medicine compents of history taking 2014

COMPONENTS OF HISTORY

BYDaniel Eshetu

Aim of this course

To understand why medical history

taking is important

To understand different

frameworks and apply them

Basic clinical skills

A skill is something you do

It is not enough to “know” how to do

something; you have to be able to do it

Basic clinical skills are

-Medical interviewing

-Physical examination and

-Communication ( history taking,explain

diagnosis to a patient ,telling your

peer about a “case”-)

INTRODUCTION

• complete medical evaluation includes

• medical history• physical examination• appropriate laboratory or imaging

studies• analysis of data • Diagnoses• treatment plan

A medical record

is a legal document in many jurisdictions

Factors in establishing rapport

• Introduce yourself in a warm, friendly

manner

• Maintain good eye contact

• Listen attentively

• Facilitate verbally and non-verbally

• Touch patients appropriately

• Discuss patients’ personal concerns

Practice of Medicine combines

*SCIENCE as the evidence base

and

*ART in the application of this

medical knowledge

The “ Classic” History Taking Sequence

• The order are :-

• Identification• Previous Admission• Chief Complaints• History of Present Illness• Past Illness• Functional Inquiry ( System Review)• Personal History• Family History• Physical Examination• Summary• Differential Diagnosis

Identification

• Name (preferably with the name of the grandparent)

• Age

• Sex

• Occupation

• Address

• Hospital number

NASOAH

Previous Admission

• List of hospitalization in the order they occurred

• Specify the date

• Name and location of the hospital

• Disease that led to admission

• Outcome as briefly as is possible, e.g.

1990 (EC). Menilik II Hospital, Addis

Ababa. Bleeding duodenal ulcer.

Discharged symptom free after

transfusion of 2 units of blood.

1992 (EC). TAH, Addis Ababa. Newly

diagnosed Diabetes Mellitus.

Discharged symptom free with daily

dose oh human insulin30 unit SC.

1999 (EC). St. Paul’s’ Hospital. Addis

Ababa. DKA. Discharged symptom free

with daily of human insulin 45 units sc

in divided dose.

Chief Complaints

• Those signs and symptoms which prompted the patient to seek medical advice

• Duration of each sign and symptom

• More than one complaint, they should be listed in the order of occurrence.

History of the Present Illness

• Chronological order of events of symptoms and further clarification of each symptom

• Follow in chronological order as the following

Date of onset

It is often useful to start the History ofthe Present Illness with the phrase“The patient was perfectly welluntil …”

Development of the signs andsymptoms, expressed as chiefcomplaints, should be traced indetail to the present time.

Mode of onset, course and duration

• sign or symptom indicate whether the onset was abrupt or gradual

• intermittent or persistent

• short lived or constant

• steady or increasing in severity

• find out if other signs and symptoms have developed

Character and Location

Clear description of the complaint is necessary

For example, an abdominal pain may be burning, aching, dull or sharp in character

Find out if there are factors or conditions that relieve or aggravate

Exacerbations and Remissions

• Conditions which exacerbate and remit

Eg.

Shortness of breath is exacerbate on exersiseand remit at rest

Effect of Treatment

Patients may have taken drugs or other forms oftherapy

Such drugs may not have been taken properlyMay have adverse effects by themselvesMay have worsened or alleviated the symptomsMay have had no effect whatsoever exceptTreatment for disease other than the one under

complaint should also be fully recorded.

“Negative-positive” Statements

Very significant aspect of the History ofPresent Illness

Conducted thoroughly as possible with aview to constructing a differentialdiagnosis

Negative statement may be as importantas a positive statement.

Statements are expressed in terms of signsand symptoms but not diseases.

