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Clinical Methods in Medicine (Clinical Skills and Practices)
SN Chugh
UNIT I: HISTORY TAKING AND REVIEW OF SYSTEM
1:
History Taking
INTRODUCTION
HISTORY TAKING
The Skills
Interview technique
Pitfalls in history taking
Chief complaint (s)
How to write the chief complaints?
The History of present illness
Aims of present history
Analysis of a symptom
History of past illness
Importance of past history
Family history
The social, personal and occupational history
Habits
Tobacco
Alcohol
Rough estimate
Illicit drug use
REVIEW OF SYSTEMS/PRESENTING SYMPTOMS
2:
Analysis of Systemic Symptoms
ANALYSIS OF SYSTEMIC SYMPTOMS
Gastrointestinal symptoms (Box 2.1)
Pain Abdomen
Associated symptoms
Causes
Vomiting
Dysphagia
Diarrhoea
Constipation
Abdominal distension/swelling
Bleeding per rectum
Symptomatology related to liver and gallbladder
1. Non specific symptoms
Mass abdomen
Jaundice
Cardiovascular system (CVS) symptoms
Symptoms analysis
Palpitation
Cough, sputum and haemoptysis
Peripheral oedema (Read also the examination of extremities Chapter 10)
Chest pain
Syncope
Other symptoms of cardiac disease
Fatigue
Nocturia
Cardiovascular disease presenting with noncardiac symptoms i.e.,
Symptoms pertaining to the respiratory system
Symptoms analysis
Cough
Sputum
Haemoptysis (Fig. 2.2)
Chest pain as respiratory symptom
Characteristics of chest pain due to the diseases of the lung and pleura
Dyspnoea due to respiratory disease.
Points to be asked on history of breathlessness
Causes of dyspnoea
Dyspnoea characteristics
Wheeze
Stridor
Symptomatology of upper respiratory tract
Clinical clues
Significance of history
Cardiac versus respiratory dyspnoea
Symptoms related to blood disorder
Terms used in relation to bleeding
Symptoms pertaining to urinary system
Pain
Abnormal urine volumes
Abnormal colouration of urine
Increased frequency of micturition
Urinary incontinence
Enuresis
Pneumaturia
Puffiness of face and oedema
Nervous system symptoms
Headache
Involuntary movements
Epilepsy/seizure
Vertigo or dizziness (Read Chapter 7 also)
Syncope
Weakness or paralysis
Episodic weakness
Terminology for motor and sensory symptoms
Sensory symptoms
The gait
Endocrinal symptoms
1. Excessive thirst (polydipsia) and excessive urination (polyuria)
Vasopressin test
Weight loss
Weight gain
Muscle weakness/myopathy
Temperature intolerance (heat or cold)
Postural instability
Symptoms of sympathetic overactivity (e.g. tachycardia, tremors, perspiration)
Dysphagia
Symptoms pertaining to genital system
Infertility
Infertility in females
Menstrual irregularities
Precocious puberty
Symptoms of rheumatic diseases
Analysis of rheumatic complaints
Arthritis
UNIT II: PHYSICAL EXAMINATION
3:
General Physical Examination
GENERAL OBSERVATIONS
Facial appearance (Table 3.1)
Nutritional status
Significance of dietary history
State of hydration
Parameters of assessment
Vitals
Definitions
Compilation of statement
4:
The Head, Scalp, Skin and Hair
HEAD AND SCALP
History
Examination
Common clinical conditions related to cranium
Mechanisms of production
Analysis of symptom of headache
Physical examination
Common types of headache
Migraine
Headache due to raised intracranial pressure
Tension or psychological headache
Investigations (Read nervous system)
THE SKIN
History
Examination
Sequence of examination
Skin colour and pigmentation
Common abnormal skin lesions
I. Distribution of the lesion as a clue to the diagnosis
Morphology of skin lesions
The Hair (Fig. 4.39)
I. Too less hair and hair loss
A. Scalp
Alopecia areata
II Too much facial and body hair
5:
