aimstcorrect medicine logbook (2014 15)

Preface

AIMST UNIVERSITY

KEDAH

MALAYSIA

FACULTY OF MEDICINE

UNIT OF MEDICINE

LOG-BOOK

NAME

_______________________________________

MAT NUMBER_______________________________________

BATCH

______________ GROUP _________________

POSTING FROM______________ TO _____________________

YEAR III/ IV /V

NOTE

STUDENTS MUST HAVE THE LOG BOOK WITH THEM DURING WARD ROUNDS / CLINICAL SESSIONS.

STUDENTS MUST OBTAIN SIGNATURES FROM THEIR SUPERVISING CONSULTANT / DOCTOR ON A DAILY BASIS

Index

Sl NoPage no.

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DECLARATION

IMat No:, hereby declare that this logbook is a record of all clinical cases that I have clerked in and the clinical activities that I have been a part of , at Hospital

during my year III / IV / V clinical posting in the unit of ....Medicine..............................

from . to..Signature

Name:

Mat No:

CERTIFICATE

Certified that this log book is a bonafide record of all clinical activities by

Mr. /Ms., Mat No.........................................

during his/her year III / IV / V clinical posting in the unit of ..........................................

at Hospital

Head of Unit Head of Department

Unit of Medicine Department of Medicine

AIMST UNIVERSITY Hospital

Date: Date:

Sl noDateName of consultantActivitySignature

Preface

This Log book will be a record of the clinical training and experience that you shall obtain during your junior clerkship. It contains notes on scheme for history taking and physical examination that is aimed at sharpening your skills in performing clinical work. The junior clerkship is an important first phase of your active clinical posting and builds on the walk-through that you had it in the seven weeks exposure you had it in the hospital environment during your second year. You are urged advised to read up various recommended textbooks on clinical methods during the course.

During the twelve week of posting this year, you are expected to present at least six long cases jointly with one of your colleagues. All the six cases should be recorded in this log book and be subjected to evaluation by clinical teacher. A total number of fifteen cases during junior clerkship and Ten cases during Senior Clerkship should be recorded by each of you. In addition to the clinical cases record must be made of all the P B L sessions that are conducted during the posting.

The cases that you will be exposed to shall cover a range of general medical problems that will provide ample opportunity to develop your communication skill and to learn and appreciate Clinical history taking and Physical examination. Accurate record of the history and examination of each case that you are involved in should be made in this log book in as much as they will form a part of your continuous assessment.

Introduction to Clinical Examination

The sole purpose of medical practice is to relieve suffering due to disease, which makes diagnosis mandatory. In order to achieve this, one needs to develop a friendly and sensitive approach to patients so as to understand them with regard to their social and family history. It is important not only to elucidate the problems posed by disease but also apply their clinical skills to advice patients and families how to manage these problems which is achieved by constant practice of the skills by combination of study and experience. Appropriate skills are needed to elicit the symptoms from the patient's description and conversation and the signs by observation and by physical examination. It is also important to respect patients rights For example, if a patient indicates that he or she does not wish to discuss certain topics, or to be examined fully, this wish must be respected. Remember always that the communication is a two way process. To arrive at a proper diagnosis it is necessary to establish the clinical features by clinical history and examination. This forms the clinical database, and interpretation of the database leads to diagnosis.

It will be comfortable for the patient if the clinician himself brings into the clinic with offer of greeting. The response of the patient to questioning will in cases reveal the clinical condition. Another aspect is the surroundings in the office, which should be pleasant and patient friendly. It is important that the doctor pays full attention while the patient presents himself. It is also good to exchange pleasantries with accompanying persons. This will provide some more information about the social background, education level, etc., of the patient himself. After the initial informal preliminaries, the doctor can proceed to presenting clinical problem. It is better to maintain a slight sense of formality and neutrality in the relationship but make it clear that you want to hear what the patient has to say and you will inspire confidence by this. It is a good to get at least some information on personal, marital status, employment, basic family & social and medical history including allergies etc., these details will help the doctor to discuss symptoms and problems. Getting Started:

As conversational skills are central to proper history it is important to remain flexible and to be prepared to change your approach if it seems that a new start is needed. Encourage patients either to start from the beginning, or to describe the particular problem that worries them the most. Expecting patients to be open, you must make it clear that you will also be open with them. If you feel there is a cloud developing in your relationship with a particular patient, try gently to find out why and clear it.