Colour, Strength and Weight

• Last paragraph of the History of the Present Illness should state how the patient came to the hospital

–on a stretcher, walking, urged by his friends’ advice

• Mention of any colour, strength or weight changes

Past Illness

• Listing of illness unrelated to the present illness, experienced in the past

• Including childhood diseases

• Serious injuries and surgery not requiring hospitalization

• Mention of each disease with an approximate date, severity, duration, complications and sequel (consequences) is essential

Functional Inquiry (system Review) Detailed account of signs and symptoms

referable to each system of the bodyAdvantages in obtaing and recording

First, it gives a clear understanding of the history of the present illnessSecondly, it is a double check on the history of the present illnessThirdly, it will permit the examiner to group signs and symptoms that need to be considered with the present complaintFourthly, it will guide the examiner to concentrate on specific systems during the physical examination

HEENT =Head, Ears, Eyes, Nose, Mouth

and Throat

Head : Headache, injury

Ears: Pain or earache, deafness,

discharge, vertigo, tinnitus.

Eyes: Disturbance of vision, pain in the

eyes or orbit, eye-strain,

lacrimation, photophobia, itching.

Nose: Frequent head colds, epistaxis,

discharge, hay-fever, sinusitis.

Mouth and throat: Teeth (dental hygiene),

bleeding gums, sore tongue,tonsillectomy,

sore throat,

Glands

Enlarged glands

Lumps in the breasts, discharge

from the nipple

Goiter with or without heat or cold

intolerance

Undescended or swollen testicles.

Respiratory system

Cough

Expectoration (amount, colour,

odour)

Haemoptysis

Chest pain

Shortness of breath

Wheezing or asthma

Cyanosis.

Cardiovascular system

Dyspnoea (degree of exercise

tolerance)

Palpitation

Orthopnoea (number of pillows

required)

Paroxysmal nocturnal dyspnoea

Swelling of the feet

Chest pain ( with character, location

and radiation)

Syncope

Stridor

Hypertension

Gastrointestinal system

Appetite

Nausea

Vomiting

Dysphagia

Food idiosyncrasy

Heart burn

Abdominal pain

Bowel habits

Jaundice

Bloody, tarry or clay-colored stools

Hemorrhoids

Genitourinary system

Flank pain (steady, colicky, etc.)

Frequency of urine (express the day to

night ratio as D/N= ----) Dysuria, urgency,

hesitancy, dribbling, haematuria, pyuria,

incontinence

Veneral disease

Menstrual history : Record as

“menarche/interval between

periods/duration of flow/amount of flow”

,e.g. 14/28/5 profuse, moderate or normal

menopause (mention if there are

postmenopausal symptoms)

Integumentary system (skin, hair

and nails)

Dry or moist skin

Rashes

Ulcers

Urticaria

Hair distribution

Pigmentary changes

Changes in fingernails

Allergy

Infantile eczema

Drug sensitivity

Urticaria

Hayfever

Asthma

Serum sensitivity

Locomotor system (musculo-

skeletal system)

Bony deformities

Joint pain or swelling

Limping

Loss of function of limbs or joints

Muscle weakness or wasting

Leg-swelling like elephantiasis.

Central nervous system (CNS)

Poor memory

Lack of orientation

Seizures

Vertigo

Diplopia

Anesthesia

Hyperesthesia

Insomnia

nervous breakdown

Personal History • Record the personal history as follows:• Early development: place of birth and early

homes, childhood development, health and activities, social and economic status.

• Education: School history, achievements and failures.

• Social activities: Recreation and other activities• Work record: Age begun, type of work, number of

jobs (mention success or failure regarding shift of jobs), industrial hazards and exposures, present work.

• Environment: living conditions.• Habits: Dietary, alcohol, tobacco,drugs,herbs

(including anthelmintics).• Marital status: Health of wife (or husband),

adjustment, number of childrenand their health.

Family History

• Father and mother: Age ,health, date and cause of death.

• Siblings: List with ages, health

( if dead, mention cause of death)

• Family disease: Tuberculosis, diabetes mellitus, hypertensive disorders, migraine.

Physical Examination

The physical examination is the examination of the patient looking for signs of disease

• 'Symptoms' are what the patient volunteers

• 'Signs' are what the physician detects by examination).

