Clinical Examination: Steps Of Taking Patient History (Medicine)
Clinical Examination: Steps Of Taking Patient History (Medicine)
A.GENERAL
EXAMINATION
1.Appearance-how
the patient look like,his state
2.Decubitus-the
position of a patient, they first state the part of the body on which the
patient is resting . For example, the right lateral decubitus would mean
that the patient is lying on his or her right side.
3.Body Build
4.Nutritional
status
5. Anaemia
6.Cyanosis
7.Jaundice
8.Clubbing
9.Koilonychia -
also known as spoon nails. A nail disease that can be a sign of hypochromic
anemia, especially iron-deficiency anemia.Koilonychia literally means
"spoon nails." It refers to abnormally thin nails (usually of the
hand) which have lost their convexity, becoming flat or even concave in shape.
In a sense, koilonychia is the opposite of nail clubbing.
10.Leukonychia-also
known as white nails, is a medical term for white discoloration appearing
on nails. The most common cause is injury to the base of the nail (the matrix)
where the nail is formed, or by a diet low in potassium.
11. Oedema
12.Dehydration
13.Neck Vein
14.Thyroid gland
15.Lymph nodes-main
lymph node sites:
-cervical
-axillary
-epitrochlear
-inguinal
16.Skin condition
17.Any abnormal
finding on body-such as lump.Characteristic that should be observe in case of
lump:
-size
-position
-consistency
-tenderness
-attachment
-edge
-surface
-shape
-pulsation
-thrill,bruit
-transillumination
18.Pulse
19.Temperature
20.Respiration
21.Blood Pressure
General Examination
According to Site:
1.Eye-upper sclera-jaundice
-lower sclera-anaemia
2.Mouth-lips-cyanosis,tobacco stain
-tongue-upper-anaemia
-lower-jaundice
-fungus,cyanosis
3.Hand-nails-Koilonychia
-Leukonychia
-clubbing
-beau's line-deep
grooved lines that run from side to side on the fingernail
4.Leg-oedema(at ankle and in case of
bedridden patient,oedema should be also check at sacrum area)
SYSTEMIC
EXAMINATION
Systemic
examination is divided into their own system but the main things to do here is:
1.Inspection-see with your eyes
2.Palpation-touch with hand
and feel
3.Percussion-striking one
finger with another(for dull or abnormal sound detection)
4. Auscultation-listening to the
internal sounds of the body, usually using a stethoscope
Examination of
Cardiovascular System:
a.pulse-rate,rhythm.symmetry ,R-F
delay,collapse ,character ,volume
b.blood pressure-lying and standing
c.Jugular venous pressure
d.examination of pericardium
1.Inspection
-shape of pericardium
-apex
beat
-any
visible pulsation
2.Palpation
-apex
beat-position and character
-any
thrill present or absent
-left
parasternal heave ( precordial impulse that may be felt (palpated) in
patients with cardiac or respiratory disease)
-palpation of the heart sound
-carotid shudder
3.Percussion -not done
4.Auscultation
-heart sound
-any
murmur present
-any
added sound
Examination of
Peripheral Vascular System
a.all peripheral pulses:present or
absent,normal volume
b.bruit over the femoral artery :present or absent
c.features of arterial insufficiency
-color of skin
-capillary features in toe
-leg raising test
d.features of venous insufficiency
-varicose vein :absent
-features of deep vein thrombosis :absent
Examination of
Respiratory System
A.FRONT OF CHEST
a.inspection
-size
and shape of chest
-apex
beat:visible or not,position
-any deformity/swelling /visible intercostal abnormalities
, accessory muscle movement
-movement of the chest
-respiration :rate,rhythm,pattern
b.palpation
-position of trachea
-apex
beat
-expansibility of chest
-vocal fremitus
c.percussion
-percussion note
-area
of superficial cardiac dullness
-upper
border of liver
d.auscultation
-breath sound
-any
added sound
-vocal resonance
B.TO BACK OF CHEST
a.inspection
-any
abnormal features
-any
scar mark
-movement of chest
b.palpitation
-expansibility
-vocal
fremitus
c.percussion