The Eyes
THE EYES (FIG. 5.1)
THE HISTORY
Examination
Visual function tests
Visual acuity
Colour vision
Visual field
General inspection
Types
Consequences of exophthalmos
Ptosis
Types
Testing for ptosis
The cornea and the lens
The iris
The pupils
Method
Common abnormality of pupil (Table 5.3 and Fig. 5.18)
Test
Squint
Method (Fig. 5.20)
The ocular fundus
Steps of examination
Uses of ophthalmoscopy including fundoscopy
Investigations for a case with eye disorder
6:
The Mouth and the Pharynx
THE MOUTH AND THE PHARYNX (FIG. 6.1)
Examination
Inspection
The gums
The oral mucosa
Palpation
7:
The Ear, Nose, Sinuses and Throat
THE EAR
THE NOSE AND PARANASAL SINUSES
THE THROAT
8:
The Neck
THE NECK
THE THYROID GLAND (Read also endocrine system)
Examination of thyroid (Read chapter 20)
Abnormalities and their interpretations
Investigations of a patient with thyroid disease
The trachea
Steps of examination
The carotid arteries and jugular veins
9:
The Breast and the Axillae
THE BREAST AND THE AXILLAE
Examination of breasts
Steps
The Axillae
Investigations for breast disease
10:
The Extremities
EXAMINATION OF EXTREMITIES
The hands and the nails
Applied anatomy and physiology
Steps of examination
Clubbing
Method of examination
Alternative method (Schamroth's window test)
Pathogenesis
The feet and the legs
Testing of dependent oedema
Types
A. Pitting oedema
Distribution of oedema
Causes (See Table 10.4)
Pathogenesis of generalised oedema
Differential diagnosis of oedema
UNIT III: SYSTEMIC EXAMINATION
11:
The Cardiovascular System (CVS)
HISTORY
GENERAL PHYSICAL EXAMINATION
SYSTEMIC EXAMINATION
Other systems examination
Respiratory system Abdomen CNS
Investigations
THE CARDIOVASCULAR SYSTEM (FIG. 11.1)
EXAMINATION OF CARDIOVASCULAR SYSTEM (CVS)
General physical examination
Cyanosis
Temperature of extremities
Clubbing of fingers (see Fig. 10.18)
Splinter haemorrhages (Fig. 11.3)
Painful finger-tips/toes
Janeway lesion
Malar flush
The arterial pulse
Blood Pressure (BP)
Definitions of normal and abnormal level
Special problems and the remedial measures
Jugular venous pulse and pressure (JVP)
Normal Jugular Venous Pressure (JVP)
Examination of jugular venous pulse and measurement of JVP
The carotid pulse
Abnormalities
Conditions of other peripheral pulses
Oedema
Jones criteria
Clinical significance
Acute rheumatic activity
Peripheral manifestations of infective endocarditis (Read case discussion on infective endocarditis in Bed-side medicine without tears by Prof. S.N. Chugh)
Examination of the precordium
Examination sequence
Auscultatory areas
Step of examination
Effect of positions
Heart sounds
Abnormalities of the heart sounds
Splitting
Added sounds (Fig. 11.31)
Murmurs
Investigations for a case with cardiovascular disease
Electrocardiography
Standard 12-lead electrocardiogram
Pathway of electrical activation of the heart (Fig. 11.34)
Indications of ECG
Stress (Exercise) Electrocardiography
Types of stress tests
Method
Result of stress test
Pitfalls
Continuous ambulatory electrocardiographic recording (Holter monitoring)
Chest X-ray
Radiographic findings in heart failure
Fluoroscopy for hilar dance
Echocardiography
Type of studies
Radionuclide scanning
Invasive cardiac investigations
Complications
PERIPHERAL VASCULAR SYSTEM
Classification
Occlusive arterial disease
Clinical presentations
Examination
The physical examination
Areas of examination
Examination sequence
Special techniques to test arterial supply of hands
Palpation of various peripheral pulses
Other areas of examination
The heart
The abdomen
The nervous system
Buerger's disease (thromboangitis obliterans)