Success in recording complete

physical findings depends on a

step-by-step and systematic

examination

Depending on the system

involved or suspected, negative

reports are as significant as

positive ones

The four cardinal methods

Inspection

Palpation

Percussion

Auscultation

Should be strictly observed

General appearance

Severity and acuteness of illness

Physique

Constitution

Nutritional state

Emotional state

facial expression

Colour change

Vital Signs

• a.Temperature

• Temperature can be measured is several different ways:

• Oral with a glass, paper, or electronic thermometer (normal 98.6F/37C)

• Axillary with a glass or electronic thermometer (normal 97.6F/36.3C)

• Rectal or "core" with a glass or electronic thermometer (normal 99.6F/37.7C)

• Aural (the ear) with an electronic thermometer (normal 99.6F/37.7C)

• Of these, axillary is the least and rectal is the most accurate.

b.Respiration

Without letting go of the patients wrist

begin to observe the patient's

breathing. Is it normal or labored?

Count breaths for 1min ad record

breaths per minute

In adults, normal resting respiratory

rate is between 14-20 breaths/minute

Rapid respiration is called tachypnea

c.Pulse

Note whether the pulse is regular or irregular:

measure rate accurately

Count for a full minute

Record the rate and rhythm.

A normal adult heart rate is between 60 and 100

beats per minute

A pulse greater than 100 beats/minute is defined

to be tachycardia

Pulse less than 60 beats/minute is defined to be

bradycardia

d.Blood Pressure

Palpate the radial pulse and inflate the cuff until

the pulse disappears. This is a rough estimate of

the systolic pressure

Release the pressure slowly, no greater than 5

mmHg per second.

Continue to lower the pressure until the sounds

muffle and disappear. This is the diastolic

pressure

Record the blood pressure as systolic over

diastolic ("120/70" for example )

Head, Ears, Eye, Nose and Mouth and Throat

• Head

• Look for scars, lumps, rashes, hair loss, or other lesions

• Look for facial asymmetry, involuntary movements, or edema.

• Palpate to identify any areas of tenderness or deformity.

Ears

Inspect the auricles and move them around

gently. Ask the patient if this is painful.

Palpate the mastoid process for tenderness

or deformity.

Insert the otoscope inspect the ear canal

and middle ear structures noting any

redness, drainage, or deformity.

Repeat for the other ear.

Eyes

Inspect lid lag, ptosis, exophthalmoses,

lacrimation, peri-orbital edema and

nystabmus

Inspect conjunctival pallor, hemorrhage,

scleral colour and pterygia

Examine the fundi by using ophthalmoscope

Nose

Tilt the patient's head back slightly.

Ask them to hold their breath for the

next few seconds.

Insert the otoscope into the nostril,

avoiding contact with the septum.

Inspect the visible nasal structures

and note any swelling, redness,

drainage, or deformity.

Repeat for the other side.

Throat

Ask the patient to open their mouth.

Using a wooden tongue blade and a good

light source, inspect the inside of the

patients mouth including the buccal folds

and under the tougue

Note any ulcers, white patches

(leucoplakia), or other lesions.

Inspect the posterior oropharynx by

depressing the tongue and asking the

patient to say "Ah." Note any tonsilar

enlargement, redness, or discharge.

Glands

• Inspect the neck for asymmetry, scars, or other lesions.

• Palpate the neck to detect areas of tenderness, deformity, or masses

Lymph Nodes

Systematically palpate with the pads of your

index and middle fingers for the various lymph

node groups.

Preauricular - In front of the ear

Postauricular - Behind the ear

Occipital - At the base of the skull

Tonsillar - At the angle of the jaw

Submandibular - Under the jaw on the side

Submental - Under the jaw in the midline

Superficial (Anterior) Cervical - Over and in

front of the sternomastoid muscle

Supraclavicular - In the angle of the

sternomastoid and the clavicle

Axillary, ingunal

Note the size and location of any palpable

nodes and whether they were soft or hard,

non-tender or tender, and mobile or fixed.