-percussion note
d.auscultation
-breath sound
-any added
sound
-vocal
resonance
Examination of The
Alimentary System
Parts:
A.Oral Cavity
B.Abdominal area
C.Genitalia
A.oral cavity
-lips
-buccal mucosa
-gum
-tongue
-teeth
-palate
-oropharynx
-breath odour
B.abdomen
1.Inspection
-size and shape of abdomen
-position of umbilicus
-movement with respiration
-any
swelling
-any
visible vein
-any
visible peristalsis
-any
scar mark/striae /pigmentation /hair distribution
-hernial orifice (cough test)
2.Palpation
a.superficial palpation
-skin temperature
- muscle guard and rigidity
-swelling :felt /not felt
b.deep palpation
-left kidney
-spleen
-liver
-gall bladder
-urinary bladder
-aorta
-para-aortic lymph nodes
-murphy's sign:present/absent
-McBurney's sign:tender/absent
c.percussion
-percussion note
-shipping dullness
-fluid thrill
d. auscultation
-bowel sound
-renal bruit
-hepatic bruit/splenic rub
C.genitalia
-external examination
-per
rectal examination :not done
-per
vaginal examination:not done
Examination of
Nervous System
A.Higher Cortical
Function
-conscious/unconscious:grading(Glasgow Coma Scale)
-appearance
,behaviour .cooperation
-emotional
state
-delusion
and hallucination
-orientation
in place and time
-memory
-intelligence
B.Speech and
language
C.Examination of
Cranial Nerves
Olfactory I
Optic II
Oculomotor
III
Trochlear IV
Trigeminal V
Abducents VI
Facial VII
Auditory
(vestibulocochlear) VIII
Glossopharyngeal IX
Vagus X
Spinal
Accessory XI
Hypoglossal
XII
a.Olfactory nerve
-smell:intact/absent/decrease /accelerate
b.Optic nerve
-acuity of
vision:right/left ( 6/6 )
-field of
vision
-color of
vision
-ophthalmoscopic examination
c.Oculomotor nerve , Trochlear nerve,Abducent nerve
-movement of
eyeball
-light
reflex :direct /indirect
-accommodation reflex
d.Trigeminal nerve
-facial
sensation
-motor
function
-corneal
reflex
-jaw jerk
e.Facial nerve
-motor
function
-sensory function(taste)
f.Auditory (vestibulocochlear) nerve
-hearing
test
-turning
fork
-positional
nystagmus
-walking in a
straight line
g.Glossopharyngeal and Vagus nerve
-nasal
voice :present/absent
-drinking test :check deglutition movement
-palate reflex
-gag
reflex
-to
say Ah...
h.Accessory nerve(spinal)
-strength sternocleidomastoid
-strength trapezius
i.Hypoglossal nerve
-tongue:shape
,spastic , fasciculation, tremor
-movement and
strength of tongue
Examination of
Motor Function
1.Bulk of muscle
2.Tone of muscle
3.Strength of
muscle
4.Any involuntary
movement
5.Coordination of
movement :upper limb and lower limb
6.Reflex
a.Superficial Reflex
-plantar reflex:right and left
-abdominal reflex :right and left
b.Deep Reflex
-knee jerk
-ankle jerk
-supinator jerk
-biceps jerk
-triceps jerk
c.Clonus
-ankle clonus
-Patellar clonus
d.Gait
Examination Of
Sensory System
1.pain
2.touch
3.temperature
4.sense of position
5.sense of
vibration
Examination Of
Cerebellar Function Test
1.head position
2.speech
3.eye: nystagmus
4.intention tremor
and past pointing :finger nose test
5.rebound phenomenon
6.Dysdiadochokinesia
7.heel knee shin
test
8.pendular
knee jerk
9.gait
SIGN OF MENINGEAL
IRRITATION
1.neck rigidity
2.Kernig's sign
3.Brudzinski's
sign.
OPHTHALMOSCOPIC
EXAMINATION
Examination Of
Genitourinary System
1.Bladder
:palpable/not palpable
2.Kidney:palpable/not
palpable
3.Renal
angle:tender/no tender
4.Genitalia
examination
5.Urine(bed side
test)-protein
-sugar
Examination Of
Locomotor System
1.vertebrae
2.joints
3.skull
Lastly...
1.Salient
features-something like a summary of your case
2.Provisional
diagnosis -your opinion about the case finding
3.Differential
diagnosis-how to differentiate between disease with same symptoms
4.Investigation(Suggestion)-about
the case
5.Clinical
diagnosis -make confirmation
6.Treatment-prescribe
drugs
by Lakdhes
reference:Macleod’s,Hamilton’ Bailey’s Demonstration of physical Sign in
Clinical Surgery ,CMC lecture.
