Table Of ContentSecond Edition 2013
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..نورخآ فقو ثيح هم اىقلطوإ
..نىشيعت يتلاك امايأ اىشع
.. ديفي ام ةفاضإو ..ديدجتلاو ريىطتلل تاجاح اودهشف
.. مكلجأ هم لمعلا اذه ناكف
:لمعلا اذه اهساسأ ىلع يىب يتلاو ، 424 ةمزلم ىلع هيلماعلا ءلاضفلا ءابطلأل اركش
ةزلحما دعاسم .د ،لنهكما زيزعمادبع .د ،بيرغلما ىده .د ،ينزيكلما امه .د ،يولبما ءاعد .د
………………………….
لاعو هيف بيع لا هم لج * * * لالخلا دسف ابيعدجت نإ
:يوورتكللاا ديربلا ىلع لصاىتلا اىجرو حارتقإ وأ ةظحلام هم ناك نإ
[email protected]
..قيفىتلاب مكل اىتايىمت
:424 لمع قيرف
يدي شرما نايما
برالمحا ءاردب
هردقما رودب
كيانلحا ماهر
ينسح نب هراس
ليقعما قوش
مشرلخا ةمطاف
صيخرما فافع
يدزه ما فوه
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NOTE: This is the second edition of this booklet. Spelling mistakes have been corrected, some
figures and definitions have been added for a better understanding.. (:
Contents
General Structure of history taking and general examination 3
History and Examination of the Cardiovascular System 15
History and Examination of the Respiratory System 30
History and Examination of the Gastrointestinal System 45
History and Examination of the Nervous System 59
History and Examination of the Genitourinary System 91
History and Examination of the Rheumatological System 99
History and Examination of the Endocrine System 113
History and Examination of the Hematological System 120
How to Report your Examination? 127
Frequently Asked Questions& Cranial Nerves 133
References 151
Prepare for a new
Challenge..
Listen, see, be involved &
try yourself..
Confidence comes from the
continual repetition of
certain activities..
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General Structure of History Taking, and General
Examination:
(cid:153) History Taking:
1. Personal data
2. Chief complaint
3. History of the presenting illness
4. Past history
5. Medication history
6. Blood transfusion
7. Allergies
8. Menstrual history
9. Family history
10. Social history
11. Systemic review
12. Summary
(cid:153) General Examination:
1. General appearance
2. Vital signs
3. The hand
4. The head
5. The neck
6. Lymph nodes
7. Lower limbs
8. The back
(cid:153) Important Analysis
Do Not Fear
Mistakes
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(cid:153) History taking:
Important Points to Put in Your Mind:
(cid:131) Say: هتاكربو الله ةوحرو نكيلع ملاسلا
(cid:131) Introduce yourself to the patient as a student doctor.
(cid:131) Take the permission.
(cid:131) Close the curtain.
(cid:131) Sit down
(cid:131) In order to obtain a good history, the clinician must:
- Establish a good relationship.
- Interview in a logical manner.
- Listen carefully.
- Allow the patient to tell the whole story then ask questions to fill in the gaps.
- Interrupt appropriately.
- Note non verbal clues.
- Correctly Interpret the information obtained.
- Show an interest.
- If the patient stops giving the story, it can be useful to provide a short summary of what
has already been said and encourage the patient to continue.
- Avoid using medical terms.
1. personal data:
(cid:131) Name.
(cid:131) Age.
(cid:131) Nationality.
(cid:131) Gender.
(cid:131) Residency.
(cid:131) Marital status.
(cid:131) Children
(cid:131) Occupation
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2. Chief complaint (CC):
(cid:131) Time of admission (admitted when?): mention the date.
(cid:131) Route of admission: through ER electively through OPC, or by referral.
(cid:131) Complaining of (no medical terms &in a chronological order).
(cid:131) If the CC is pain, mention the site.
(cid:131) The duration (for how long?) of each symptom alone.
(cid:131) Chronic illness (es), e.g., the patient is known to be….. since…. on (medications) ….., and
mention if there are any complications.
(cid:131) Analysis of the CC(s) in a chronological order:
- Onset and offset.
- Duration.
- Course.
- Character.
- Severity.
- Aggravating and relieving factors.
- Associated symptoms.
(cid:131) Systemic review of the systems involved in the CC(s).
(cid:131) Previous episodes: if yes:
- How many times?
- When was the first and last episode?
- Same or more severe episodes (progression).
- How did it relieve?
- Did the patient go to a doctor?
- The diagnosis?
- What was done (medications, investigation, or hospital admission)?
(cid:131) Constitutional symptoms: fever, loss of appetite, and weight loss.
(cid:131) Risk factors.
(cid:131) hospital course: (what was done to the patient during this admission: investigations,
medications, procedures and their results)
(cid:131) Functional history: (how the disease affects the patient's life daily activity) e.g: going to
the school or work.
(cid:131) Analysis of the chronic illnesses that related to the CC(s):
- It was diagnosed on (where and when?) by type of investigation?
- Monitoring (yes or no, if yes how?).
- Regular follow up in a health care center.
- Medications. Always taken or missed.
- Complications and their duration.
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3. Past History:
(cid:131) Past Medical:
- Chronic illnesses not related to the CC(s).
- Childhood problems.
- Any other disease, e.g infection, inflammation, tumor, and for each disease.
a. When was diagnosed? By which type of investigations?
b. Controlled or not.
c. Drug compliance.
d. Complications, and their duration.
(cid:131) Past surgical or interventional procedures: What? Why? When? Complications?