OBSERVE YOUR PATIENT

The communication process is to enable you to make assessment of patient's general demeanour.

Personality and Presentation.

Sign of disability, physical or mental?

What clues does the gesture convey?

The general approach and psychological feelings.

Is he or she expressing all the facts or withholding certain things.

the gait.

the voice (whether normal or hoarse).

Make it clear to your patients that you expect them to speak freely and give their own account of the problem. Avoid suggesting symptoms until the patient has finished this description, when you may wish to obtain more detail or to enquire specifically about certain symptoms not so far mentioned. If there are points that are not fully described, or which you think are important, do not be afraid to ask directly for more information. However, recognize that this will interrupt the patient's flow of recall, and that you will then need to restart the spontaneous description that you interrupted.

While making notes, try to keep eye contact with the patient. Listen to the patients complaints; make up your mind of what is being said and record enough to help you remember the important points. Later, you can write up a fuller account of the history and pertinent points based on the weight placed on various items and, most importantly, what the patient actually said. What patients say, word for word, is often as important as any later reconstruction of the history.

Direct but relevant questions form an essential component of historytaking. It is rather ideal to bring up those direct questions once the patient has completed expressing the complaints. If you are not sure of something or noticed any abnormality, ask for more details directly. These can again be brought in more detail while examining the patient. After a clear understanding of the case and presentation, it is always good to start examining symptom wise starting from the primary complaint.

Try and relate the history from the preliminary information you have obtained as regards to the patient's occupation, past medical history and family history to the symptoms.

Use common and colloquial words that patient can understand. Use words like passing urine, motion etc., rather than using medical terminology.

Another important but difficult to establish, is the functional disorders which needs careful and detailed interrogation.

Exaggeration of symptoms may pose problem while interrogating the patient though the symptom may be true. This has to be sympathetically approached but firm in approach so as to analyse the depth of the symptom. It is important to establish good and reasonable relationship with the patients, which might not be easy in some Difficult and angered patients, which might be because of distress or disbelief. Adopt a soothing attitude and keep reassuring the patient.

Some time during integration the patient may introduce unrelated information without context but could be a clue to the underlying disease state.

Information obtained from a concerned and observant relative is often helpful.

ANALYSIS

The main objective of the history is to analyse the disturbance of function and structure responsible for the patient's symptoms. Symptoms always have a physiological or anatomical basis. Certain physiological symptoms have to be properly analysed or will lead to erroneous diagnosis. The most common examples are thirst, passing of large quantities of urine etc; which should be correlated with other symptoms. Even if there are any negative data it should also be analysed.

PAIN is one of the commonest complaints which bring the patient to the doctor. Systematic analysis of this symptom is important and a standard approach is essential for the evaluation of the same.

Simple questions like Where is the pain? What is the nature of pain? How is the pain relieved?, will be helpful assessing pain. The other leading questions with regard to radiation of pain, severity, timing and duration and character, occurrence or aggravation and relief will be useful in proper understanding of the symptom. PAST HISTORY

It is important to go through the past history in light of the current illness. But make sure that the patient's description of the diagnosis of an earlier illness is consistent and likely to be correct check on the treatment he or she had and possibly try checking the information from the earlier physician or hospital. Check on the medication including the non prescribed and non proprietary drugs and also about alternative or herbal remediessome of the latter can be powerful and may produce serious unwanted effects such as renal failure. You should also considering asking about sexual habits and drug abuse if deemed necessary. It is equally important to know whether is patient had any allergies for drugs or otherwise.

