1. History Taking

2. Personal History

Name

Age

Sex

Occupation

Residence

Marital state, number of children

Menstrual history in some cases

Special habits of medical importance (e.g. smoking:number of cigarettes & duration)

Social history

3. Complaint: In the patients own words& duration 4. History of the present illness

Symptoms are analyzed in relation to each other and chronologically.

Onset : Sudden ,acute or gradual.

Course:- Progressive

- Stationary

- Regressive

- Fluctuating

- Responce to Tx

Negative informationin some cases may be important e.g. centralchestpain not related to effort

Review of other systems

5. Past history:

Previous illness

Drugs

Pregnancies.

Familyhistory:

Similar disease

DM

Hypertension

Allergy

Trauma

Surgery

Blood transfusion

Travel abroad

Radiotherapy

6. Example of a symptoms analysis Pain :ask about 1-Site:

Midline pain arise from single structure

( heart -liver- pancrease -GIT).

Localized or diffuse

Diaphragmatic pleura --> tip of shoulder

Myocardial ischemia --> retrosternal, Lt arm, Lt shoulder

3-Character of pain:aching, colicky, stabbing, burning. 2- Radiation : 7. Pain (cont .) 4-Severity of pain 5-Duration: e.g.- Trigemimdneuralgia( seconds) - Intestinalcolic(minutes) 6-Frequency &Periodicity 7-Time of occurence: e.g.

Morning headache inmigraine &HTN

After rising in frontal sinusits.

At the end of the day in tension headache

8. Pain (cont .) 8- Aggravating factors :e.g. swallowing in esophagitis 9- Relieving factors:e.g. stop walking in ischemic pain 10-Associated phenomena:e.g. marked swaeting in cardiac pain 9. General Examination 10. Routine Data or Vital Signs :

Temperature

Pulse

Blood pressure

Respiratory rate

11. Radial Artery 12. Pulse Examination 13. Sphygmomanometer cuff 14. Length of the cuff 15. Stethoscope 16. Brachial Artery 17. BP measurement 18. Temperature Normal:36 .5 - 37.2 0 c -Diurnal variation -Age -Menstrual cyclevariation Fever: T>37.4 0 c -Infection-Tissue injury 19. Hyperpyrexia :T> 41.5 0 c

Neoplastic causes

Collagen diseases

Drugs

Endocrine causes

CNS causes

20.

Shock.

Hypothyroidism

Panhypopituitarism

Starvation

Damage to anterior hypothalamus

Old age

Drugs e.g.phenothiazine

Hypothermia: 21. Types of fever

Continuous Fever: Day & night changes < 1 0C-Pneumonia

-Meningitis

Relapsing Fever: Brucellosis- spirochaetal relapsing fever- Bel Epstein fever (Hodgkins disease)- charcoat fever (biliary obstruction)

Intermittent Fever: reaches base line during day

- Malaria

Remittent Fever : variation > 1 0C

-Septic conditions

22. Color changes

Normal complexion depends on:-

Thickness ofskin

EdemaandMyxoedema pallor

Vascularity , Hb

Reduced Hg> 5 gm cyanosis

Presence of pigments .

Bilirubin ++ --> jaundice

Carotencauses yellowish discoloration

23. Pallor

Look formucous membrane in inner aspect oflips

Hb < 6 gm/dl--> pale palmar creases

Causes of pallor:

Anemia

Anxiety

Shock

Edema

24. Cyanosis

Bluish discoloration

-Central ~~~ lateral aspect of under surface

of the tongue (warm hands)

-Peripheral ~~~ extremities(cold hands)

D.D of central cyanosis:++ methemoglobin

N.B redcyanosisis due to COpoisoning

25. Cyanosis 26. Body Built 1 Body Built(weight & Hight)BMI = BW (kg) / Ht (m 2 ) >40 30-40 25-30 20-25 Morbid Obesity Obese Over weight Normal 27. Body Built 2

Factors affecting the body built :

Racial

Familial

Genetic

Endocrine

Malnutrition in young age

Child hood disease.

Body Built 28. Decubitus :

Rigid dorsal decubitus

Lateral decubitus

Coild up

Opisthotonus

Orthopnea

prayers posture

Squatting

Tri Pod position

29. Tri Pod position Patient with emphysema bending over inTri-PodPosition 30. Examination of theHEAD & FACE 31. HEAD & FACE Head : Face :

Size

Shape

Localized swelling

Expression

Edema and swelling

Complexion

Color change ( pallor -cyanosis -jaundice)

Individual organs

Asymmetry

Malar flush------

32. Facial swelling causing asymmetry Facial swelling 33. Facial swelling:Rt periorbital 34. Normal Eye 35. Jaundice 36. Jaundice2 37. Eye Lids EdemaXanthelasmaDark ring Ptosis3rd nerve paralysis- Horners syndrome Myathenia gravisCongenital retractionThyrotoxicosis 38. Edema of the eye lids 39. Eye ball

