- ask patient to tell 1,1,1 7 use stethoscope o check vibration on both sidesGASTRO-INESTINAL SYSTEM (GIT)  Oral cavity  Abdomen  Inspection 1. Shape of abdomen – can be distended due to Fat, Flatus (gas), Fluid 2. Umbilicus- position, shape 3. Abdominal movements 4. Pulsations – aortic aneurysm – pulsation seen on the midline 5. Dilated veins 6. Peristalisis – if intestinal obstruction is there, peristalisis will be visible 7. Scars or sinuses 8. Hernia orifices – inspected on standing & coughing 9. Genitals  Palpation 1. Superficial palpation– anticlockwise palpation a. Tenderness b. Guarding- normally soft, but when we press muscles contract & become hard c. Rigidity 2. Deep palpation – liver, spleen, kidney(bimanual palpation), caecum, colon & other mass a. Size b. Surface c. Margin – sharp/rounded d. Consistency- soft/ firm/ hard e. Tenderness  Percussion 1. For free fluid a. Fluid thrill b. Horse shoe dullness- moderate ascites c. Shifting dullness- moderate ascites d. Knee-elbow position 2. Organ percussion a. Liver
  9. 9. b. Spleen c. Other lumps  Auscultation 3. Peristaltic sound 4. Arterial bruit 5. Hepatic splenic rub  Per rectal examination  Per vaginal examination AREAS OF ABDOMEN EPIGASTRIUM Rt. HYPOCHONDRIUM Lt. HYPOCHONDRIUM RIB MARGIN Rt. LUMBAR Lt. LUMBARILIAC TUBEROSITY ILIAC TUBEROSITY Rt. ILIAC Lt. ILIAC MID CLAVICULAR LINES SUPRA PUBIC / HYPOGASTRIUM