Vasospastic disorders
Aneurysmal disease (abdominal aortic aneurysm –AAA)
Investigations of PAD
VENOUS SYSTEM
The history
Examination of venous system
Specific Conditions
I. Deep vein thrombosis (DVT)
Clinical features
Investigations
Differential diagnosis
Complications
II. Superficial venous thrombophlebitis (Fig. 11.57)
III. Varicose veins and chronic venous insufficiency
Types
IV. Chronic leg ulceration
12:
The Respiratory System
HISTORY
GENERAL PHYSICAL EXAMINATION (GPE)
SYSTEMIC EXAMINATION
Other systems examination
The cardiovascular system
The abdomen
The CNS
Provisional diagnosis
Differential diagnosis and Investigations
THE RESPIRATORY SYSTEM
History
Present history
Past history
Family history
Personal and occupational history
General physical examination (GPE)
Other features
Examination of chest
Examination of anterior chest including lateral chest
Steps of examination
Method (Fig. 12.15)
Other palpable vibrations
Normal areas of resonance and dullness
Rules of percussion
Abnormalities of percussion note
To elicit the horizontal fluid level in hydropneumothorax
Method of auscultation (Fig. 12.21)
Auscultation in special situations
Breath sounds
Vocal resonance
Added (adventitious) sounds
Other sounds
Inspection
Palpation
Percussion
Auscultation
Examination of other systems
Investigation of a patient with respiratory disease
Microbial examination
Histopathological and cytological examination
Skin tests
Serological tests
Pulmonary function tests
A. Exercise tests
B. Forced expiratory time
Invasive procedures
Laryngoscopy
Bronchoscopy
Mediastinoscopy
Thoracentesis or pleural aspiration (Fig. 12.34)
Ventilation perfusion scan
Pulmonary angiography
Lung biopsy
13:
The Abdomen
HISTORY
GENERAL PHYSICAL EXAMINATION
SYSTEMIC EXAMINATION
THE ABDOMEN
Gastrointestinal system
Hepatobiliary system
Present history
Past history
Family history
Personal history
General physical examination (GPE)
Systemic examination of the abdomen
Common abnormalities
1. The Skin
2. The Umbilicus
3. Shape of the abdomen
Common abnormalities
Abdominal movements
Peristalsis
Pulsations
Hernias
1. Light palpation (Fig. 13.18)
2. Deep palpation (Fig. 13.19)
Common abnormalities
A. The liver
The gallbladder
The characteristics of gallbladder mass/ palpable gallbladder
Common abnormalities
Enlargement of the gallbladder
The Spleen
Splenomegaly
The kidneys
Urinary bladder
Abnormality
Aortic and other pulsations
An abdominal lump, if any
Physical examination of an abdominal lump/mass
I. General
II. Local
Differential diagnosis of a mass in abdomen
I. Mass in the abdominal wall (e.g. cold abscess)
II. Intra-abdominal mass (e.g. mass in right hypochondrium)
III. Mass in epigastrium (see the Box 13.11)
IV. Mass in the left hypochondrium
V. Mass in right and left lumbar regions (see the Box 13.12)
VI. Periumbilical mass
VII. Mass in right iliac fossa
VIII. Mass in the hypogastrium
IX. Mass in the left iliac fossa
Method
Abnormalities
Percussion for splenic dullness
Abnormalties on auscultation
EXAMINATION OF THE GROINS AND BACK
The anus, rectum and prostate
Applied anatomy
Method
Palpation (digital examination)
Investigations of gastrointestinal system
Radiological examination
Endoscopy
Upper GI endoscopy
Endoscopic retrograde cholangio-pancreatography (ERCP)
Lower GI endoscopy
Other procedures
Biopsy of small Intestine (Fig. 13.55)
Secretory studies
Tests for exocrine pancreatic function
Malabsorption tests (see Table 13.3)
Investigations of hepatobiliary system
Aims of investigations
Biochemical tests
Bilirubin
Urine tests
Enzymes
Alkaline phosphatase
Gamma-glutamyl transference (γ-GT)