Exophthalmus:

Congenital

Local condition

Cavernous sinus

A.V aneurysm

Thyrotoxicosis

Enophthalmus:dehydration-----

40. Pupils

Pupils : size equality -light reaction

Small pinpointpupils

Mid position fixed pupil:(4-6mm)slightly dilated withno light reactionMid brain damage

Horner syndrome

pontine Hge

Drugs: morphine, heroin , narcoti

Sympath. Damage

Hypothalamic

Metabolic

< 1mm( 1- 2.5 nm ) Unilateral Bilateral small pupils 41. Horner syndrome 42. Pupils 2 Large dilatedpupils anoxia Bilaterally dilated pupils (fixed): drugs (atropine - phenothiazine- tricyclicantidepressants) (Reactive) Unilaterally dilated pupil ( Fixed dilated) Oculomotor paralysis Temporal lobe herniation ---Mid brain .

Cocaine

Amphetamine,

LSD

(Sympath. Agonists )

43. Conjunctiva

Hemorrhage

Subconjunctivl haemorrage withsevere cough

Hypertension

Septicaemia

Bleeding tendency

Chemosis: edema 44. Conjunctivitis 45. Sclera

Scleritis

Episcleritis

46. Scleritis 47. Nodular Episcleritis in a patient with CD 48. Cornea Nose Ear

Tophi

Discoloration

Cyanosis

Ochronosis

Dischrge

49. Parotid glands

Unilateral enlargement as in acute parotitis

Bilateral enlargement as in Sjogren Syndrome

50. Unilaterally enlarged parotid 51. Mouth: Lips

Color

Angular stomatitis

Chelitis

Hypertrophy

Herpes labialis

Acromegaly

Telangiectasia

Myxoedema

Trauma

Angioedema

52. Breath

Fetid breath (Fetor oris)

Alcohol

Acetone : D.K.A

Ammonia ---> uraemia

Fetor hepaticus

Local oral condition

pyorrhea

Suppurative lung syndrome

Pyloric obstruction

53. Mouth :Dryness and increased salivation

Dehydration

Mouth breathing

Anxiety

Drugs, e.g. anticholinergics

Sj gren syndrome

Causes of Dry Mouth

Ptyalism: increasedsalivation

54. Normal oral cavity 55. Left peritonsillar abscess 56. Teeth

Loose teeth: - D.M- Hyperparathyroidism

Wide spaced teeth: acromegaly

Discoloration:

Tobacco

Poor oral hygiene

Flourosis

xxxxx 57. Tooth abscess Tooth Abscess 58. Gums

Pyorrhea

Bleeding as in:

Hypertrophy as in:

Addison

Heavy metal ( lead and bisthmus) poisoning

Drugs like epanutin

Monocytic leukemia

Pigmentation as in:

Chronic liver disease

Thrombocytopenia

59. Tongue 1

color

pale

Bright red( firy tongue- pellagra)

Atrophic glossitis( iron , B12 , riboflavin- pellagra)

Black--> iron mixture

coated--> dehydration

Strawberry tonguescarlet feve

Leukoplakia:precancerous

Pigment :Addisons disease

60. Tongue 2

Dry tongue(see causes of dry mouth)

Scrotal tongue(mongolism)

Tremors

Large tongue (macroglossia)as in acromegaly

Anxiety

Smoking

Parkinsonism

Chronic Alcoholism

61. Buccal mucosa 1

Stomatitis

(Red, swollen& tender)

Catarrhal

Ulcerative

Monilia

Aphthous

Vincents angina

Pigmentation

Dark skinned

Addison disease

Intestinal polyposis

Arsenic

Hemochromatosis

62. Buccal mucosa 2

Enanthema : Kopliks spots

Petechial Hge:Infective endocarditis- leukaemia

Palate:

Tonsils

Deformity

Paralysis

Vesicles

63. Neck

Insepction

Palpation

Lymph Nodes

Salivary glands

Thyroid

other swellings

Deformity

Asymmetry

Position

Limitation of movement

Pulsations

64. Thyroid gland:anatomy Isthmus 65. Palpation of the thyroid gland:posterior approach 66. Palpation of the thyroid gland: anterior approach 67. Neckveins Jugular Vein Carotid Artery Nopulsations palpable. Palpable pulsations. Pulsations obliterated by pressure above the clavicle. Pulsationsnotobliterated by pressure above the clavicle. Level of pulse wave decreased on inspiration; increased on expiration. No effects of respiration on pulse. Usually two pulsations per systole (x and y descents). One pulsation per systole. Prominent descents. Descentsnotprominent. Pulsations sometimes more prominent with abnominal pressure.No effect of abdominal pressure on pulsations 68. Cervical lymph nodes 69. Examination of Axillae

Lymph nodes

Any swelling

70. Examination of the axilla 1 71. Axillary lymphadenopathy 72. Examination of the axilla 2 73. Examination of theBreast