Thyroid Gland

Inspect the neck looking for the thyroid

gland. Note whether it is visible and

symmetrical

A visibly enlarged thyroid gland is called a

goiter.

Move to a position behind the patient.

Move laterally from the midline while

palpating for the lobes of the thyroid

The normal gland is often not palpable

Note the size, symmetry, and position of the

lobes, as well as the presence of any nodules

Respiratory System

• General Considerations• The patient must be properly undressed and

gowned for this examination • Ideally the patient should be sitting on the end of

an exam table • The examination room must be quiet to perform

adequate percussion and auscultation • Observe the patient for general signs of

respiratory disease (finger clubbing, cyanosis, air hunger, etc.)

• Try to visualize the underlying anatomy as you examine the patient

Inspection

Observe the rate, rhythm, depth, and

effort of breathing. Note whether the

expiratory phase is prolonged

Listen for obvious abnormal sounds

with breathing such as wheezes

Observe for retractions and use of

accessory muscles (sternomastoids,

abdominals)

Observe the chest for asymmetry,

deformity, or increased anterior-

posterior (AP) diameter

Palpation

Identify any areas of tenderness or

deformity by palpating the ribs and

sternum

Assess expansion and symmetry of

the chest by placing your hands on

the patient's back, thumbs

together at the midline, and ask

them to breath deeply.

Check for tactile fremitus

Percussion

Proper Technique

Proper Technique

Hyperextend the middle finger of

one hand and place the distal

interphalangeal joint firmly against

the patient's chest

With the end (not the pad) of the

opposite middle finger, use a quick

flick of the wrist to strike first finger

Categorize what you hear as normal,

dull, or hyperresonant

Percuss from side to side and top to

bottom

Compare one side to the other

looking for asymmetry

Note the location and quality of the

percussion sounds you hear

Find the level of the diaphragmatic

dullness on both sides

Ask the patient to inspire deeply

The level of dullness (diaphragmatic

excursion) should go down 3-5cm

symmetrically

Auscultation

Use the diaphragm of the

stethoscope to auscultate breath

sounds.

Auscultate from side to side and top

to bottom

Compare one side to the other looking

for asymmetry

Normally Vesicular breath sounds and

Bronchovesicular

Note the location and quality of the

sounds you hear

Cardiovascular Examination

• General Considerations

• The patient must be properly undressed and in a gown for this examination

• The examination room must be quiet to perform adequate auscultation

• Observe the patient for general signs of cardiovascular disease (finger clubbing, cyanosis, edema, etc.)

Arterial Pulses

Rate and Rhythm

Note whether the pulse is regular or

irregular.

Count for a full minute and record

Record the rate and rhythm.

Volume

Character

Condition of Vessel Wall

Pulse Classification in Adults (At Rest)

Normal Bradycardia Tachycardia

60 to 100 bpm less than 60 bpm more than 100

RegularRegularly

IrregularIrregularly Irregular

Evenly spaced beats,

may vary slightly

with respiration

Regular pattern

overall with

"skipped" beats

Chaotic, no real pattern,

very difficult to measure

rate accurately [2]

Blood Pressure

Record the blood pressure

as systolic over diastolic

(120/70)

Blood pressure should be

taken in both arms on the

first encounter

Jugular Venous Pressure

Position the patient supine with the head of the

table elevated 5 degrees

Adjust the angle of table elevation to bring out

the venous pulsation

Identify the highest point of pulsation

Using a horizontal line from this point, measure

vertically from the sternal angle

This measurement should be less than 4 cm in a

normal healthy adult

Precordium

Inspection

Active or quite

precordium

Location of apical

impulse

Deformity

Palpation

Palpate for the point of maximal impulse (PMI

or apical pulse). It is normally located in the

4th or 5th intercostal space just medial to the

midclavicular line and is less than the size of a

quarter.

