1

Introduction to Clinical Examination

3-Day SeminarTCH

April 2010

2

Clinical ExaminationThe General Principles

Clinical ExaminationHistoryInspection AuscultationPalpationPercussion

LOOKLISTENFEEL(MOVE)

Interviewing & Communication Skills

History taking can take longer than the physical examinationUse variety of questioning skills§ Open-ended questions§ Closed questions§ Specific/searching questions

Generally start with open-ended and progress to closed questions if aspects of history remain unclear

3

The Interview

Setting§ Quiet area to conduct the interview§ Position patient next to you rather than across desk

¥ Physically closer¥ Reduce barriers¥ Facilitates information exchange

Time§ Timing should be appropriate

The Interview

Initial approach§ Introduce self and obtain consent§ Sit beside patient § Establish basis for interaction

¥ First name or more formal§ Give outline of what you intend to do and how long it

will take§ History taking and examination should ideally be

carried out at the same time

The Interview

First Questions§ Ask patient to outline the problem using open ended

questions§ If patient has multiple complaints – list them

chronologically§ Write summary of patients comments

¥ Avoid becoming to immersed in writing – constantly re-establish eye contact

4

Mrs Edwina Stephenson aged 57, housewife§ Increasing breathlessness for 3 months

§ Evidence of night time shortness of breath for three weeks

§ A dry cough for the last 6 days

History

Important?

Estimated 70 - 80% diagnosis is based on history

What does the patient think about while travelling to the hospital /

waiting to be examined?

What do healthcare professionals commonly do on meeting the patient?

5

Taking a HistoryPresenting complaintHistory of the presenting complaint(s)Social History

§ Education§ Employment History§ Drug History§ Tobacco consumption§ Alcohol consumption§ Foreign Travel§ Home circumstances

Medical History§ Family History

Systems Review§ Cardiovascular system§ Respiratory system§ Gastrointestinal system§ Genitourinary system§ Nervous system§ Cranial nerve symptoms§ Endocrine history§ Musculoskeletal system§ Skin

Presenting Complaint & History of Presenting Complaint

List presenting complaints in chronological orderExplore each complaint in greater detail§ Explore patients own ‘diagnosis’

Presenting Complaint & History of Presenting Complaint

Four fundamental questions§ From which organ(s) do the symptoms arise?§ What are the likely cause?§ Any predisposing or risk factors?§ Any complications?

For each symptom explore:§ Mode of onset§ Static, decreasing or increasing in severity§ Exacerbating or relieving factors

6

Assessment of PainType

§ Quality can determine organ of origin

§ Assist with list of possible descriptors

§ Colicky; crampy; griping; dull; throbbing; tight; knife or vice like

SiteSpreadPeriodicity or constancyRelieving factorsExacerbating factorsAssociated symptoms

§ Grade severity by determining effect on lifestyle

Social History

Education§ Age left school; any

higher form of education?

¥ Useful background information to assess deterioration in intellect

Social HistoryEmployment history

§ Working conditions¥ Occupational hazards?

§ Stress in the workplace¥ Can predispose to non-specific syndromes

Drug History§ Ask for labelled bottles or written list§ Remember to ask about non-prescription

medicines§ Duration of medicine use§ Consider iatrogenic disease and polypharmacy as

a cause of symptoms§ List allergies§ Ask about illicit drug use

¥ First ask about cannabis, LSD and amphetamines-exposure may predispose to harder drugs

7

Social HistoryTobacco consumption

§ What form of tobacco?§ How long?§ If they previously smoked:

¥ When did they stop?¥ How long did they abstain?

Alcohol§ History often inaccurate, tendency to underestimate§ Patients consider beer and wine to be less

problematic than spirits§ Establish type of alcohol consumed

¥ Calculate amount in units¥ If vague: ask how long bottle lasts

§ Third party history is often more revealing§ Other features:

¥ Nausea, tremulousness, solitary drinking, day-time drinking, days without alcohol?

Social HistoryForeign Travel

§ Recent trips abroad?¥ Countries visited; hygiene levels¥ Adequate prophylaxis if malaria

endemic country visitedHome circumstances

§ How did the patient cope in the community before their illness?

¥ Relevant for the elderly and people with poor domestic and social support network systems

§ Live alone?¥ Any support from family or

community?¥ Pets?

§ Can they climb stairs§ Attendance to personal needs

Medical History

Recall has varying degrees of detail and accuracyAsk:§ Ever been to hospital or undergone a surgical

procedure?¥ Include caesarean sections

Explore any specific illnesses or diagnoses to verify accuracy

8

Medical HistoryFamily History§ May reveal evidence of inherited disorder§ Immediate family may have bearing on patient’s current

symptoms§ Ask:§ Married or regular partner?

¥ Are they well§ Children?

¥ Ages & state of health?¥ Childhood deaths amongst offspring? Cause?

§ Siblings and parents¥ Any family members die at a relatively young age? Cause?

Systems Review

Ask some general questions regarding health:§ Are you sleeping well?