SPECIAL QUESTIONS FOR WOMEN

Certain information regarding the menstrual and obstetric and gynaecological history is important and essential. Others should include intake of oral contraceptives or other hormones etc.,

OCCUPATIONAL HISTORY

Another important aspect of history taking is regarding the patients occupation and exposure to toxic and industrial pollutants.

GENETIC HISTORY

The genetic history has become necessary because of role of genetic factors in many diseases. They could be inherited with dominant or recessive or sex linked. Mitochondrial inheritance in certain brain and muscle disease is also well understood. Inherited disorders are generally more common in populations in which first cousin marriages are common, as happens in isolated communities, and among certain religious groups, especially in some Muslim communities. Diabetes and Coronary Artery Disease especially lipoproteineamias show inherited factors in their causation.

THE PHYSICAL EXAMINATION

After going through the exercise of history taking, record all the salient and important features. After having completed the history taking, the doctor should proceed to the physical examination: the routine combined with specific, relevant to that patient. The examination should be thorough but without much discomfort to the patient. The depth of examination should be decided based on the severity of the condition. Start the examination in a manner that is relevant to the patient's symptoms but develop a systematic approach to each functional system in order to gain information that is both complete and relevant. GENERAL APPROACH

The examination room should be well lit, warm and exclusive ambience. Make the patient comfortable.

First inspect the physique and expression, to rule out any obvious physical disability / skeletal disorders / obesity/ wasting / malnutrition etc., Information regarding the patient's health can be gained looking at the face. Nephrotic Syndromes, Congestive Cardiac Failure, Anaemia are some examples.

The next is to look at the skin for examination of pallor, colour, pigmentation, cyanosis (Central and Peripheral) and cutaneous eruptions etc.,

The skin is dry and inelastic in dehydration - the skin can easily pinched up.

Pallor is a sign of anaemia and best observed in conjunctiva. Cyanosis is best observed in finger nails.

The next is to observe for the presence of oedema. Oedema of face is characteristic of early phase of acute nephritis, which is most marked when the patient rises in the morning.

Dependent oedema, which is typically around the ankle and dorsum of foot, is present in Congestive Cardiac Failure, and in conditions associated with a low plasma protein level such as malnourishment etc., The other types of oedema are lymphedema, venous obstruction etc., The lymphedema does not pit on pressure.

Pitting is demonstrated by applying sustained finger pressure on the swelling (odema) and on release it will leave a depression.

There can be localised oedema in angioneurotic oedema and urticaria.

THE HANDS AND FEET:

The Hands and Feet of the patient should be examined next. The strength of grip, state of the joints, the character of the nails, the presence or absence of finger clubbing (obliteration of angle between nail bed and skin), koilonychias (soft, thin and brittle and spoon shaped).the presence of nail bed infarcts, staining, tremors, erythemas, petichia are to be observed. THE NECK should be inspected and palpated next. Swellings in the neck are usually best felt from behind. Cervical nodes and thyroid gland, submandibular salivary gland or any masses are to be noted down.

Observe the trachea from front for any deviation.

Pulsations in the vessels must be noted. Any arterial pulsation is both seen and felt as a distinct thrust, whereas venous pulsation can be seen but not felt as a thrust.

THE BREASTS

The examination of breast is a necessary feature of general examination of every woman especially nulliparous women, spinsters and women with a family history of breast cancer. Examine the symmetry, nipple, areola and the skin for ulceration, discharge, retraction of nipple, and peau de orange (orange peel appearance). Palpate each breast with palm in all the quadrants of breast for any mass lesion and its relation to deeper structures.

Male breast is examined for any mass, and it is likely to be fat or a palpable disc of breast tissue beneath the areola in younger individuals or gynacomastia.

AXILLAE

Axilla is examined for any enlarged lymphnodes.

The arm is then lowered in the flexed position to rest across the examiner's arm and palpation is continued from downwards along the chest wall using fingers.