Serum proteins
Blood ammonia
Serum lipids and cholesterol
Other biochemical tests
Bromsulphalein (BSP) clearance
Serological test for viral hepatitis (Read case discussion of hepatitis in bed-side Medicine without tears by Prof. SN Chugh)
Hepatitis B virus (HBV) antigens and antibodies
Acute Infection
Hepatitis B core antigen and antibody (HBcAg and anti-HBc)
Hepatitis B envelope antigen (HBeAg) and antibody (anti-HBe)
Chronic Infection
Hepatitis C virus antibodies
Hepatitis D-antigen and antibody
Hepatitis E virus antibody
Autoantibodies
Diagnostic Procedures
Imaging
Endoscopy
Abdominal paracentesis (removal of ascitic fluid)
Liver biopsy
Liver aspiration (Figs 13.63A and B)
Laparoscopy
Portal pressure
Examination of vomit
Examination of faeces
Acute abdomen
14:
The Urogenital System and Sexually Transmitted Diseases
HISTORY
GENERAL PHYSICAL EXAMINATION
SYSTEMIC EXAMINATION
Abdominal examination
Genitalia examination
Male genitalia
Female genitalia
Provisional diagnosis Differential diagnosis Investigations
THE URINARY SYSTEM (Fig 14.1)
THE GENITALIA
History
Present history
Past history
Family history
Drug history
Sexual history
Menstrual and obstetrics history
Examination
General physical examination
The abdomen (Read Chapter 13)
Investigations of a case with renal disease
Urine examination
Blood biochemistry
Radiology and Renal imaging
Examination of genitalia
The male genitalia
The scrotum and its contents
Abnormalities of scrotum and its contents (Table 14.3)
Female genitalia
Abnormalities of the uterus
Internal examination by a vaginal speculum and taking a cervical smear (Figs 14.47 and 14.48)
15:
The Nervous System
HISTORY
GENERAL PHYSICAL EXAMINATION
SYSTEMIC EXAMINATION
Diagnosis
Differential diagnosis Investigations
THE NERVOUS SYSTEM
The central nervous system
Peripheral nervous system
The cranial nerves
The peripheral nerves
The motor system
Body parts representation in motor cortex (Fig. 15.4) and internal capsule
Hierarchy of the motor control (Fig. 15.5)
Symptomatology of motor system
Motor system lesion (motor deficit)
Spinal reflex arc (Fig. 15.6)
The sensory system (Fig. 15.7)
Cortical and subcortical centres (higher centres) for sensation
Symptomatology of sensory system
Clinical signs/terms
Patterns of sensory disturbance
Spinal dermatomes
How to count the vertebra?
Spinal myotomes
Blood supply of the brain and spinal cord
Anatomy of cerebral circulation
Clinical significance of cerebral circulation
Specific vascular syndromes of brain (stroke)
Syndrome of transient ischaemic attacks (TIAs)
Syndrome of internal carotid artery occlusion
Syndrome of middle cerebral artery (MCA)
Syndrome of anterior cerebral artery
Syndrome of posterior cerebral artery
Brainstem infarction (vertebrobasilar artery syndrome)
Lacunar syndromes (small vessel stroke)
Blood supply of spinal cord and spinal artery syndromes
Venous drainage of brain and dural sinus thrombosis
Presenting complaints and symptoms
History
Past history
Drug history
Family history
Social and personal history
Examination
General physical examination
Systemic neurological examination
Mental status/functions
Released reflexes/return of primitive reflexes
Speech and language
Mechanism of speech production (Fig. 15.17B)
Apraxia
Examination of neck and cervical spine movements
Examination of gait and balance
Examination of cranial nerves
The olfactory (first) cranial nerve
The optic (second) cranial nerve
The Oculomotor (III), the Trochlear (IV) and the Abducens (VI) cranial nerves
The third nerve
The fourth nerve
The sixth nerve
Supranuclear 3rd, 4th and 6th nerve lesions
