case history
TRANSCRIPT
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 homosexuality
Chief 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 questions
History of presenting illness
Each chief complaint is to be elaborated one by one
Duration, onset, progress etc
No leading questions
Negative 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
Progress Diurnal variation Any other
BREATHLESSNESS 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 rest
COUGH 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
Haemoptysis
ABDOMINAL PAIN Duration Onset Site Type Radiation Aggravating factors Relieving factors Associated symptoms
ANOREXIA (loss of apetite) Duration H/o emotional upset H/o fever H/o weight loss H/o alcoholism H/o drug intake Associated symptoms
CONSTIPATION Duration Pain H/o constipation alternating with diarrhea H/o drug intake
DIARRHOEA Duration
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 stools
Past 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 confirmation
Personal 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 parag etc
Family history
History of diabetes, hypertension, CAD, asthma etc in the family Consanguinity in the parents
Menstrual history
Age at menarche Duration of each cycle Regular / irregular cycle Approximate volume loss per each cycle Age at menopause Post menopausal bleeding
Obstetric history
No. of times conceived No. of living children No. of abortions Mode of delivery Complications
Treatment history
Previous medical or surgical treatment Present medications the patient is on Drug allergy
GENERAL 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), subconjuctiaval haemorrhage(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
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, dorsalis paedis, 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/ min
SYSTEMIC 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 arteryb) De Murset’s sign – when sitting idle, head nods with pulsec) Quincke’s sign – pressing on edge of nail, makes it blanch & each pulse comes and goesd) Water hammer pulse – hold wrist & elevate above level of head & pulse can be felt on the palm
Central cardiovascular system Inspection
1. Pricondrium – pectus cavinatum , pectus excavatum2. 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. Epigastricb. Lt. parasternalc. Pulmonary aread. Suprasternale. Supraclavicular
4. Dilated veins5. Scars & sinuses
Aortic area – Right intercoastal space- right of sternum 2nd intercoastal area
Pulmonary area- Left 2nd intercoastal space near sternum
Mitral area – Apical impulse area
Tricuspid area- Left lower sternal area
2nd Aortic area – 3rd Left intercoastal space
Palpation1. Apical impulse
a. Locationb. 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 murmur4. Other pulsations 5. Tenderness – chostrochondral junction
Percussion 1. Right border – corresponds to Rt. Border of sternum2. Left border- corresponds with apical impulse3. Left 2nd space- pulmonary artery if dull
Using both middle fingers.
Pleximeter – left middle finger
Plexar – Right middle finger
Auscultation 1. Heart sounds2. Murmur
a) Systolic / diastolicb) Site where best heardc) Graded) Conductione) With bell/ diaphragm- bell for low pithched – mitral stenotic valve, diaphragm for
high pitched3. Other sounds
a) Pericardial rubb) Opening snap
Auscultation areasAortic- 2nd intercoastal space – Rt. SidePulmonary- 2nd intercoastal space – Lt sideMitral – apical impulseTricuspid – lower left sternal borderSystolic mumur- 6 grades
1. Very soft2. Soft3. Moderate4. Murmur with thrill5. Loud murmur with
thrill6. Even if we lift
stethoscope we can hear
c) Ejection click
Chest areas are
a. Supraclavicular areab. Infra clavicular areac. Mamary aread. Axillary areae. Infra axillary areaf. Supra scapular areag. 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 etcb) Intercoastal spaces (hallowing, bulging, flattening, retraction)c) Subcoastal angled) Shoulder (drooping)e) Spinesf) Spino-scapular distanceg) Supraclavicular fossae
2. Respiratory movementsa) Character (abdomino-thoracic, thoraco-abdominal)b) Equalityc) 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 impulse4. Others
a) Scarsb) Sinusesc) Pulsationsd) Dilated veins
Palpation1. 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) Tracheab) Apical impulse
3. Measurementsa) Chest circumference during inspirationb) Chest circumference during expirationc) 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. Tenderness6. Palpable rales, rhonchi, rub etc.
Percussion1. Clavicular percussion – directly using middle finger- resonant-(normal), dull- (tumour, fibrous)2. Intercoastal percussion3. Liver dullness- if emphysema present it will not be resonant on breathing as chest expansion is
less4. Tidal percussion5. Cardiac dullness- within normal limits or obliterate (emphysema)
Auscultation 1. Breath sounds- normal/diminished2. 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 sides
GASTRO-INESTINAL SYSTEM (GIT) Oral cavity Abdomen
Inspection1. Shape of abdomen – can be distended due to Fat, Flatus (gas), Fluid2. Umbilicus- position, shape3. Abdominal movements4. Pulsations – aortic aneurysm – pulsation seen on the midline5. Dilated veins6. Peristalisis – if intestinal obstruction is there, peristalisis will be visible7. Scars or sinuses8. Hernia orifices – inspected on standing & coughing9. Genitals
Palpation1. Superficial palpation– anticlockwise palpation
a. Tendernessb. Guarding- normally soft, but when we press muscles contract & become hardc. Rigidity
2. Deep palpation – liver, spleen, kidney(bimanual palpation), caecum, colon & other massa. Sizeb. Surfacec. Margin – sharp/roundedd. Consistency- soft/ firm/ harde. Tenderness
Percussion1. For free fluid
a. Fluid thrillb. Horse shoe dullness- moderate ascitesc. Shifting dullness- moderate ascitesd. Knee-elbow position
2. Organ percussiona. Liverb. Spleenc. Other lumps
Auscultation3. Peristaltic sound4. Arterial bruit5. Hepatic splenic rub
Per rectal examination Per vaginal examination
AREAS OF ABDOMEN
EPIGASTRIUM
Lt. HYPOCHONDRIUM
Lt. LUMBAR
Lt. ILIAC
SUPRA PUBIC / HYPOGASTRIUM
Rt. ILIAC
Rt. LUMBAR
Rt. HYPOCHONDRIUM
RIB MARGIN
ILIAC TUBEROSITY ILIAC TUBEROSITY
MID CLAVICULAR LINES