(cid:131) Hospital admissions: When? Why? What was done? ICU admission?
(cid:131) Past accidents and their consequences, e.g. fractures, trauma.
(cid:131) History of physiotherapy or rehabilitation.
4. Medication history:
Drug For (the disease) route dose frequency duration
(cid:131) Any complication (adverse effects) of the medications.
(cid:131) Use of herbal medications (especially in liver diseases, or jaundice).
5. Blood transfusion:
(cid:131) When Why? How many units? Complications?
6. Allergies:
(cid:131) Against what, egg, food, drugs, contrast.
(cid:131) What is the kind of the allergic reaction (symptoms)?
(cid:131) How does it relief?
- If negative, say: "No known allergy (NKA)"
7. Family history:
(cid:131) Family members and their health.
(cid:131) Causes of death.
(cid:131) Similar illness (or presentation) in the family: duration, their ages when the disease
presents.
(cid:131) Any inherited disease: diabetes, hypertension, cancer, or any inherited disease that is
illness related.
(cid:131) Congenital abnormalities or diseases.
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8. Menstrual history:
(cid:131) Age of menarche.
(cid:131) Age of menopause.
(cid:131) LMP (last menstrual period).
(cid:131) Regularity (note if there is dysmenorrhea or amenorrhea).
(cid:131) Duration.
(cid:131) Amount.
(cid:131) Pregnancies (number, any problem with pregnancy?).
(cid:131) Deliveries (number, normal/c-section).
(cid:131) Abortions (number, cause).
(cid:131) OCP (oral contraceptive pills) and HRT (hormonal replacement therapy): if yes, for how
long and which type.
(cid:131) Any gynecological problems, e.g: bleeding, tumor.
9. Social history:
(cid:131) Place of birth, and residency.
(cid:131) Marital status and number of children.
(cid:131) Who is taking care of the patient (to assess if he/she can do his/her daily activity or
needs help).
(cid:131) Level of education.
(cid:131) Socioeconomic status.
(cid:131) Occupation.
(cid:131) Habits: smoking, drinking alcohol, drug abuse.
(cid:131) Any activities or exercise.
(cid:131) History of traveling to an endemic area (where?) or contact with infectious people
(when?).
(cid:131) History of close contact with animal.
(cid:131) Immunization.
10. Systemic review:
(cid:131) CVS, Respiratory, GIT, GUT, CNS, Endocrine, Rheumatological, Hematological, Skin.
11. Summary:
(cid:131) Age.
(cid:131) Gender.
(cid:131) Chronic illnesses.
(cid:131) CC(s) and the duration.
(cid:131) Important negatives.
(cid:131) The patient was admitted for further evaluation and management.
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(cid:153) Examination:
1. Pre-exam Checklist : WIPE
(cid:131) Wash your hands.
(cid:131) Introduce yourself to the patient.
(cid:131) Positioning of the patient and his/her Privacy.
(cid:131) Exposure.
** Remember:
(cid:131) Always examine from the right side of the patient (and tell the examiner if you are left
handed).
(cid:131) Ask the patient if there is any tenderness before touching him/her.
2. General appearance (ABCDE):
(cid:131) Appearance: young, middle aged, or old, and looks generally ill or well.
(cid:131) Body built: normal, thin, or obese.
(cid:131) Connections: such as nasal cannula (mention the medications), nasogastric tube, oxygen
mask, canals or nebulizer, Holter monitor, I.V. line or cannula (mention the medications).
(cid:131) Color: jaundiced, pale, or cyanosed.
(cid:131) Distress: in pain, respiratory (using accessory muscles), or neurological (abnormal movements)
distress.
(cid:131) Else: mental functions: consciousness, alertness, and orientation.
3. Vital signs:
(cid:131) Pulse rate:
- Rate: counting over 30 seconds, normally 60-100.
- Rhythm: regular or irregular.
- Synchronization by comparing with the other side (radioradial or radiofemoral delay).
- Character and volume: determined from the carotid.
(cid:131) Blood pressure (BP) : Normal BP defined as a systolic reading less than 140, and diastolic
reading less than 90.
(cid:131) Temperature: Normal body temperature ranges from 36.6-37.2 C.
(cid:131) Respiratory rate:
- It is traditional to count it while taking the pulse.
- The normal rate at rest should not exceed 25 beat per minute (range 16-25).
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4. The hand:
(cid:131) Dorsum:
- Muscle wasting.
- Pigmentations.
- Skin lesion (including scars).
- Tendon xanthomata*: hyperlipidemia.
(cid:131) Palm:
- Signs of infective endocarditis such as Osler's nodes* and Janeway lesions*
- Palmar xanthomata: hyperlipidemia.
- Sings of a respiratory disease, or nicotine staining.
- Palmar erythema (redness of the palms of the hands): liver cirrhosis, polycythemia,
pregnancy.
- Pigmentation of palmar creases: Addison's disease but may be normal in Asians and
black.
- Pallor of palmar creases: anemia (becomes clearer with hyperextend fingers).
- Dupuytren's contracture*: alcoholism.
- Raynaud's phenomenon*
(cid:131) Nail
- Clubbing.*
- Signs of infective endocarditis like splinter hemorrhage.
- Leukonychia*: hypoalbuminemia, liver disease, or nephritic syndrome.
- Koilonychias*: iron deficiency anemia.
(cid:131) Flapping tremor*
- CO retention.
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- Hepatic encephalopathy.
- Renal failure.
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* See next page