The fifth (trigeminal) cranial nerve
Testing of the 5th nerve
Facial pain
Trigeminal neuralgia (tic douloureux)
The seventh (facial) cranial nerve
The vestibulocochlear (viii) nerve
Testing of VIII nerve
The glossopharyngeal (ix), vagus (x) and accessory (xi) nerves
IX nerve palsy
X nerve palsy
Causes of IX and X nerves palsy (see the Box 15.13)
The hypoglossal (xii) nerve
I. Signs of unilateral XII nerve palsy
II. Bilateral XII nerve palsy
Common abnormalities
The motor system
Testing of the muscles of upper and lower limb (Table 15.26 and Fig. 15.51)
The reflexes
The superficial reflexes
Co-ordination and gait
Tests of co-ordination
Involuntary movements
Muscle spasm and muscle cramps
Sensations
General principles
Testing sequence
Common abnormalities of a single nerve lesion (mononeuritis)
Sensory vs cerebellar ataxia (It has already been discussed)
Autonomic nervous system (ANS)
Applied anatomy and physiology
1. Tests for cardiovascular functions
Nervous system at a glance
Quick neurological examination
General physical examination
Gait
Cranial nerves
Motor function
Sensory
Investigations
Biochemical
Radiological
B. Imaging
Electrophysiological tests
IV. Biopsy
16:
The Examination of Unconscious Patient
HISTORY
Symptoms
Present history
Past history
Family history
Personal history
GENERAL PHYSICAL EXAMINATION
SYSTEMIC EXAMINATION
Nervous system
Cardiovascular system
Respiratory system
Abdominal examination
Endocrinal system
Diagnosis
Investigations
UNCONSCIOUSNESS OR COMA
Definition
Coma like syndromes
Pathophysiology and causes of coma
Clinical evaluation of a patient with coma
History
General physical examination
Systemic examination
Neurological examination
Other systems examination
Brain death testing
Investigations
17:
The Locomotor System
HISTORY
GENERAL PHYSICAL EXAMINATION (GPE)
FORMAT FOR LOCOMOTOR SYSTEM EXAMINATION
SYSTEMIC EXAMINATION
Examination of the other systems
THE LOCOMOTOR SYSTEM
History
Past medical history
Family history
Social or occupational history
Drug history
Assessment of rheumatological disorders
Screening system for locomotor abnormality and disability (Fig. 17.7). Ask the following three screening questions;
General physical examination
Aims of the examination
Examination of the joints and bones
Inspection
Palpation (feel and move the joint)
Examination of individual joints
1. Temporomandibular joint
The spine
Applied anatomy and physiology
The movements and muscle groups
Examination of the spine
Tests for nerve root compression
Upper limb joints
The shoulder
Examination of the shoulder
The elbow
Examination of elbow
The wrist and hands
Examination
Testing of the movements
Test for sensations
LOWER LIMB JOINTS
Investigations
Tests for rheumatoid factor
Antinuclear antibodies (ANA)
Antibodies to other nuclear antigens
Serum Uric Acid
Synovial fluid examination
Radiology and imaging techniques
18:
The Blood
HISTORY
GENERAL PHYSICAL EXAMINATION
SYSTEMIC EXAMINATION
Diagnosis
Differential diagnosis
Laboratory investigations
THE BLOOD
History
Causes of anaemia (Table 18.1)
Symptoms and signs specific to certain anaemia (see the Table 18.2)
Leucopenia and neutropenia
Leucocytosis and leukaemoid reaction
Leucoerythroblastic anaemia
Leukaemias
Myelomatosis
Polycythaemia (high haemoglobin and PCV)
Lymphadenopathy (Read examination of neck Chapter 8)
Splenomegaly or hepatosplenomegaly (Read abdominal examination Chapter 13)
Bleeding
Thrombosis
Pancytopenia
Examination of a patient with haematological disorder
Abdominal examination
The anus
Investigations for a haematological case
19:
The Psychiatric Assessment
HISTORY