Parasternal heave

Thrill (systolic, diastolic, both)

Pericardial friction rub

Percussion

Cardiac outline

Auscultation

Listen with the diaphragm at the right 2nd

interspace near the sternum (aortic area)

Listen with the diaphragm at the left 2nd

interspace near the sternum (pulmonic

area)

Listen with the diaphragm at the left 3rd,

4th, and 5th interspaces near the sternum

(tricuspid area)

Listen with the diaphragm at the apex (PMI)

(mitral area)

Record S1, S2, (S3), (S4), as well as the

grade and configuration of any murmurs

Added heart Sounds, Gallop,opening

Snap,pericardial friction rub,murmur

Murmur Grades

Grade Volume Thrill

1/6very faint, only heard with optimal

conditionsno

2/6 loud enough to be obvious no

3/6 louder than grade 2 no

4/6 louder than grade 3 yes

5/6heard with the stethoscope partially off the

chestyes

6/6heard with the stethoscope completely off

the chestyes

Gastrointestinal System

• General Considerations

• The patient should have an empty bladder. • The patient should be lying supine on the

exam table and appropriately draped. • The examination room must be quiet to

perform adequate auscultation and percussion.

• Watch the patient's face for signs of discomfort during the examination.

• Consider the inguinal/rectal examination in males. Consider the pelvic/rectal examination in females

Use the appropriate terminology to locate your

findings:

Right Upper

Quadrant (RUQ)

Right Lower

Quadrant (RLQ)

Left Upper

Quadrant (LUQ)

Left Lower

Quadrant (LLQ)

Midline:

Epigastric

Periumbilical

Suprapubic

Inspection

Look for scars, striae, hernias,

vascular changes, lesions, or

rashes

Look for movement associated

with peristalsis or pulsations

Note the abdominal contour

Is it flat, scaphoid, or

protuberant?

Palpation

General Palpation

Begin with light palpation

At this point you are mostly looking for

areas of tenderness

The most sensitive indicator of

tenderness is the patient's facial

expression (so watch the patient's

face, not your hands)

Proceed to deep palpation after

surveying the abdomen lightly

Try to identify abdominal masses or

areas of deep tenderness

Palpation of the Liver

Place your fingers just below the right

costal margin and press firmly

Ask the patient to take a deep breath

You may feel the edge of the liver

press against your fingers

Or it may slide under your hand as the

patient exhales

A normal liver is not tender

Palpation of the Spleen

Use your left hand to lift the lower

rib cage and flank

Press down just below the left costal

margin with your right hand

Ask the patient to take a deep breath

The spleen is not normally palpable

on most individuals

Percussion

Percussion

Percuss in all four quadrants using proper technique

Categorize what you hear as tympanitic or dull

Tympany is normally present over most of the

abdomen in the supine position

Unusual dullness may be a clue to an underlying

abdominal mass

Liver Span

Percuss downward from the chest in the right

midclavicular line until you detect the top edge of liver

dullness

Percuss upward from the abdomen in the same line

until you detect the bottom edge of liver dullness

Measure the liver span between these two points

This measurement should be 6-12 cm in a normal

adult

Splenic Dullness

Percuss the lowest costal interspace in

the left anterior axillary line

This area is normally tympanitic

Ask the patient to take a deep breath

and percuss this area again

Dullness in this area is a sign of splenic

enlargement

Auscultation

Place the diaphragm of your

stethoscope lightly on the abdomen

Listen for bowel sounds

Are they normal, increased,

decreased, or absent?

