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