Gynecomastia:

Physialogicl

Drugs

Liver cell failure

Klinefelter

Testiculr atrophy and tumors

Adrenal tumors

Estrogen

Spironolactone

Chloropromazine

74. Epitrochlear LN 75. Examination of the Upper Limbs:Edema 76. DVT of the right arm 77. Cellulitis of the upper limb Examination of upper limbs:Cellulitis 78. Cellulitis of the upper limb2 79. Examination of Hands

Shape & Size

Wasting of the muscles

Signs of peripheral vascular disease

Staining of nails:as in heavy cig smokers

White nailsuraemia - liver cell failure

Splinter Hg S.A.B.E

See also joint examination 80. Acromegaly 81. Peripheral Vascular Disease of the UL 82. Wasting of the thenar eminance 83. Nicotine staining 84. Wrist: Ganglion 85. Skin 1

Pigmentation

Texture

Elasticity

Thickness

Striae

Eruption

86. Skin 2

Pigmentation

Leucoderma: -Vitiligo-leprosy- SLE

- Pityriasisversicolor

Cloasma

Sun burn

Post- inflammatory

X-ray

Neurofibromatosis

Addisons disease

Pellagra

Hemochromatosis

Ochronosis

Arsenic

Locaalized Generalized 87. Skin 3 2-Texture:

Dryness

Sweating

Dehydration

Myxedema

Anxiety

Thyrotoxicosis

Respiratory failure

Hyroglycaemia

Toxemia

88. Skin 4 3.Elasticity: cutis loxa - old age - progeria 4.Thickness : -Acromegaly - Elephantiasis- Occupational 5.Striae:

Pregnancy

Obesity

Cushings syndrome

89. Skin 5 6-Eruption:

Distribution: distribution of sensory nerve HZ

Arrangement:

Morphology:

Linear lymphangitis

Annular psoriasis

Serpiginous Syphilis

Irregular urticria

Monomorphic

Pleomorphic

Type: Macule- papule- nodule- plaque- vesicles- bullae-pustule - wheals - scales - crust erosion - fissure-ulcers

scar - atrophy -sclerosis.

90. Skin 6

Dilated Blood vessels

Petechie 1-2 mm (Hess test)

Purpura: e.g. thrombocytopenia ,Senile purpura

Ecchymosis > 5 mm

Collaterals

Telangiectsia.

Haemangioma

Vascular spiders

Campbell de Morgan spots

91. Telangiectasia 92. Skin-Hair

Fall of hair :

Look for Distribution:{head, face, axillae, and pubis)

Hirsutism: excessive growth ofbody hair of a female

Idiopathic

Racial

Endocrine: Cushing- adrenogenital syndrome- polycystic ovary.

Endocrine:Myxoedem - Addisons disease - Sheehans syndrome- Eunchiadism

Infection

Localized fall of hair: Alopecia areata

93. Lymph nodes 1

Group {cervical (superfacial and deep) , scalene (Lt virchow),axillary, epitrochlear,inguinal }.

Size

Consistency

Tenderness

Matting

Mobility

Relation tosurroundingstructures.

94. Lymph nodes 2

Lymphadenopathy:

Localized :

Acute lymphadenitis

T.B

Hodgkin disease

Generalized:

Viral : glandulr fever

Leukemia. Lymphoma

Syphilis

Sarcoidosis

95. Examination of the Lower Limbs 96. Peripheral pulsation :Dorsalis pedis 97. Peripheral puls ations:Dorsalis pedis2 98. Peripheral pulsations :post tibial artery 99. Peripheral pulsations : posterior tibial artery 2 100. Popliteal artery 101. Acute vascular insufficiency: mottled appearance 102. Chronic arterial insufficiency 103. Digital gangrene 104. Chronic Venous Insufficiency 105. Neuropathic ulcer in a diabetic patient 106. Lower limbs: edema 1

Inspection

Pressure over bony prominancefor 5 to 30 sec just behindand below medial malleoli andsacrum

For soft tissue edema:

pinching dimpling of skin( Peoud orange)

press with the stethoscope

107. Lower limbs:Edema 2

Edema may be:

Hardas inchronic. lymphatic obstruction.

Soft

Causes of Soft Edema:

Localized edema:Inflammtory (hot, red, tender)- Angioneurotic - DVT- Paralysis --> paralyzed side

Generlized edema:

Renal

Cardiac

Nutritional

Hepatic

108. LL edema 109. Pitting edema of the lower limb 110. Erythema nodosum 111. Onychomycosis 112. Genitalia and Joints Genitalia Joints:

Swelling

Deformity

Overlying skin

Tenderness

Atrophy of muscles

Limitation of movement

Hypermobility

Eruption

113. Rheumatoid arthritis 114. RA: boutonniere finger 115. Rheumatoid arthritis 2 116. Heberdens nodes Heberdens nodes 117. Gout:MCP joints 118. Leprosy