¥ Difficulty getting to sleep? Waking in middle of night or early hours of morning?

§ Weight loss, fevers, rashes or night sweats?No need to repeat questionsDevelop a routine to avoid missing out a particular system

Systems ReviewCardiovascular system

Chest pain§ Location, quality, periodicity, triggering factors, radiation, exercise

inducedDyspnoea

§ Short of breath?¥ After climbing one flight of stairs? Walking on flat 100m?

Orthopnoea? Paradoxical nocturnal dyspnoea?Ankle swelling

§ Any noticed?¥ Uni or bi lateral? Persistent? Noticeable at end of day?

Palpitations§ Any noticed?

¥ Regular/irregular? Duration? Demonstrate rate; Other symptoms

9

Systems ReviewRespiratory System§ Cough

¥ Can be difficult to quantify the problem¤ Dry? Productive?¤ Sputum:

ç Amount? Mucoid? Purulent? § Haemoptysis

¥ Fine blood streaking or more?¥ Recent? Follow bout of violent coughing?

§ Wheezing¥ Constant or intermittent¥ Environmental triggers? Exercise triggers?¥ Using bronchodilators

Systems ReviewGastrointestinal system§ Change in weight

¥ Weight loss or gain? Alteration in fit of clothes§ Abdominal pain

¥ Avoid asking about indigestion – often used to describe flatulence

¥ Determine site; quality; relationship to eating; relieving factors; persistence?

§ Vomiting¥ Nausea or vomiting?

¤ Relationship to pain¤ Projectile? Regurgitation? Bloodstained? Coffee ground? Are food

items still recognisable hours later?

Systems ReviewGI system (cont)

§ Flatulence and regurgitation¥ Burping or passing of flatus?¥ Retrosternal burning

¤ Posture¥ Waterbrash?

§ Dysphagia¥ Problem swallowing?

¤ Solids more than liquids or vica-versa¥ Can patient identify site where obstruction occurs?

§ Bowel habit¥ Change in bowel habits

¤ Frequency or consistency¤ Appearance? Black/pale? Difficult to flush? Bleeding? Mucous?¤ Any medication¤ Pain or discomfort on defecation

10

Systems ReviewGenitourinary system

§ Frequency¥ Daytime and night time ratio¥ Polyuria?

¤ Associated with thirst & fluid intake§ Pain

¥ During or immediately after micturation?¥ Urethral discharge?¥ Offensive, cloudy or bloodstained urine?

§ Menstruation¥ History

¤ Ratio to summarise number of days between each period (e.g. 7/28)¥ Menorrhagia?¥ Dysmenorrhoea¥ Change in quality or quantity?

D = 6-8

N 0-1

Systems Review

GU system (cont)§ Sexual activity

¥ Number of partners; homosexual encounters; safe sex; previous STD; painful intercourse; loss of libido; impotence

Nervous system§ Headache

¥ Pain assessment¤ Affected by head movement, coughing, sneezing¤ Recent or chronic

§ Loss of consciousness¥ Avoid terms such as blackouts

Systems ReviewNervous system (cont)

§ Loss of consciousness (cont)¥ Any warning symptoms; incontinence; injury or bitten tongue¥ Trigger factors¥ Symptoms after attack

Dizziness & vertigo§ Is dizziness continuous or does it occur in attacks§ Vertigo is described as sense of rotation of body or environment

Speech§ Problem of articulation or use of wrong words

Memory§ Short or long term loss§ Persistent or intermittent

11

Systems ReviewCranial Nerve Symptoms§ Vision

¥ Negative symptoms- visual loss or positive symptoms –shimmering

¥ Intermittent?§ Diplopia§ Facial Numbness§ Deafness§ Dysphagia§ Limb motor or sensory symptoms§ Loss of coordination

Systems ReviewEndocrine history§ Weight loss; polydipsia; polyuria§ Heat intolerance; weight loss; irritability; palpitations;

increased appetite§ Constipation; weight gain; altered skin texture; poor cold

tolerance; depressionMusculoskeletal system§ Bone/joint pain§ Single joint or more diffuse§ History of trauma

Systems Review

Skin§ Rashes

¥ Distribution; pruritis; occupation; chemicals or perfumes

12

Choreographing Physical Examination

Examination ProcessGeneralSkin ENT CardiovascularRespiratory Abdominal

Male GenitaliaFemale Breasts & GenitaliaMusculoskeletalNeurological

General Examination

First impressionsClinical SyndromesNutritional statusHydrationColourOedemaTemperatureLymphoreticular examination

13

Taking a HistoryPresenting complaintHistory of the presenting complaint(s)Social History

§ Education§ Employment History§ Drug History§ Tobacco consumption§ Alcohol consumption§ Foreign Travel§ Home circumstances

Medical History§ Family History

Systems Review§ Cardiovascular system§ Respiratory system§ Gastrointestinal system§ Genitourinary system§ Nervous system§ Cranial nerve symptoms§ Endocrine history§ Musculoskeletal system§ Skin

SummaryHistory

Inspection Auscultation

PalpationPercussion