TEMPERATURE

Before taking the temperature, the thermometer should be washed in antiseptic solution or in cold water, and well shaken so that the mercury is brought down and after taking temperature it should be washed well. The thermometer must be accurate and use a thermometer (either be in the centigrade (Celsius) scale or Fahrenheit scale) which ever is familiar. The thermometer is kept well below the tongue and held firmly with the lip in adults and grown up children and in infants the axilla is the choice. It should be kept for a full minute. For collapsed, comatosed and elderly patients, rectal temperature can be recorded.

FEVER

A rise in temperature beyond the normal (37C or 98.6F) is called fever or pyrexia. The fever could be continuous when fever does not fluctuate more than about 1'C (1.5'F) during 24 hours, but at no time touches the normal. Fever is Remittent when the daily fluctuations exceed 2'C, and intermittent when fever is present only for several hours during the day. When a paroxysm of intermittent fever occurs daily, the fever is described as quotidian; when on alternate days, it is tertian; when two days intervene between consecutive attacks, it is quartan. These classical types are of fevers are not encountered frequently.

PULSE

Count the pulse for a full half minute when the patient is at rest and composed. The rate in health during the stress of a medical examination varies from about 60 to 80 beats / minute. The common causes of a rapid pulse are recent exercise, excitement or anxiety, shock, fever and thyrotoxicosis. A slow pulse is characteristic of severe hypothyroidism and of complete heart block.

RESPIRATION

Count the patient's respirations for a full minute, starting when the patient's attention is elsewhere. It is convenient to do this when the patient thinks you are still counting the pulse. The normal rate in an adult is about 1418 / minute. Observe the breathing and record if it is noisy. The noisy breathing could be because of obstruction in the nasal passages, larynx, trachea, bronchi. Also observe the pattern of breathing.

ODOURS

The odours can also give some leading information. The smell of alcohol and paraldehyde are easily recognizable on the breath. The odour of diabetic ketosis has been described as 'sweet and sickly'; that of uraemia as 'ammoniacal or fishy'; and that of hepatic failure as 'mousy', but too much reliance on such delicate distinctions is unwise. Halitosis (bad breath) is common in patients whose dental hygiene has been poor, and is associated especially with chronic gingivitis (periodontal or gum disease).

ROUTINE PHYSICAL EXAMINATION

The object of a routine examination is to check the different body systems to exclude abnormality. In considering symptoms related to the patient's presenting complaint a more focused and detailed examination is necessary.

EYES

The examination of the eye forms an important aspect of examination and consists of the following:Simple tests of visual acuity: compare one eye against the other.

Look for Exophthalmos or enophthalmos, Ptosis and oedema of the lids.

Conjunctivae: Anaemia (pallor), Jaundice (yellowish discolouration) or Inflammation

Pupils: Size, Equality, Regularity, Reaction to light, Accommodation

Eye movement: Nystagmus, Strabismus.

Ophthalmoscopic examination of the fundi and ocular chambers.

FACE

Facies, jaw movements, Facial symmetry or asymmetry, Rash, Features of endocrine disease or hyperlipidaemia.

MOUTH AND PHARYNX

(torch and tongue depressor should be used)

Breath odours Lips: colour and eruptions Tongue: protrusion and appearance Teeth and gums (if patient has dentures, notice whether they fit properly and reasons for wearing)

Buccal mucous membrane: colour and pigmentation.

PHARYNX

Movement of Soft Palate. State of Tonsils.

NECK

Movement, pain and range, Veins, Lymphatic glands, Thyroid, Carotid pulses and bruits.

UPPER LIMBS

General examination of arms and hands.

Fingernails: Clubbing or Koilonychias.

Pulse: Rate, Rhythm, Volume and Character.

Blood pressure

State of the arterial wall of radials and brachials

Axillae: Lymph glands.

Muscles: Muscle wasting, Fasciculation, Tests for power, tone, reflexes and coordination

Cutaneous sensation: check all modalities to exclude root or nerve lesions

Joints: movement, pain and swelling; rheumatiod nodules and xanthelasma at elbows.

THORAX

Examine Anterlorly and laterally for:

Type of chest, asymmetry if any,

Breasts and nipples,

Respiration: rate, depth and character,

Pulsations, Dilated vessels, Position of trachea.