PHYSICAL AND PSYCHOLOGICAL EXAMINATION
Investigations
THE PSYCHIATRIC ASSESSMENT
Psychiatric history
General informations
Second hand informations
Presenting/chief complaints
History of present illness
Past medical and psychiatric history
Treatment history
Family history
Personal history
Pedisposing and precipitating factors
Forensic history
Premorbid personality (PMP)
Case No. 1: Chest pain
Clinical presentations
Provisional diagnosis: Cardiac neurosis Differential diagnosis
Investigations
Case No. 2: Chronic fatigue
Clinical presentations
Provisional diagnosis: Chronic fatigue syndrome Differential diagnosis
Investigations
Case No. 3: Chronic headache
Headache characteristics
Provisional diagnosis: Chronic headache (psychogenic) Differential diagnosis
Investigations usually prescribed /done
Case No. 4: Chronic backache
Clinical presentations
Provisional diagnosis: Chronic low back pain. Differential diagnosis
Investigations done
Case No. 5: Sleep disturbances
Clinical presentations
Provisional diagnosis: Insomnia Differential diagnosis
Investigations done/required
Case No. 6: Abdominal pain
Clinical presentations
Provisional diagnosis: Abdominal neurosis Differential diagnosis
Investigations done/required
Case No. 7: Panic attacks
Examination
1. Physical
2. Psychological examination
Physical examination
Psychiatric or mental state examination (MSE)
Cognition (neuropsychiatric) assessment
Investigations
Psychological tests
20:
The Endocrinal System
HISTORY
GENERAL PHYSICAL EXAMINATION
SYSTEMIC EXAMINATION
Diagnosis and differential diagnosis Investigations
THE ENDOCRINE SYSTEM AND METABOLISM
The history
Past history
Family history
Social history
General physical examination (GPE)
Hypogonadism
Systemic examination
Investigations of a case with endocrinal disorders
Stimulation and suppression tests used in endocrinology
Gonadal axis
Growth axis
Thyroid axis
Adrenal axis
Endocrinology of blood pressure and thirst
Thirst
Water deprivation test
Results
Endocrinal imaging
Serological tests
BRIEF SYNOPSIS OF FEW COMMON ENDOCRINAL DISORDERS
Thyrotoxicosis (Table 20.6 and Fig. 20.15)
Clinical presentations
Definitions
Causes of thyrotoxicosis (Box 20.10)
Methods of demonstration
Hypothyroidism (Table 20.8 and Fig. 20.20)
Definitions
Causes of hypothyroidism
Clinical presentations
Gigantism and acromegaly (Figs 20.22 A and B and Table 20.10)
Cushing syndrome (Table 20.11, Fig. 20.23)
Causes of Cushing's syndrome (Fig. 20.23)
Addison's disease (Fig. 20.24 and Table 20.12)
Causes
Hypopituitarism (Fig. 20.25 and Table 20.13)
Causes
Diabetes mellitus (Fig. 20.26)
Clinical presentations of diabetes mellitus
UNIT IV: APPENDICES
Appendices
APPENDIX – I
Making the best use of the result
Microbial tests
Serological test
Collection of the samples of other tissues (CSF, pus, fluid)
Blood culture
Urine culture
Examination of faeces
Parasitic infections
The respiratory tract
Sputum
The genital tract
The skin
Virus detection
The eyes
Bacterial pathogens
CHEMICAL ANALYSIS OF THE URINE
Proteinuria
The boiling test
The salicylsulphonic acid test
Dipstick test
Urine for 24 hour proteinuria
Tests for urine sugar
Test for Bence-Jones protein's
Test for microalbuminuria
Dipstick test (uristix-test – Fig. A.4)
Urine for ketone bodies
Rothera's test
Ferric chloride (Gerhardt's) test
Ketostix test
Urobilinogen and Porphobilinogen
Ehrlich's aldehyde test
Test for bile salts
Test for blood and haemoglobin
SEMEN ANALYSIS
APPENDIX – II
Centigrade and Fahrenheit scale
SI units
Normal Values (Reference Values)
INDEX
TOC
Index
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