Listen for bruits over the renal

arteries, iliac arteries, and aorta

Genitourinary System

Costo-vertebral angle and suprapubictenderness,size, location and mobility of kidneys

In male : scrotom, and urethral orificeTestes-- >size, tumors, descent

In female : vaginal dischargeLabia majoria and minora-- >

choncroid,condylomata,etc

Integumentary System

• Skin• Texture, dry, moist and temperature• Purpura, rashes, ulcers, urticaria hypo-

or hyper-pigmentation• Hair• Sparse, boldness, alopecia and texture• Nails• Colour, shape capillary pulse and

splinter hemorrhages

Locomotor System

• Inspection

• Look for scars, rashes, or other lesions

• Look for asymmetry, deformity, or atrophy

• Always compare with the other side

• Spine Scoliosis, Kyphosis, Gibbus

Palpation

Examine each major joint and muscle group in

turn

Identify any areas of tenderness

Identify any areas of deformity, dislocation

Always compare with the other side

Spine tenderness on percussion or on pressure

Range of Motion

Start by asking the patient to move through an

active range of motion (joints moved by patient)

Proceed to passive range of motion (joints moved

by examiner) if active range of motion is

abnormal

Specific Joints

Fingers ; Thumb ; Wrist ; Forearm ;

Hip ; Knee

Ankle ; Foot ;

Spine

Nervous System

• General Considerations

• Always consider left to right symmetry • Consider central vs. peripheral deficits • Organize your thinking into these categories:

– Mental Status – Cranial Nerves – Motor – Coordination and Gait – Reflexes – Sensory

Mental Status

The Mini Mental Status Examination is

a useful screening tool

Orientation in person, place and time,

memory ( past ,present )

Level of consciousness Intelligence,

mood, attention speech, hallucination

and delusions

Level of education, cooperation with

the examiner

Cranial Nerves

• I – Olfactory

• II - Optic• Examine the Optic Fundi • Test Visual Acuity ScreenVisual Fields by Confrontation • Test Pupillary Reactions to Light • Test Pupillary Reactions to Light

III - Oculomotor

Observe for Ptosis

Test Extraocular Movements

Test Pupillary Reactions to Light

IV - Trochlear

Test Extraocular Movements (Inward

and Down Movement )

VI - Abducens

Test Extraocular Movements (Lateral

Movement)

V – Trigeminal

Test Temporal and Masseter Muscle

Test the Three Divisions for Pain Sensation

Test the Corneal Reflex

VII - Facial

Observe for Any Facial Droop or Asymmetry

Ask Patient to do the following, note any

lag, weakness, or assymetry:

Raise eyebrows

Close both eyes to resistance

Smile, Frown, Show teeth, Puff out

cheeks

Test the Corneal Reflex

VIII - Acoustic

Screen Hearing

Test for Lateralization

Compare Air and Bone Conduction (Rinne)

IX – Glossopharyngeal & X - Vagus

Listen to the patient's voice, is it hoarse or nasal?

Ask Patient to Swallow

Ask Patient to Say "Ah"

Watch the movements of the soft palate and

the pharynx.

Test Gag Reflex (Unconscious/Uncooperative

Patient)

Stimulate the back of the throat on each side.

It is normal to gag after each stimulus

XI - Accessory

From behind, look for atrophy or assymetry of the

trapezius muscles

Ask patient to shrug shoulders against resistance.

Ask patient to turn their head against resistance.

Watch and palpate the sternomastoid muscle on

the opposite side

XII - Hypoglossal

Listen to the articulation of the patient's words.

Observe the tongue as it lies in the mouth

Ask patient to:

Protrude tongue

Move tongue from side to side

Motor

Inspection

Involuntary Movements

Muscle Symmetry, Left to Right

Proximal vs. Distal, Atrophy

Pay particular attention to the hands, shoulders,

and thighs

Gait

Muscle Tone

Ask the patient to relax

Flex and extend the patient's fingers, wrist, and

elbow

Flex and extend patient's ankle and knee.