Look for and palpate apex beat

Palpate over precardium for thrills.

Palpate respiratory movements

Estimate tactile vocal fremitus

Percuss the lungs.

Auscultate the heart sounds

Auscultate the breath sounds

Estimate vocal resonance.

Cervical and Axillary glands.

Examine Posteriorly (patient sitting) for:

Respiratory movement

Estimate tactile vocal fremitus

Percuss the lung resonance

Auscultate the breath sounds

Estimate vocal resonance

Movements and deformities of the spine

Palpate from behind: cervical glands and thyroid.

Look for sacral oedema.

ABDOMEN

Inspection: size, distension, symmetry.

Abdominal wall: movement, scars, dilated vessels

Visible peristalsis or pulsation

Pubic hair

Hernial orifices

Palpation: Tenderness, Rigidity, Hyperaesthesia,

splashing, masses, liver, gallbladder, spleen,

kidneys, bladder

Percussion: masses, liver, spleen, bladder

Auscultation: bowel sounds, murmurs

Impulse on coughing at hernial orifices

Inguinal glands

Male genitalia: penis, scrotum, spermatic cord;

female genitalia: examine if relevant

Abdominal reflexes

Rectal examination when ever indicated

Gynaecological examination when ever indicated.

LOWER TIMBS

General examination of legs and feet, Stance, balance and gait, Oedema of feet and ankles, Varicose veins,

Muscles: muscle wasting, fasciculation, tests for power, tone, reflexes (including plantar response) and coordination

Joints: movement, pain and swelling, Peripheral pulses, Temperature of feetFormulating a Diagnosis:

On complition of the history and examination, the clinician has usually come to a working diagnosis. This is supported by further investigations and subsequent progress of the disease. Sometimes it is difficult to diagnose a patients problem which may be linked to inexperience or the disease is in a stage of resolution or may be in early stages of presentation. It is worthwhile working on the diagnosis by first indentifying the system involved.

Case No

Name of the Patient:

Age:

Sex:

Occupation:

Race:

Religion

Nationality

Place:

Presenting Complaints with Duration

(in Chronological order)

History of Present illness

Past history (from Childhood)

Previous treatment / drug intake / Drug abuse/ drug allergy if any

Family History

Occupational history

Menstrual history

Age of Menarche

Menstrual history

Obstetric history

Para .. Gravida.

Age of menopause

Daily habits/routine

Systemic enquiry

Physical Examination (General)

Systemic examination ( Should include examination of all the relevant systems)

Summary of the Case

Provisional Diagnosis:

Laboratory Investigations (Clinical lab and Imaging)

Definitive Diagnosis

Suggested Treatment

Follow-up.

Date:

Case No 2:


Age:

Sex:

Occupation:

Race:

Religion

Nationality

Place:






Family History


Menstrual history

Age of Menarche

Menstrual history

Obstetric history

Para .. Gravida.

Age of menopause


Systemic enquiry



Summary of the Case




Suggested Treatment

Follow-up.

Date:

Case No 3:


Age:

Sex:

Occupation:

Race:

Religion

Nationality

Place:






Family History


Menstrual history

Age of Menarche

Menstrual history

Obstetric history

Para .. Gravida.

Age of menopause


Systemic enquiry



Summary of the Case




Suggested Treatment

Follow-up.

Date:

Case No 4:


Age:

Sex:

Occupation:

Race:

Religion

Nationality

Place:






Family History


Menstrual history

Age of Menarche

Menstrual history

Obstetric history

Para .. Gravida.

Age of menopause


Systemic enquiry



Summary of the Case




Suggested Treatment

Follow-up.

Date:

Case No 5:


Age:

Sex:

Occupation:

Race:

Religion

Nationality

Place:






Family History


Menstrual history

Age of Menarche

Menstrual history

Obstetric history

Para .. Gravida.

Age of menopause


Systemic enquiry



Summary of the Case




Suggested Treatment

Follow-up.

Date:

14

aimstcorrect medicine logbook (2014 15)

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