There is normally a small, continuous resistance to

passive movement

Observe for decreased (flaccid) or increased

(rigid/spastic) tone

Muscle Strength

Test strength by having the

patient move against your

resistance

Always compare one side to the

other

Grade strength on a scale from 0

to 5 "out of five":

Grading Motor Strength

Grade Description

0/5 No muscle movement

1/5Visible muscle movement, but no movement at

the joint

2/5 Movement at the joint, but not against gravity

3/5Movement against gravity, but not against added

resistance

4/5 Movement against resistance, but less than normal

5/5 Normal strength

Coordination and Gait

Rapid Alternating Movements

Ask the patient to strike one hand on

the thigh, raise the hand, turn it over,

and then strike it back down as fast as

possible

Ask the patient to tap the distal thumb

with the tip of the index finger as fast

as possible

Ask the patient to tap your hand with

the ball of each foot as fast as

possible

Point-to-Point Movements

Ask the patient to touch your index finger

and their nose alternately several times

Move your finger about as the patient

performs this task

Hold your finger still so that the patient can

touch it with one arm and finger

outstretched

Ask the patient to move their arm and

return to your finger with their eyes closed

Ask the patient to place one heel on the

opposite knee and run it down the shin to

the big toe

Repeat with the patient's eyes closed

Romberg

Be prepared to catch the patient if

they are unstable

Ask the patient to stand with the feet

together and eyes closed for 5-10

seconds without support

The test is said to be positive if the

patient becomes unstable (indicating a

vestibular or proprioceptive problem)

Gait

Ask the patient to:

Walk across the room, turn and come

back

Walk heel-to-toe in a straight line

Walk on their toes in a straight line

Walk on their heels in a straight line

Hop in place on each foot

Do a shallow knee bend

Rise from a sitting position

Reflexes

Deep Tendon Reflexes

The patient must be relaxed and positioned

properly before starting

Reflex response depends on the force of

your stimulus. Use no more force than you

need to provoke a definite response

Reflexes can be reinforced by having the

patient perform isometric contraction of

other muscles (clenched teeth)

Reflexes should be graded on a 0 to 4 "plus"

scale:

Tendon Reflex Grading Scale

Grade Description

0 Absent

1+ or + Hypoactive

2+ or ++ "Normal"

3+ or +++ Hyperactive without clonus

4+ or ++++ Hyperactive with clonus

Biceps (C5, C6)

Triceps (C6, C7)

Brachioradialis (C5, C6)

Abdominal (T8, T9, T10, T11, T12)

Knee (L2, L3, L4)

Ankle (S1, S2)

Clonus

If the reflexes seem hyperactive,

test for ankle clonus:

Support the knee in a partly flexed

position

With the patient relaxed, quickly

dorsiflex the foot

Observe for rhythmic oscillations

Plantar Response

(Babinski)

Stroke the lateral aspect of the sole of each foot

with the end of a reflex hammer or key.

Note movement of the toes, normally flexion

(withdrawal)

Extension of the big toe with fanning of the other

toes is abnormal. This is referred to as a positive

Babinski

Sensory

General

Explain each test before you do it.

Unless otherwise specified, the patient's

eyes should be closed during the actual

testing

Compare symmetrical areas on the two

sides of the body

Also compare distal and proximal areas of

the extremities

When you detect an area of sensory loss

map out its boundaries in detail

Vibration

Subjective Light Touch

Position Sense

Pain

Temperature

Light Touch

Discrimination

Summary

Subjective. This will include those

relevant points obtained from the Chief

Complaints, the History of the Present

Illness, the Functional Inquiry, Personal

and Family History.

Objective. This will include only the

positive physical findings.

Differential Diagnosis

The different possible diagnosis should be

listed in the order of priorities, i.e. the

most likely diagnosis on top of the list and

the least likely diagnosis at the end of the

list

The differential diagnosis must include

only those conditions that are relevant to

the presenting problem(s)

Discussion of Differential Diagnosis

A logical approach to the discussion of a

given list of possible diagnoses will

require a careful analysis of the history,

the physical findings, and the appropriate

investigation relevant to the presenting

problem(s) before arriving at a plausible

final diagnosis

Discussion of the differential diagnosis

must start from the bottom of the list

This will permit a step by step exclusion

of the least likely conditions

The diagnosis must be confirmed by

laboratory and other diagnostic tests and

procedure

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